بیماران مبتلا به افسردگی مقاوم به درمان یک پاسخ مناسب به درمان شناختی مبتنی بر ذهن آگاهی نشان می دهند

Mindfulness-based Cognitive Therapy (MBCT) is a class-based programme designed for use in the prevention of relapse of major depression. Its aim is to teach participants to disengage from those cognitive processes that may render them vulnerable to future episodes. These same cognitive processes are also known to maintain depression once established, hence a clinical audit was conducted to explore the use of MBCT in patients who were currently actively depressed, and who had not responded fully to standard treatments. The study showed that it was acceptable to these patients and resulted in an improvement in depression scores (pre-post Effect Size=1.04), with a significant proportion of patients returning to normal or near-normal levels of mood.

The emotional, social and economic burden of depression for sufferers, their families and society is significant, with 12 month prevalence rates estimated at 2.9–12.6% and lifetime risk estimated at 17–19% (Kessler et al., 1994). The fact that depression is often a chronic relapsing condition, with relapse rates of 50–80% in those who have been depressed before (Judd, 1997) has contributed to the WHO prediction that, by 2020, depression will be the second biggest contributor to ill-health burden world-wide (Murray & Lopez, 1998). Individual CBT has been shown to be effective at treating acute depression and reducing relapse (DeRubeis et al., 2005; Hollon et al., 2005) but waiting lists for individual therapy are lengthy in most healthcare settings. Even treatment by normally ‘effective’ means leaves a substantial minority failing to meet criteria for remission. In a trial to examine relapse risk in the 12 months following antidepressant versus cognitive treatment, Hollon et al. (2005) found that, of the patients recruited for the first (acute treatment) phase, only 58% of the ADM group and the same proportion of the CT group met predefined criteria for recovery and were able to proceed to the relapse phase of the study. The fact that around 40% did not meet such criteria following an adequate ‘dose’ of treatment show that there is still a great deal to do to help those patients who are often called ‘treatment resistant’. Moreover, depression has another feature that is a considerable cause for concern: the development of a chronic clinical course, which also resists treatment. In these cases, patients report continuing symptoms of depression and accompanying distress about these symptoms. Some 15–39% of cases still meet criteria for Major Depressive Disorder (MDD) 1 year after symptom onset (Berti Ceroni, Neri, & Pezzoli, 1984; Van Valkenburg, Akiskal, Puzantian, & Rosenthal, 1984), and 22% of cases may continue to do so up to 2 years later (Keller, Lavori, Lewis, & Klerman, 1983). Of particular concern is the risk of suicidal behaviour in such patients. One in seven patients hospitalised for major depression die by suicide (Powell, Geddes, Deeks, Goldacre, & Hawton, 2000) and the Population Attributable Ratio (PAR) for depression in serious but non-fatal suicidal behaviour (that proportion of suicidal behaviour that would be removed if depression were taken out of the picture) is 80 per cent (Beautrais et al., 1996). If suicidal ideation occurs during one episode of depression, it tends to recur in later episodes (Williams, Crane, Barnhofer, van der Does & Segal, 2006), making the question of how best to treat recurrent and persistent depression particularly urgent for such at-risk patients. What is it that keeps people depressed? Nolen-Hoeksema's Responses Styles Theory (1991) suggests that people who engage in ‘repetitive and passive thinking about one's symptoms of depression’ tend to prolong the very symptoms they are trying to reduce. Ruminators often hold positive (but erroneous) beliefs that it will help, not realising that they are reducing their capacity to effectively problem-solve (Watkins & Moulds, 2005). Evidence suggests that the cognitive processes that increase vulnerability to future episodes are the same as those that maintain depression. These processes are depressive rumination (Jacobson, Martell & Dimidjian, 2001; Nolen-Hoeksema (1991) and Nolen-Hoeksema (2000); Watkins & Teasdale, 2004) and high cognitive reactivity to mood shifts, where the experience of low mood more easily triggers negative thinking in previously depressed patients (Segal, Gemar, & Williams, 1999; Teasdale, 1999). Mindfulness-based Cognitive Therapy (MBCT) arose out of an investigation into the cognitive processes that render depressed individuals vulnerable to repeated relapse and recurrence (Teasdale, Segal, & Williams, 