While depression is often treated with anti-depressant medication, there is good evidence that cognitive therapies are also effective. These are 'talking therapies' which aim to help people with depression to minimise the impact of negative thoughts and develop strategies for coping with difficult feelings or situations.
There are a range of these therapies, but this Highlight looks at new evidence relating to two types: cognitive behavioural therapy (CBT) and mindfulness-based cognitive therapy (MBCT). The NHS Increasing Access to Psychological Therapies programme has improved access to these therapies, although availability is still variable and there are waiting lists in some areas.
Published: May 2016
The findings boiled down, alongside practical questions for healthcare professionals and patients.
For patients with mild to moderate depression, could help be a few mouse clicks away?
1 in 5
people affected by depression at some point during their lifetime.
the cost to health services from depression per year in the UK.
recurrence rate for people who have experienced several periods of depression.
Three recent NIHR studies have provided useful new evidence on particular aspects of talking therapies for depression. This Highlight considers some of the key points arising from the studies, but it is not a complete review of all the evidence in this area (see About the research for more information).
What does this new evidence tell us about when, and for whom, cognitive therapies may be effective?
Computerised cognitive behavioural therapy
- Two types of computerised cognitive behavioural therapy (CBT), delivered in primary care, did not appear to be more effective than usual care alone in reducing depression.
- This form of CBT was accessed by patients on computers at home, with the offer of regular technical support by telephone but no direct contact with a therapist. Most patients did not complete the course.
- There is some existing evidence from small-scale studies that computerised CBT might be more effective if accompanied by support from trained practitioners. The NIHR has funded a study to explore this further.
Combining CBT and anti-depressants
- Face to face CBT, used in conjunction with anti-depressant medication, appeared to be effective for people whose depression had not responded to medication alone.
- Patients who received both CBT and anti-depressants were more likely to have improved depressive symptoms and better quality of life, up to four years later, compared to people who just took anti-depressants.
Mindfulness-based cognitive therapy
- Mindfulness-based cognitive therapy (MBCT) may provide an alternative for people with recurrent depression, especially those who have difficulty in adhering to maintenance anti-depressant medication.
- Patients who participated in MBCT, instead of anti-depressants, had similar relapse rates to those who continued with anti-depressants alone.
- There are some early indications that MBCT may be particularly effective for people who have experienced severe childhood abuse, and whose depression may therefore be especially difficult to treat. This area requires more research.
Does the research tell us anything about cost-effectiveness?
- CBT and anti-depressants together were likely to be cost-effective for people with depression who have not responded to anti-depressants alone.
- MBCT was no more cost-effective than anti-depressants. However, costs were similar for patients receiving MBCT and those receiving anti-depressants, as were outcomes, so from a cost perspective MBCT may be a reasonable alternative.
What do patients think about these types of cognitive therapy?
- Interviews with participants in some of the studies suggest that many people find cognitive therapies useful, and in some cases were glad to have an alternative to anti-depressants.
- Patients had mixed feelings about computerised CBT accessed at home without contact with a therapist. It was convenient for some but others found it hard to maintain their motivation (which is a particular problem for people with depression).
- Both MBCT and CBT are intensive processes requiring significant commitment of time and effort. This will not suit everyone, and interviews with study participants suggest that those with other health conditions found it particularly difficult. MBCT is typically delivered in a group setting which, again, may not suit everyone.
- There is currently no clear evidence about which patients might be more or less likely to benefit from cognitive therapies, so all patients should be considered for these therapies. It is important that patients know about all the different treatment options and what they involve before making a decision.
Key questions for GPs and other healthcare professionals
- Are you aware of the range of cognitive therapies on offer in your area for patients with depression?
- How many of your patients with depression have been offered some sort of talking therapy? Does this include patients for whom anti-depressants have not been effective?
- Are patients able to access a range of options (such as group, individual, face to face, online therapies), according to the stage and severity of their depression, their preferences and other circumstances?
- Do you know about newer therapies, such as MBCT, what they involve and for whom they might be suitable?
- What factors do you consider when assessing whether a patient might benefit from computerised CBT? Do you encourage patients to feed back to you if they are struggling to complete a computerised CBT package?
Key questions for patients
- Do you know about the different cognitive therapies that are available in your area?
- Has your GP explained which ones might be most suitable for you?
- Are you aware of what the therapy involves – for example, if it is delivered in a group or individually, or from your computer at home; and the time commitment required?
Current NICE guidance recommends a ‘stepped’ approach to depression care, with patients first being offered lower intensity treatments before progressing to higher intensity, face to face treatments and/or medication, if their symptoms do not improve. Computerised or online CBT is offered by a number of providers, and involves completing a series of modules usually from a home computer with varying degrees of support but usually minimal or no direct contact with a therapist.
