Review articleMindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis
Introduction
In the last decade, interest in and research investigating mindfulness and mindfulness-based interventions has increased exponentially (Baer, 2003, Chiesa and Serretti, 2010). Mindfulness is currently defined in psychological terms as being characterized by paying total attention to the present moment with a non-judgmental awareness of inner and outer experiences (Kabat-Zinn, 1994). Increasing evidence suggests the potential usefulness of mindfulness-based interventions for the treatment of a large number of physical and mental disorders (Lynch et al., 2007, Raes et al., 2009, Chiesa and Serretti, 2010) as well as for the reduction of stress levels in healthy subjects (Chiesa and Serretti, 2009).
One of the most widely diffused mindfulness-based interventions is Mindfulness-based cognitive therapy (MBCT), a manualized 8-week skills-training group program (Segal et al., 2002) based upon the theoretical framework of information processing theories (Teasdale et al., 1995) and integrating aspects of Cognitive behavioural therapy for major depression (MD) (Beck et al., 1979) with components of the Mindfulness-based stress reduction program developed by Kabat-Zinn (Kabat-Zinn, 1990). MBCT was originally designed to teach patients in remission from recurrent MD to become more aware of, and to relate differently to, their thoughts, feelings, and bodily sensations. An example includes recognizing thoughts and feelings as passing events in the mind rather than necessarily accurate readouts of reality. The original program teaches skills that allow individuals to disengage from habitual, automatic dysfunctional cognitive routines as a way to reduce future risk of relapses and recurrences of MD (Segal et al., 2002).
More recently, however, MBCT has also been used for other clinical targets including, among the others, the reduction of inter-episodic depression and anxiety levels in patients suffering from bipolar disorder (BD) (e.g. Williams et al., 2008b) and the reduction of residual anxiety symptoms in patients suffering from anxiety disorders (e.g. (Kim et al., 2009)), finding preliminary support for the usefulness of MBCT for such conditions. Also, a number of uncontrolled studies have recently provided preliminary evidence for the usefulness of MBCT for patients with treatment-resistance MD (Kenny and Williams, 2007, Eisendrath et al., 2008) and for patients suffering from insomnia (Heidenreich et al., 2006, Ong et al., 2008, Yook et al., 2008), even though findings deriving from such studies should be considered with caution as very often initially positive findings derived from early uncontrolled studies are not supported when controlled studies are undertaken. Of note, while in some cases, such as for remitted BD and treatment-resistant MD patients, no adaptation of the original MBCT program was required (Kenny and Williams, 2007, Williams et al., 2010), many adaptations including, as an example, the observation of the association between worried thoughts, mood and behaviours as well as psycho-education about cognitive distortions specific to panic disorder (PD) and generalized anxiety disorder (GAD) (Evans et al., 2008, Kim et al., 2009), were required in trials dealing with patients with non-affective psychiatric disorders such as anxiety disorders.
The importance of interventions such as MBCT that, in adjunct to standard treatments, could optimize standard care and enhance treatment outcomes can be best understood if one considers that psychiatric disorders are usually characterized by a chronic course, are related to a high social and economical burden (Mintz et al., 1992, Lish et al., 1994, Wyatt and Henter, 1995, Judd, 1997) and are only partially responsive to current treatments (Geddes et al., 2000, Scott et al., 2006, Goldberg et al., 2005, Segal et al., 2002, Paykel, 2007, Watkins and Teasdale, 2004). Taking as an example MD, note that it has a lifetime incidence in the United States of up to 12% in men and 20% in women (Kessler et al., 2003) and that it accounts for 4.4% of the global disease burden worldwide (World Health Organization, 2002). Unfortunately, however, according to recent findings, no more than 37% of patients suffering from MD achieve clinical remission after the first antidepressant (AD) treatment and the overall remission rate after several pharmacological treatments is about 67% (Rush et al., 2006). Additionally, despite receiving adequate psychological and/or pharmacological treatments such as cognitive psychotherapy or AD medications, patients who have experienced an MD episode carry a risk for relapse over the period of 1 year as high as 30-70% depending on prior and current therapeutic strategies (e.g (Rush et al., 2006, Hollon et al., 2005). Taking into account such issues, the importance of interventions like MBCT, which could enhance current treatment options by reducing residual symptoms and preventing further relapses, becomes obvious, especially if one considers that MBCT also has the advantage of a group format that allows greater accessibility in clinical care.