1995) with a view to offering a programme that would target those cognitive vulnerabilities (Segal, Williams, & Teasdale, 2002). The intervention was designed as a class-based intervention to increase accessibility to effective relapse prevention. It incorporates, as a central component, mindfulness training as developed by Kabat-Zinn and his colleagues at the University of Massachusetts Medical Center (Kabat-Zinn, 1990), and adds components of cognitive behaviour therapy for depression (Beck, Rush, Shaw, & Emery, 1979). Two studies have demonstrated this group programme's efficacy in reducing relapse rates of depression at 12 month follow-up compared to treatment as usual (Ma & Teasdale, 2004; Teasdale et al., 2000). MBCT teaches participants to observe their thoughts and feelings through the repeated practise of intentionally returning attention to a neutral object (e.g. the breath or body sensations) in the present moment. Participants are taught how to cultivate direct experiential awareness, together with an attitude of non-judgmental acceptance, towards whatever is present (including sad mood, which in previously depressed patients is likely to trigger patterns of global negative self-referent thinking). The cultivation of awareness during mindfulness practise enables patients to see more clearly when negative and ruminative responses are being triggered, and allows them to decentre from such patterns of thought, seeing them as mental events, rather than necessarily valid reflections of reality. Unlike standard CBT, where the focus is on changing the content of thoughts, MBCT's focus is on fostering meta-cognitive awareness and the modification of meta-cognitive processes that maintain unhelpful reactive or ruminative mind states. So although MBCT was designed for patients in remission, the above analysis suggests that it might be helpful for symptomatic patients who remain caught in such unhelpful thought processes. The present article describes a clinical audit of a consecutive series of patients referred for MBCT, focussing on those who had continuing symptoms of depression despite treatment with antidepressant medication (ADM) or CBT or both. The two randomised controlled studies conducted on MBCT had shown that those with three or more episodes had a significant reduction in relapse rates but that those with two or less had a non-significant trend towards an increased risk of relapse in the year of follow-up (Ma & Teasdale, 2004; Teasdale et al., 2000). The inclusion criteria for the MBCT programme therefore retained the three-or-more-episodes feature for those who had been recurrently depressed, but was expanded to include patients whose mood disorder was running a chronic course, where it was hypothesised the depression was being maintained by a similar ruminative cognitive style. The audit was conducted to examine the effects of this approach with this group, the acceptability of the class format, and the feasibility of including both recovered and symptomatic patients in the same classes. It was hypothesised that the class format, with a mix of recovered and symptomatic patients, would be acceptable as the meta-cognitive approach taken means there is no need to work with the unique content of each individual's automatic thoughts, whether currently negative in tone or not. There are compelling reasons to wish to check out the possible relevance of MBCT for patients who remain in episode. The developers of MBCT have been very cautious about using MBCT for such patients. ‘It is important to note that MBCT was specifically developed for remitted patients and is unlikely to be effective in the treatment of acute depression, where factors such as difficulty in concentrating and the intensity of negative thinking may preclude acquisition of the attentional control skills central to the programme’ (Teasdale et al., 2000, p. 622). However, since a considerable proportion of the patients in this study had already received CBT, we wished to examine patients’ responses to an approach that might represent a back-up procedure if the currently available empirically supported treatments (ESTs) such as CBT and anti-depressant medication fail. Finally, we were particularly interested in those patients who had suicidal ideation as part of their symptoms of depression. We wished to examine the hypothesis that such patients might respond significantly less well to MBCT. Such patients are known to be highly reactive to depressed mood and to react to small mood shifts with impaired problem solving ( Williams, Barnhofer, Crane, & Beck, 2005), and we were concerned that this pattern might undermine the ability or motivation to practise mindfulness.