Mindfulness-Based Cognitive Therapy

Question:

"I have been hearing a lot about mindfulness, meditation, and cognitive therapy being combined to help prevent relapses in depression. Tell me more about it."

Rakesh Jain, MD, MPH:
There is currently a virtual explosion in the knowledge base regarding this topic. Cognitive-behavioral therapy (CBT) is by now an established and efficacious intervention for many different psychiatric conditions. In the last decade a modified version of CBT—modified to include elements of meditation derived from ancient Eastern practices—has been studied and now vividly demonstrates to be effective in depression. This hybrid form of therapy is called mindfulness-based cognitive therapy (MBCT), and I for one am entirely sold on it.

Let me layout a scientific and clinical case for why all of us, regardless of our practice setting, should be aware of this new manual and experiential-based therapy, and offer it to our patients.

First, let’s examine the shortcomings in our current depression armamentarium. Pharmacological treatment of depression is indeed making great progress. However, let’s be truthful with each other, shall we — the rates of response, remission, and relapse (the curse of the three Rs as I call it) — remain scandalously high. If the truth be told, the Emperor is indeed naked, or at best, is partly clothed. An issue facing American psychiatry, and for that matter global psychiatry, is that we are overly reliant on medications as a path of salvation for our patients. CBT, physical exercise, and improved socialization are all proven non-pharmacological treatments in depression.

Before we take a look at MBCT techniques, let’s examine the neurobiological signature of medication. Considerable and replicated evidence shows that people who meditate on a regular basis are volumetrically different than non-meditators. This includes increased volumes of hippocampus even with as little as an 8-week course of meditation-based stress reduction, ¹  to decreased volume of amygdala also after an 8-week similar course of practice. ²  But there is more, studies demonstrate that meditation also has a positive effect on the autonomic and inflammatory systems ³ —both as you well know, are deeply dysregulated in individuals suffering from major depression. Additionally, evidence points to meditation practice as being helpful in pain modulation, ⁴  this presumably occurring as a result of the activation of the pain inhibitory parts of our brains (the cingulate and the insular cortex).

How exactly does MBCT work? Some work has been done to examine the pathways by which this happens. MBCT may “turn down” an individual’s cognitive reactivity, ⁵  a well known cause of both depression and its relapse. If practiced regularly, MBCT can break the cycle of depressive thinking.

Research and clinical evidence for MBCT’s effectiveness is ever growing. We now have evidence for its effectiveness in generalized anxiety disorder, ⁶  panic disorder, ⁷  treatment-resistant depression, ⁸  and, most recently, in prevention of relapse in major depression after stabilization with medications and then discontinuation. ⁹

This last study, published by Segal and colleagues, is truly impressive as MBCT was shown to be as effective in relapse prevention as continuation of pharmacotherapy. They have also published a manual for us clinicians:  Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse . I would encourage you to buy it, like I have, should you have an active interest in offering MBCT to your patients. Remember, MBCT can be offered to patients both on medication and not on them. Additionally, there is a patient, self-guided MBCT book also written by this same group that I have been recommending to my patients:  The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness . A big plus of this second book is that it includes an audio CD that patients can use for meditation practice.

Want to know more about MBCT, and perhaps pick up a few practical tips on how to actually conduct the group/individual classes? Come to this year’s  24th Annual U.S. Psychiatric and Mental Health Congress  in Las Vegas on November 7-10. You will get a lot more information on MBCT. In fact, Steven D. Hickman, PsyD, director of the MBCT program from the University of California at San Diego, is presenting two separate sessions on meditation and MBCT for the treatment of both anxiety and mood disorders. There will be didactic and practical, experiential meditation sessions each day too. Do come to find out more and learn how to apply this information in your own practice! I certainly will be attending his sessions.

Ancient mindful meditation wisdom when married to Western cognitive therapy principles produces a powerful new treatment modality called MBCT. I believe it’s time for all of us to learn more about it, and apply it in our practices!

—Rakesh Jain, MD, MPH