As demand for CBT currently outstrips availability, computerised CBT offers a promising alternative that could make this therapy more easily accessible. To date, evidence suggests that computerised CBT may be effective in depression, but findings vary and many studies have been carried out by the companies that produce CBT packages.
A new NIHR study, called REEACT, evaluated the effectiveness of two commonly used computerised CBT packages for people with depression, compared to usual GP care.
After four months, participants receiving computerised CBT showed no additional improvement in depression compared to those receiving usual care from their GP. Outcomes were no better for a pay-to-use commercial service (Beating the Blues) than for a free one (MoodGYM). With either package, participants had access to telephone support from a non-specialist, mainly to deal with technical issues.
The REEACT study was the first large, randomised trial to look at the effectiveness of computerised CBT in a primary care setting – which is the way it would normally be delivered in usual NHS practice. It involved almost 700 participants from 100 GP practices.
Although the findings in the REEACT study were less encouraging than previous research, it’s important to note that the majority of participants did not complete the course of CBT, with fewer than one in five finishing all the sessions. The most common number of sessions completed was just one or two (out of either six or eight, depending on the package used). This means that it is not possible to tell whether people might have benefited from the CBT, had they completed the course. In addition, the study looked at two CBT packages, but other packages are available which could offer different results.
Interviews with participants found that people had differing views about the course, with some appreciating the flexibility of a home-based programme, whilst others found it difficult to maintain motivation without support. There was no obvious pattern to determine which types of patient (for example, male or female) would favour computerised CBT or do well with it.
This study does not overturn previous findings that showed computerised CBT to be effective, but it does indicate that many people with depression may be unlikely to complete a course of computerised CBT if it is provided with only technical support and no input from a therapist.
The NIHR has funded a second, related study, REEACT2, to explore the effect of adding telephone facilitation to computerised CBT, in the form of a weekly call from a trained practitioner to discuss progress and undertake exercises. This study hasn’t published yet, but it will provide useful evidence about whether adding this type of support improves adherence to and outcomes from computerised CBT. See About this research for a link to the project
An NIHR study has found that individual, face to face cognitive behavioural therapy (CBT) used alongside anti-depressant medication, was effective for people with depression who had not responded to treatment with antidepressants alone.
There is already evidence suggesting CBT is effective for depression that hadn’t been treated before and for people with chronic depression. But this is first large scale trial to evaluate whether using CBT in combinationwith anti-depressants might be more effective than continuing anti-depressants alone, for people who had not responded to initial treatment.
Antidepressant medication is commonly prescribed to people who report moderate symptoms of depression. However a recent study found that only one third of patients responded fully to this form of treatment, and half did not experience a significant decrease in their symptoms. When people do not get better after receiving the standard medication for an adequate period of time, this is known as treatment-resistant depression. There is little evidence that approaches such as increasing the dose of medication or switching to an alternative drug are effective.
The study was a randomised trial with nearly 500 participants from 73 GP practices. One group of patients was offered usual care that included continuing on their anti-depressant medication, while a second group received a course of 12-18 sessions of individual, face-to-face CBT in addition to medication. After six months, 46% of people who had received the CBT reported that their symptoms had reduced by at least a half, compared to just under 22% of people in the group receiving medication only.
People who had received CBT also reported greater improvements in their quality of life. Benefits were still evident up to four years after the treatment. While there was an additional cost associated with delivering the CBT, this was still found to be cost-effective when compared to the gain in health experienced by participants.
The researchers interviewed a number of the participants about their experiences of CBT. Most participants felt the therapy had been helpful, even those who had not completed the course. However many also reported that the therapy was challenging, often because of practical difficulties in attending sessions or because of problems with the homework element. Patients with other health conditions seemed to find it particularly challenging.
These findings are in line with NICE guidance, which suggests offering a combination of high-intensity psychological therapy and drug treatment together for people with moderate to severe depression, particularly those who have not responded to other treatments.
More than half of people who experience depression once will go on to have at least one more episode. For people who have experienced several periods of depression, recurrence rates can be as high as 80%, even if an individual episode was treated successfully.
A new NIHR study has found that mindfulness-based cognitive therapy (MBCT) may be a viable alternative to anti-depressants in preventing depression relapse. MBCT is a type of cognitive therapy that uses mindfulness techniques in addition to CBT techniques to help avoid negative thought patterns. There is already good quality evidence to suggest that MBCT is more effective than usual care in preventing relapse, but to date there had been no large trials to test whether MBCT could work better than anti-depressants.
At present, the National Institute for Health and Care Excellence (NICE) recommends that people with a history of recurrent depression should take maintenance anti-depressant medication for up to two years. This medication can have side effects and some people find they are unable to keep taking it for the recommended length of time, or would like an alternative to medication.
The NIHR trial recruited over 400 people, then randomly allocated them to one group who continued with their normal maintenance anti-depressants, or another group who tapered off their medication and received a course of MBCT. After two years, there was no evidence of a difference in rates of depression relapse between the two groups: 44% of the MBCT group had experienced a relapse compared to 47% of the medication group. There was little difference in other outcomes, such as number of depression-free days and quality of life.