Coelho et al. (2007) were the first authors to systematically review findings about the potential usefulness of MBCT for MD. In their review they concluded that available evidence suggested that for patients with three or more previous depressive episodes, MBCT could have an additive benefit to usual care. However, they also pointed out the notion that further research was needed to extend available findings and to clarify whether MBCT could have any specific effects (Coelho et al., 2007). More recently, Williams et al. (2008a) further pointed out the importance of authors other than the developers of the original MBCT program performing independent trials on the efficacy of such therapy for MD and for further disorders so as to provide evidence for the treatment transportability and generalizability.
Since the publication of the first reviews on this topic (Coelho et al., 2007, Williams et al., 2008b), a number of research groups have answered the call for independent trials focusing on the efficacy of MBCT for MD (e.g., Bondolfi et al., 2010, Godfrin and van Heeringen, 2010) as well as for further psychiatric disorders. Additionally Williams et al. (2008a) answered a number of critical questions raised by Coelho and colleagues regarding, as an example, the absence of randomization details and the lack of data about group effect on final outcomes in their early articles.
Overall, such observations suggest the need for a new update on this topic so as to summarize the continuously increasing amount of data about MBCT for psychiatric disorders as well as to give indications for further research. Note, in fact, that even though a meta-analysis focusing on the efficacy of mindfulness-based interventions, including MBCT and MBSR, for the reduction of anxiety and depressive symptoms has recently been published (Hofmann et al., 2010), that meta-analysis provided only an overall effect size for the combination of the effects of both MBSR and MBCT on depressive and anxiety symptoms. However such meta-analysis did not provide quantitative data about the effects of MBCT over a control condition as well as data about psychological changes and further measures (e.g. changes in the quality of life (QOF)) following MBCT. In addition, little attention has been paid so far to several key issues such as therapist's experience, adherence to practice, differences in prognostic factors at baseline and further issues which could represent undetected biases in mindfulness research (Orme-Johnson, 2008).
Accordingly, the aim of the present work is to review controlled studies focusing on the usefulness of MBCT for psychiatric disorders. In particular, building on the observations stated above, the primary hypotheses of this review are as follows: 1) MBCT in adjunct to usual care could be significantly better than usual care alone for reducing MD relapses in patients with three or more prior depressive episodes and not significantly different from an “active” control group on the same outcome measure, 2) the augmentation of MBCT could be useful for reducing residual depressive symptoms in patients with MD, 3) for reducing depressive and anxiety symptoms in patients with BD with residual symptoms and 4) for reducing anxiety symptoms in patients with anxiety disorders. Additionally, we have explored the relative effects of MBCT over other treatment strategies on further measures including differences in psychological measures, QOF and cost/effectiveness of MBCT.
Section snippets
Literature research
A literature search was independently undertaken by the reviewers using MEDLINE, ISI web of science, the Cochrane database, EMBASE, PsychINFO and references of retrieved articles. The search included papers indexed by web based electronic databases mentioned above published up to July 2010. The search strategy considered only studies published in English. The main search terms were MBCT, “mindfulness meditation” and “mindfulness based cognitive therapy” in combination with the name of each
Search results
The original search identified 286 particles. Two-hundred forty-five articles were excluded because they did not investigate the use of MBCT for patients suffering from psychiatric disorders. After the inclusion and exclusion criteria were applied to the remaining 41 studies, 16 trials, three of which (Williams et al., 2000, Thuile et al., 2009, Hargus et al., 2010) were based on subsamples of early trials (Teasdale et al., 2002, Barnhofer et al., 2009), could be included in the present review
Discussion
The present review and meta-analysis showed many important results. First of all, our findings suggest that the augmentation of MBCT to standard care could result in significantly lower relapse or recurrence rates in patients suffering from MD in comparison with standard care alone. In addition, we observed that MBCT + gradual discontinuation of maintenance ADs was not significantly different from antidepressants’ continuation with respect to the number of relapse rates at 1 year.
Note, however,
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