Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials

Abstract

Importance: Relapse prevention in recurrent depression is a significant public health problem, and antidepressants are the current first-line treatment approach. Identifying an equally efficacious nonpharmacological intervention would be an important development.

Objective: To conduct a meta-analysis on individual patient data to examine the efficacy of mindfulness-based cognitive therapy (MBCT) compared with usual care and other active treatments, including antidepressants, in treating those with recurrent depression.

Data sources: English-language studies published or accepted for publication in peer-reviewed journals identified from EMBASE, PubMed/Medline, PsycINFO, Web of Science, Scopus, and the Cochrane Controlled Trials Register from the first available year to November 22, 2014. Searches were conducted from November 2010 to November 2014.

Study selection: Randomized trials of manualized MBCT for relapse prevention in recurrent depression in full or partial remission that compared MBCT with at least 1 non-MBCT treatment, including usual care.

Data extraction and synthesis: This was an update to a previous meta-analysis. We screened 2555 new records after removing duplicates. Abstracts were screened for full-text extraction (S.S.) and checked by another researcher (T.D.). There were no disagreements. Of the original 2555 studies, 766 were evaluated against full study inclusion criteria, and we acquired full text for 8. Of these, 4 studies were excluded, and the remaining 4 were combined with the 6 studies identified from the previous meta-analysis, yielding 10 studies for qualitative synthesis. Full patient data were not available for 1 of these studies, resulting in 9 studies with individual patient data, which were included in the quantitative synthesis.

Results: Of the 1258 patients included, the mean (SD) age was 47.1 (11.9) years, and 944 (75.0%) were female. A 2-stage random effects approach showed that patients receiving MBCT had a reduced risk of depressive relapse within a 60-week follow-up period compared with those who did not receive MBCT (hazard ratio, 0.69; 95% CI, 0.58-0.82). Furthermore, comparisons with active treatments suggest a reduced risk of depressive relapse within a 60-week follow-up period (hazard ratio, 0.79; 95% CI, 0.64-0.97). Using a 1-stage approach, sociodemographic (ie, age, sex, education, and relationship status) and psychiatric (ie, age at onset and number of previous episodes of depression) variables showed no statistically significant interaction with MBCT treatment. However, there was some evidence to suggest that a greater severity of depressive symptoms prior to treatment was associated with a larger effect of MBCT compared with other treatments.

Conclusions and relevance: Mindfulness-based cognitive therapy appears efficacious as a treatment for relapse prevention for those with recurrent depression, particularly those with more pronounced residual symptoms. Recommendations are made concerning how future trials can address remaining uncertainties and improve the rigor of the field.

Conflict of interest statement

Conflict of Interest Disclosures: All authors with the exception of Drs Warren (independent statistician) and Schweizer (independent systematic reviewer) were investigators on 1 or more of the original randomized clinical trials that contributed data to the individual patient data and secured grant funding for these trials. Dr Williams founded the Oxford Mindfulness Centre and was its director until 2013. Dr Kuyken is its current director. Dr Speckens is founder and clinical director of the Radboud UMC Centre for Mindfulness and Dr Ma is director of the Centre for Mindfulness, Hong Kong. Dr Crane and Ms Huijbers are affiliated with the Oxford and Radboud University–based mindfulness centers, respectively. Drs Teasdale, Williams, and Segal receive royalties for books on mindfulness-based cognitive therapy that they have coauthored. Drs Williams, Kuyken, Speckens, Ma, and Segal additionally receive payments for training workshops and presentations related to mindfulness-based cognitive therapy. Dr Kuyken donates all such fees to the Oxford Mindfulness Foundation, a charitable trust that supports the work of the Oxford Mindfulness Centre, as does Dr Speckens to the Radboud UMC. Dr Segal is a member of the scientific advisory board for Mindful Noggin, which is part of NogginLabs, a private company specializing in customized web-based learning. Dr Kuyken was an unpaid director of the Mindfulness Network Community Interest Company until 2015. Drs Byng, Kuyken, and Williams gave evidence to the UK Mindfulness All Party Parliamentary Group. No other disclosures were reported.

Figures

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-analyses Flow Diagram From Record Identification to Study Inclusion

Figure 2. Random EffectsMeta-analyses Comparing Mindfulness-Based Cognitive Therapy (MBCT) With Other Variables

Forest plot of 2-stage meta-analysis of aggregate data on hazard ratio scale comparing (A) risk of relapse of depression in participants receiving MBCT with participants not receiving MBCT; (B) risk of relapse of depression in participants receiving MBCT with participants receiving an alternative active therapy; and (C) risk of relapse of depression in participants receiving MBCT with participants receiving antidepressant medication. Weights are from random effects analyses.

Figure 3. Interactive Effect Between Mindfulness-Based Cognitive Therapy (MBCT) Status and Baseline Depression With Regard to the Relative Hazard of Depressive Relapse

Predictive margins for the relative hazard of depressive relapse comparing participants receiving MBCT with those not receiving MBCT at baseline depressionz scores, derived from a model including MBCT status, baseline depression z score, the interaction between MBCT status and baseline depression z score, baseline mindfulnessz score, age at onset of depression, and number of past episodes of depression (5 or more/4 or fewer).