This is the 6^th in a series of blog posts about the recent day seminar introducing a Scottish draft guideline for "Non-pharmacological management of depression."  In my last post I discussed Gary Morrison's initial presentation of the day's second session on "Effectiveness of Psychological Therapies in Depression 1".  Gary talked about the evidence for CBT and related interventions (BA, CAT, CBASP).  The second presentation of this session was by Neil Rothwell, a Consultant Clinical Psychologist from Falkirk and District Royal Infirmary.  Neil discussed "Mindfulness and Problem Solving".  SIGN proposes a Grade A recommendation that "Mindfulness based cognitive therapy is recommended as a treatment option to reduce relapse in patients with depression who have had three or more episodes."  Mindfulness as a therapeutic approach is a very interesting phenomenon.  It reminds me of a pharmacology lecture I went to as a university student.  The lecturer joked that when new medications are introduced there is a predictable sequence of responses from the public and health professionals.  First there tends to be scepticism, then a surge of enthusiasm with the medication being used both for appropriate and inappropriate indications, then a backlash as side-effects and limitations become more apparent, and finally (hopefully) a mature stage where the new medication is seen in context with an understanding of when it is the best treatment available for certain specific conditions, when it is inappropriate, and when it can have potentially damaging side effects.  A recent article in the New York Times (Carey 2008) did a very good job of overviewing the excitement and some of the silliness around mindfulness's recent therapeutic history.  As the author, Benedict Carey, wrote "At workshops and conferences across the country, students, counselors and psychologists in private practice throng lectures on mindfulness. The National Institutes of Health is financing more than 50 studies testing mindfulness techniques, up from 3 in 2000, to help relieve stress, soothe addictive cravings, improve attention, lift despair and reduce hot flashes.  Some proponents say Buddha's arrival in psychotherapy signals a broader opening in the culture at large - a way to access deeper healing, a hidden path revealed.  Yet so far, the evidence that mindfulness meditation helps relieve psychiatric symptoms is thin, and in some cases, it may make people worse, some studies suggest. Many researchers now worry that the enthusiasm for Buddhist practice will run so far ahead of the science that this promising psychological tool could turn into another fad." 

Happily some of the best evidence is for Mindfulness Based Cognitive Therapy (MBCT) in reducing speed of relapse for people who have recovered from their third (or subsequent episode of major depression) (Teasdale, Segal et al. 2000; Ma and Teasdale 2004).  There is some evidence that for people who have had only one or two episodes of depression, learning MBCT may actually make them more likely to relapse - possibly an approach such as active problem solving would be more appropriate in this group.  This caution that mindfulness based techniques might be applicable for those with recurrent depressive problems, but be less effective than alternative approaches for those without this kind of psychological history, is replicated in a recent study comparing standard CBT with a mindfulness based approach in trying to improve quality of live (including depressive symptoms) in rheumatoid arthritis sufferers (Zautra, Davis et al. 2008).  Ma and Teasdale themselves sounded this note of caution about possible limited applicability in depression when they wrote "MBCT was most effective in preventing relapses not preceded by life events. Relapses were more often associated with significant life events in the 2-episode group. This group also reported less childhood adversity and later first depression onset than the 3-or-more-episode group, suggesting that these groups represented distinct populations."  Interestingly a recent systematic review on the effects of the related approach, Mindfulness Based Stress Reduction (MBSR), on anxiety and depression (Toneatto and Nguyen 2007), examined 15 relevant research studies and concluded "MBSR does not have a reliable effect on depression and anxiety."  I happen to believe that careful research, clarifying possible benefits produced by mindfulness based therapies, is an exciting and welcome development.  Research in these areas has often not been of the highest standard (Ost 2008).  Caution is crucial.  As has been said many times before "It's important to keep an open mind, but not so open that one's brains fall out."  For a more general discussion of MBCT and how it may overlap with approaches such as relaxation therapies, imagery, and hypnosis, see a paper I wrote a couple of years ago (Hawkins 2006).

Neil continued his presentation to say that SIGN gave a grade B recommendation that "Problem solving therapy may be considered as a treatment option for patients aged over 50 with depression."  The evidence given for this recommendation is the Cuijpers et al meta-analysis (Cuijpers, van Straten et al. 2007).  Surprisingly no mention is made of the more general Malouff et al meta-analysis, with its sub-analysis on depression symptoms (Malouff, Thorsteinsson et al. 2007).  The Simon et al paper using problem solving therapy (PST) for adult diabetic sufferers with comorbid depression may have been just too recent to have been included in the SIGN literature scan (Simon, Katon et al. 2007).  The report from National Space Biomedical Research Institute (see NSBRI link below) that problem solving is being used as the basis for a computerized self-help programme to help astronauts suffering from depression on long haul space flights is certainly too recent!  I'm concerned that SIGN's current statement about PST makes the approach sound as though it is specifically geared for older populations - for example like Reminiscence Therapy.  This is clearly not the case.  The data may well be stronger, at the moment, for its use in older adults.  I think though that SIGN's recommendation would benefit if it pointed out that there is some evidence (and continuing research) for benefits using PST in younger adult depression sufferers.

Carey, B. (2008). Lotus Therapy. New York Times, New York Times Company.  [Free Full Text]
Cuijpers, P., A. van Straten, et al. (2007). "Problem solving therapies for depression: a meta-analysis." Eur Psychiatry 22(1): 9-15.  [PubMed] 
Hawkins, J. (2006). "Alternative treatments for depression 3: diet, acupuncture & mindfulness training." Journal of Holistic Healthcare 3(4): 32-39.  [Free Full Text]
Ma, S. H. and J. D. Teasdale (2004). "Mindfulness-Based Cognitive Therapy for Depression: Replication and Exploration of Differential Relapse Prevention Effects." Journal of Consulting and Clinical Psychology 72(1): 31-40.  [PubMed] 
Malouff, J. M., E. B. Thorsteinsson, et al. (2007). "The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis." Clinical Psychology Review 27(1): 46-57.  [Abstract/Full Text] 
NSBRI report (2008) "Coming soon: Self-guided, computer-based depression treatment" http://www.physorg.com/news141480157.html  Accessed September 25.
Ost, L.-G. (2008). "Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis." Behaviour Research and Therapy 46(3): 296-321.  [Abstract/Full Text]
Simon, G. E., W. J. Katon, et al. (2007). "Cost-effectiveness of systematic depression treatment among people with diabetes mellitus." Arch Gen Psychiatry 64(1): 65-72.  [PubMed]
Teasdale, J. D., Z. V. Segal, et al. (2000). "Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy." J Consult Clin Psychol 68(4): 615-23.  [PubMed]
Toneatto, T. and L. Nguyen (2007). "Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research." Can J Psychiatry 52(4): 260-6.  [PubMed]
Zautra, A. J., M. C. Davis, et al. (2008). "Comparison of cognitive behavioral and mindfulness meditation interventions on adaptation to rheumatoid arthritis for patients with and without history of recurrent depression." J Consult Clin Psychol 76(3): 408-21.  [PubMed]