Outcomes of Online Mindfulness-Based Cognitive Therapy for Patients With Residual Depressive Symptoms: A Randomized Clinical Trial

Abstract

Importance: Patients with residual depressive symptoms face a gap in care because few resources, to date, are available to manage the lingering effects of their illness.

Objective: To evaluate the effectiveness for treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only.

Design, setting, and participants: This randomized clinical trial was conducted in primary care and behavioral health clinics at Kaiser Permanente Colorado, Denver. Adults identified with residual depressive symptoms were recruited between March 2, 2015, and November 30, 2018. Outcomes were assessed for a 15-month period, comprising a 3-month intervention interval and a 12-month follow-up period.

Interventions: Patients were randomized to receive usual depression care (UDC; n = 230) or MMB plus UDC (n = 230), which included 8 sessions delivered online for a 3-month interval plus minimal phone or email coaching support.

Main outcomes and measures: Primary outcomes were reduction in residual depressive symptom severity, assessed using the Patient Health Questionaire-9 (PHQ-9); rates of depressive relapse (PHQ-9 scores ≥15); and rates of remission (PHQ-9 scores <5). Secondary outcomes included depression-free days, anxiety symptoms (General Anxiety Disorder-7 Item Scale), and functional status (12-Item Short Form Survey).

Results: Among 460 randomized participants (mean [SD] age, 48.30 [14.89] years; 346 women [75.6%]), data were analyzed for the intent-to-treat sample, which included 362 participants (78.7%) at 3 months and 330 (71.7%) at 15 months. Participants who received MMB plus UDC had significantly greater reductions in residual depressive symptoms than did those receiving UDC only (mean [SE] PHQ-9 score, 0.95 [0.39], P < .02). A significantly greater proportion of patients achieved remission in the MMB plus UDC group compared with the UDC only group (PHQ-9 score, <5: β [SE], 0.38 [0.14], P = .008), and rates of depressive relapse were significantly lower in the MMB plus UDC group compared with the UDC only group (hazard ratio, 0.61; 95% CI, 0.39-0.95; P < .03). Compared with the UDC only group, the MMB plus UDC group had decreased depression-free days (mean [SD], 281.14 [164.99] days vs 247.54 [158.32] days; difference, -33.60 [154.14] days; t = -2.33; P = .02), decreased anxiety (mean [SE] General Anxiety Disorder-7 Item Scale score, 1.21 [0.42], P = .004), and improved mental functioning (mean [SE] 12-Item Short Form Survey score, -5.10 [1.37], P < .001), but there was no statistically significant difference in physical functioning.

Conclusions and relevance: Use of MMB plus UDC resulted in significant improvement in depression and functional outcomes compared with UDC only. The MMB web-based treatment may offer a scalable approach for the management of residual depressive symptoms.

Trial registration: ClinicalTrials.gov identifier: NCT02190968.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Segal reported being a codeveloper of Mindfulness Based Cognitive Therapy (MBCT) and receiving royalties from Guilford Press for the MBCT treatment manual and patient books; reported presenting keynote addresses at conferences, and MBCT clinical training workshops where he has received a fee, including from the Mind and Life Institute, the Omega Institute, and the University of California San Diego Center for Mindfulness; reported receiving revenue from online MBCT therapist training tools available on mindfulnoggin.com; and reported being a cofounder of Mindful Noggin, Inc, which supports online dissemination of MBCT. Dr Dimidjian reported receiving royalties from Guilford Press for a book based on MBCT for new and expectant mothers; reported presenting at conferences where she received a fee, including from the Mind and Life Institute and Becoming Jackson Whole; reported receiving revenue from online MBCT therapist training tools available on mindfulnoggin.com; and reported being a cofounder of Mindful Noggin, Inc, which supports online dissemination of MBCT. Dr Beck reported receiving grants from the National Institute of Mental Health during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. CONSORT Diagram

MDE indicates major depressive disorder; MMB, mindful mood balance; and PHQ-9, Patient Health Questionnaire -9.

Figure 2.. Differences Between the Mindful Mood Balance (MMB) Plus Usual Depression Care (UDC) Group and the UDC Only Group on Primary and Secondary Measures

The vertical dotted line represents the end of the treatment interval; horizontal black dashed line, Patient Health Questionnaire–9 threshold of 5.