Implementation of Mindfulness-Based Cognitive Therapy into the UK National Health Service

 

Prevalence of depression

- Affects 20% of population at some point in their life.
- More than 50% of those who do recover will have at least one further episode.
- Those with a history of 2 or more episodes have 70-80% chance of recurrence.
- People with early onset depression and who experience depression in old age have a heightened risk of relapse
- In high-income countries, it is predicted to become the number one cause of disease burden by 2030.
- In 1990 it was the fourth most common cause of loss of disability-adjusted life years (DALYs) in the world, and it is projected to become the second most common cause by 2020).
- Suicide accounts for nearly 1% of all deaths and nearly two-thirds of this figure occur in people with depression.
- Social deprivation increases risk of depression.

Background - Mindfulness-based cognitive therapy (MBCT) is a group-based clinical intervention program designed to reduce relapse or recurrence of major depressive disorder (MDD) by means of systematic training in mindfulness meditation combined with cognitive-behavioral methods.

Research - In total nine RCTs of MBCT have been conducted in various countries (UK, Canada, Australia, Belgium, Switzerland, Netherlands). The results of six of these trials (N=593) were gathered into a meta-analysis which aggregated data at the trial level, and suggested that MBCT was associated with a relative risk reduction of 43% for participants with three or more previous episodes (Piet & Hougaard, 2011). A subsequent individual patient data meta-analysis (Kuyken et al., 2016) of nine trials (N=1329) concluded that:

- MBCT is associated with a significant reduction in the risk of depressive relapse/recurrence over 60 weeks compared with usual care (31% risk reduction within trials with no active control; 21% risk reduction within trials with active control; and 23% risk reduction within trials comparing MBCT to anti-depressants);
- MBCT reduces the risk of depressive relapse/recurrence compared with the current mainstay approach, maintenance antidepressants;
- Results are generalizable across sex, age, education, or relationship status;
- The effects are similar across the European and North American countries the trials were conducted in, and across the range of different trial teachers;
- Treatment effect of MBCT on the risk of depressive relapse/recurrence is larger in participants with higher levels of depression symptoms at baseline, suggesting that MBCT may be particularly helpful to those who still have significant depressive symptoms;
- Adverse events were formally recorded in 6 of 9 studies, but none were attributed to MBCT.

An important clinical implication of the emerging evidence base is that MBCT is particularly helpful for those who are most at risk of relapse/recurrence – those with a history of childhood adversity and those who are unstable in their remittance from depression. It seems that depression vulnerability comes not necessarily just from the number of prior episodes but from being highly reactive to small changes in mood.

NICE guidance - MBCT was recommended by the National Institute for Health and Clinical Excellence (NICE) in 2004. IN 2009 the recommendation was updated and given ‘key priority’ status.

‘Of the treatments specifically designed to reduce relapse group-based mindfulness-based cognitive therapy has the strongest evidence base with evidence that it is likely to be effective in people who have experienced three or more depressive episodes’. (NICE 2009).

Uptake of MBCT in the UK health Service is very variable. A small number of areas have well developed MBCT services that are integrated into care pathways for depression. In many areas, it is rarely possible to access MBCT through the NHS and there are no strategic plans to implement.

Our aims: To facilitate the implementation of National Institute for Health and Clinical Excellence (NICE) guidance on Mindfulness-Based Cognitive Therapy (MBCT) for the prevention of recurrent depression across the UK, with a particular focus on Wales.

Our activity:
- Publication of paper based on a UK wide survey identifying MBCT implementation barriers/facilitators (Crane & Kuyken, Published online 22nd June 2012).
- Publication of online resource kit for clinicians to support implementation (http://mindfulnessteachersuk.org.uk/pdf/MBCTImplementationResources.pdf)
- Conference presentations on this theme
- MBCT teacher training programmes: many trainees on our Master’s and continuing professional development programmes work within the NHS. We are working closely with several health trusts across the UK to deliver bespoke MBCT training programmes that are affordable and workable for NHS clinicians.
- Liaison with Betsi Cadwaladwr University Health Board to support the implementation of MBCT in North Wales.
- The ASPIRE research project (Improving the Accessibility of MBCT in the UK NHS) a research programme funded by the National Institute of Health Research led by Prof Jo Rycroft-Malone (Bangor University) with Prof Willem Kuyken (Exeter University), Rebecca Crane (Bangor University), Prof Stewart Mercer, (Glasgow University) which ran from 2014 - 2017. The research aimed to ascertain the current state of MBCT implementation across the UK and develop an Implementation Plan. Its specific aims were to:

o Scope existing provision of MBCT in the health service across England, Northern Ireland, Scotland and Wales.
o Develop an understanding of the perceived benefits and costs of embedding MBCT in mental health services.
o Explore facilitators that have enabled services to deliver MBCT.
o Explore barriers that have prevented MBCT being delivered in services.
o Articulate the critical success factors for the routine and successful use of MBCT as recommended by NICE.
o Synthesise the evidence from these data sources and, in consultation with stakeholders, develop an Implementation Plan that services can use to facilitate the implementation of MBCT.

You can read the report of the research here.

References

Crane, R.S. & Kuyken, W. (2012) The Implementation of Mindfulness-Based Cognitive Therapy: Learning from the UK Health Service Experience, Mindfulness, http://www.springerlink.com/openurl.asp?genre=article&id=doi:10.1007/s12671-012-0121-6

Davidson, R. J. (2016). Mindfulness-based cognitive therapy and the prevention of depressive relapse measures, mechanisms, and mediators. JAMA Psychiatry., doi:10.1001/jamapsychiatry.2016.0135

Kuyken, W., Warren, F. C., Taylor, R. S., Whalley, B., Crane, C., Bondolfi, G., . . . Dalgleish, T. (2016). Efficacy of mindfulness-based cognitive therapy in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials.
JAMA Psychiatry, 73(6), 565-574. doi:doi:10.1001/jamapsychiatry.2016.0076.

Piet, J., & Hougaard, E. (2011). The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review, 31(6), 1032-1040. doi:10.1016/j.cpr.2011.05.002

The NICE Guideline on the Treatment and Management of Depression in Adults, (2010) Guideline 90, commissioned by the National Institute for Health & Clinical Excellence, published by the British Psychological Society and The Royal College of Psychiatrists, National Collaborating Centre for Mental Health, Depression

Rycroft-Malone, J., Anderson, R., Crane, R. S., Gibson, A., Gradinger, F., Owen-Griffiths, H., . . . Kuyken, W. (2014). Accessibility and implementation in UK services of an effective depression relapse prevention program – mindfulness-based cognitive therapy (MBCT): ASPIRE study protocol. Implementation Science, 9(62)

Rycroft-Malone J, Gradinger F, Griffiths HO, Crane R, Gibson A, Mercer S, Kuyken, W (2017) Accessibility and implementation in the UK NHS services of an effective depression relapse prevention programme: learning from mindfulness-based cognitive therapy through a mixed-methods study. Health Serv Deliv Res 5 (14)