This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Cognitive behavioural therapy (CBT) is a well-established talking therapy that helps people re-evaluate the way they think and behave. A self-help version, supported by trained practitioners, is offered by the NHS to many people with depression. However, many people drop out of this therapy.
This study compared CBT with a mindfulness-based therapy (including daily mindfulness practice) combined with CBT. Both approaches were delivered as supported self-help. People in the study were provided with self-help workbooks and had 6 sessions with a trained practitioner.
The randomised study included 410 adults with mild to moderate depression. It found that mindfulness-based self-help reduced the severity of depression more than CBT self-help in the short-term. People in the mindfulness group were less likely to need subsequent psychological therapy. Overall, NHS costs for the mindfulness approach were £500 less per person than for CBT.
The researchers suggest that mindfulness-based cognitive therapy (delivered as self-help supported by a practitioner) could give people with mild to moderate depression another effective treatment choice.
What’s the issue?
More than 1 in 10 people around the world will experience depression during their lifetime. CBT is an effective therapy, delivered as self-help supported by a practitioner. This is the first option recommended by NICE for people with mild to moderate depression. In self-help CBT, people are provided with a self-help book or a self-help online course to work through. People with depression are usually also supported by a trained practitioner.
Compared with face-to-face CBT with a CBT therapist, supported self-help takes less practitioner time and does not require a highly trained CBT therapist. It therefore allows more people to access the treatment. However, many people with depression do not complete the course.
Mindfulness-based cognitive therapy is another approach recommended by NICE for mild to moderate depression. It is delivered via 8 weekly group sessions led by a highly-trained therapist. The therapy encourages people to become aware of their thoughts, sensations and urges in the moment. It helps them to accept without judgement whatever they experience, and to make conscious choices about how best to respond. However, this group therapy is not widely available.
Researchers assessed a self-help version of mindfulness-based cognitive therapy, which is closely aligned to the group version. A self-help workbook provides a week-by-week guide to developing mindfulness skills so that people become better able to notice, accept and respond to their experiences in a way that could free them from depression. In the study, daily mindfulness practice was combined with CBT for depression.
Researchers compared this self-help mindfulness-cognitive therapy with self-help CBT for people with mild to moderate depression. All participants were supported by a trained practitioner.
The study included 410 adults with mild to moderate depression referred to 10 NHS Talking Therapy services in England. Participants’ average age was 32 years. Most (62%) were women (as expected, since more women than men are diagnosed with depression).
The study looked at self-help therapy, supported by a practitioner. Half the participants were randomly assigned to receive mindfulness-cognitive therapy (204 people) while the others (206 people) received CBT alone. All participants received self-help workbooks, which included diaries, worksheets and planning activities. Both groups were offered 6 phone or face-to-face support sessions of 30-45 minutes with a practitioner.
Participants completed a questionnaire on depression severity before their treatment started and again after 16 and then 42 weeks. Similar numbers dropped out of both groups.
The researchers found that:
- after 16 weeks, people in the self-help mindfulness cognitive therapy group had greater reductions in depression symptoms
- after 42 weeks, both groups had similar reductions in depression symptoms
- after 42 weeks, the mindfulness-cognitive therapy was more cost effective than the CBT; health and social care costs (including GP appointments, medication and other therapy sessions) were £500 lower per person on average for people receiving mindfulness-cognitive therapy.
A small number of people in both groups described unhelpful experiences of their treatment. Some felt under pressure to progress through the workbook; others said they were stressed by the face-to-face meetings with a practitioner.
Why is this important?
This study found that mindfulness-cognitive therapy, delivered as self-help supported by a practitioner, is an effective and cost-effective alternative to CBT (delivered in a similar way) for adults with mild to moderate depression. The research demonstrates that this mindfulness-based approach could give people with depression another treatment choice.
Drop-out rates in the study were similarly high (about 30%) in both groups. Future research could investigate the reasons why people stop therapy and how they could be encouraged to continue. More engaging (often digital) versions of CBT, delivered as supported self-help, are increasingly used in the NHS. It would be useful to compare them with a digital version of supported self-help mindfulness-cognitive therapy.
The overall care costs to the NHS and social care services for people allocated to the self-help mindfulness-cognitive therapy were lower than for self-help CBT. In particular, the CBT group received more individual psychological therapy following their treatment in the study. The researchers suggest they may have been left with greater unmet need.
Further research could also explore cost-effective ways of training practitioners to deliver mindfulness-based CBT.
The researchers are exploring how mindfulness cognitive therapy, delivered as supported self-help, could be used in practice. They are working initially with the services that took part in the study. They plan to formally develop and evaluate the implementation of the approach, which will include practitioner training and supervision, monitoring outcomes and acceptability.
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This Alert is based on: Strauss C, and others. Clinical effectiveness and cost-effectiveness of supported mindfulness-based cognitive therapy self-help compared with supported cognitive behavioral therapy self-help for adults experiencing depression. The low-intensity guided help through mindfulness (LIGHTMind) randomized clinical trial. JAMA Psychiatry 2023; 80: 415 – 424.
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Funding: This study was funded by the NIHR Research for Patient Benefit (RfPB) Programme.
Conflicts of Interest: Two authors have received funding from Headspace, the meditation app. See the original paper for full disclosures.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.