The students in my Atypical Development class were quick to insist that some “chemical imbalance” must be at the heart of every mental illness, and that we could not define “psychological disorder” without it. I can easily imagine the vehement objections that will be raised when I point out that a sizable number of people still believe that mental health is a matter of will (You’re anxious? Stop worrying so much! You’re depressed? Snap out of it!). And so I must start preparing now, weeks in advance of getting to different styles of therapy, to broach the tricky but true proposition of the middle ground: That “chemical imbalance” is an oversimplification, there are ways to adjust brain chemistry other than medication, and that people may indeed be able to change the way they think to avoid falling into depression or other mental ills.
While I would never suggest that someone currently experiencing severe depression try to just “snap out of it”, or to find a way out on their own, there are several interesting studies about the benefits of mindfulness for helping people remain healthy after overcoming episodes of clinical depression. Depression may not be so much a temporary condition that can be cured as it is a chronic illness, and helping people mindfully change their thinking can help them manage it.
One early study, published by Teasdale and colleagues in 2000, found that a mindfulness training program was more effective than just “treatment as usual” in preventing relapses into depression. The program they designed combined key aspects of Mindfulness Based Stress Reduction with Cognitive Behavioral Therapy, so it was naturally called Mindfulness Based Cognitive Therapy (MBCT). In Teasdale’s view, traditional cognitive behavioral therapy tries to change what your thoughts are, while MBCT would try to change “awareness of and relationship to thoughts” (p.616). The goal is that patients will learn to recognize that they are having negative thoughts, remember that ruminating on these thoughts will lead to depression, and use mindfulness to stop ruminating by shifting thought to something else in the here-and-now.
To test MBCT, Teasdale and colleagues recruited 145 patients from Wales, England, and Canada, about half of whom took an MBCT course for 8 weeks, meeting once a week for 2 hours to learn about mindfulness, practice recognizing negative thought patterns, and create strategies they would follow if they recognized they were sliding into depression. The other half of the patients continued “treatment as usual” under the guidance of their primary doctor. Ten weeks after the mindfulness program ended, only 8% of the MBCT trainees were again depressed – but 28% of those only getting treatment as usual were. By the time a full year had passed, only 40% of MBCT trainees had relapsed into depression, significantly fewer than the 66% of those receiving treatment as usual, even though both groups reported equal rates of seeking help from their doctor, participating in counseling, or using medication.
Later research showed that MBCT didn’t just enhance “treatment as usual” in preventing relapses; it’s just as good as medication. Even after a patient is no longer depressed, their doctor may prescribe “maintenance” antidepressants for up to 2 years, to prevent the depression from coming back. But antidepressants have side effects, they’re expensive, and people aren’t great about following doctor’s orders. So Kyuken and colleagues (including Teasdale, now a senior author) tested whether MBCT would be a good alternative to maintenance medication, with a new set of 123 recruits who were in remission from depression but still on medication. Half of them participated in the MBCT program, and about four weeks in were encouraged to start tapering their medication under their doctor’s supervision – and 75% were off their meds in six months. Even though they were no longer on medication, though, they were no more likely to relapse into depression a year after the MBCT training ended (47% relapsing, versus 60% of those on maintenance medication), with the same severity of symptoms and distress and fewer “residual” symptoms.
That study may even have underestimated the advantages of mindfulness compared to maintenance medication. The researchers went the extra mile to ensure that those on maintenance medication were actually taking their medication, checking up every three months and working with physicians and patients if there were any problems, so medication might not be as effective in the real-world where people might not be able to stick to their medication as prescribed. The researchers also considered cost, and decided that MBCT was about as expensive as medication – under the socialized UK health care system. For people in the states who struggle with health insurance, an 8 week course of MBCT might be considerably cheaper than two years of antidepressants.
At this stage of research, no one can say for sure what it is about the mindfulness training that helps prevent relapses into depression, or how it works. We can’t even recommend it for everyone who is recovering from depression, because the patients in these studies were volunteers who were willing to go off their medication, participate in group therapy, and had time to commit to the MBCT program – which prevented a full third of the patients researchers contacted from signing up. We certainly don’t know what was different for the 53% of MBCT trainees who made it to 15 months without relapsing, compared to the 47% who didn’t. But I will be presenting these studies to my students as evidence that even if genetics and “chemical imbalances” are a root cause of depression, that doesn’t mean medication is the only solution, or even the best one. We have so much more to learn about neuroplasticity and how the way we think can change our brains, and perhaps in the future we’ll see that mindfulness can keep our brains in balance.
Teasdale, J.D., et al. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 616-623 DOI: 10.1037//0022-006X.68.4.615
Kuyken, W., et al. (2008). Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology, 76, 966-978 DOI: 10.1037/a0013786