The study also found some indication that MBCT may have been particularly effective for people who had experienced more severe childhood abuse. There is evidence that a history of childhood abuse is linked to poorer outcomes for people with depression, so an alternative form of therapy could be very useful. However this analysis was based on a small sub-group of patients and would need more research to confirm it.
This study compared MBCT with anti-depressants, but not with a group who received no treatment, soit is difficult to draw firm conclusions about the overall effectiveness of MBCT. However, there is good evidence that maintenance anti-depressant medication can reduce the chances of a relapse compared with no medication or other intervention. The results suggest that MBCT is likely to have similar benefits, so although MBCT wasn’t significantly better than medication, it could be an option for some people who would prefer not to stay on anti-depressants.
The cost of MBCT was found to be similar to that of anti-depressant medication over the two-year period studied. When other costs – such as productivity losses – were calculated, these were also similar for the two therapies. Cost-effectiveness was no better for MBCT than for anti-depressant treatment, but since costs and outcomes were similar, it appears to provide a reasonable alternative from a cost perspective.
The NIHR is funding an ongoing study to explore why provision of MBCT services remains uneven in some areas, and how it could be improved.
What is the research that this Highlight is based on?
This Highlight is based on findings from the following four NIHR-funded studies:
- Littlewood E, Duarte A, Hewitt C, Knowles S, Palmer S, Walker S, et al. A randomised controlled trial of computerised cognitive behaviour therapy for the treatment of depression in primary care: the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Health Technol Assess 2015;19(101)
- Wiles N, Thomas L, Abel A, Barnes M, Carroll F, Ridgway N, et al. Clinical effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: the CoBalT randomised controlled trial. Health Technol Assess 2014;18(31)
- Wiles, Nicola J et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. The Lancet Psychiatry 2016.
- Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, et al. The effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse/recurrence: results of a randomised controlled trial (the PREVENT study). Health Technol Assess 2015;19(73)
We selected these studies because they are relatively recent, high quality and fall within the specific area of cognitive therapies for depression. There are two further studies underway which are highly relevant to the issues discussed here, and which publish later in 2016:
- HTA 06/43/504: The second randomised evaluation of the effectiveness and acceptability of computerised therapy trial (REEACT-2) Does the provision of telephone support enhance the effectiveness of computer-delivered Cognitive Behaviour Therapy? Chief Investigator: Simon Gilbody
- HS&DR 12/64/187: Accessibility and implementation in UK services of an effective depression relapse prevention programme: mindfulness based cognitive therapy. Chief Investigator: Jo Rycroft-Malone (You can read a blog about this project here).
The NIHR is also funding research on another talking therapy, called behavioural activation, and these studies will publish during 2016:
- HTA 10/50/14: COBRA (Cost and Outcome of BehaviouRal Activation): a Randomised Controlled Trial of Behavioural Activation versus Cognitive Behaviour Therapy for Depression
- HTA 08/19/04: Collaborative care and active surveillance for screen-positive elders with sub-clinical depression: a pilot study and definitive and randomised evaluation - the CASPER trial. Chief Investigator: Simon Gilbody
- HTA 10/57/43: The CASPER-PLUS Trial: Collaborative care for screen-positive elders with Major Depressive Disorder. Chief Investigator: Simon Gilbody
There are other NIHR studies that have some relevance to the topic – you can find out more at nihr.ac.uk
How strong is the research evidence in this area?
There is already good evidence to support the use of cognitive behavioural therapy for depression. Previous studies have found CBT more effective than no treatment, more effective than some alternatives, and about the same as medication for chronic depression.
There is also existing evidence that mindfulness-based cognitive therapy is more effective than usual care alone in preventing depression relapse, although this seems to be the case mainly for people who have experienced three or more previous episodes of depression.
This Highlight is not a systematic review and does not aim to pull together all the relevant evidence on depression or on cognitive therapies, but rather to focus on a small group of interesting new studies. All the studies discussed in this Highlight are randomised controlled trials (RCTs), with between 400 and 700 participants. Although they are single studies – rather than reviews of a number of studies – they can be considered good quality evidence. Each study provides evidence on a specific aspect of depression care that was previously missing, or weak.
How does this fit with current guidance?
NICE has published detailed guidance on the management of depression, which includes advice on when cognitive therapies may be most appropriate. The studies covered in this Highlight in some cases support NICE guidance, and in others provide additional useful context or clarification:
- NICE guidance states that ‘low intensity’ psychosocial treatments – such as computerised CBT – should be offered to people with mild to moderate depression, with limited facilitation from a trained practitioner. The study discussed here suggests that people with depression may have difficulty completing a course of computerised CBT if it is delivered without support from a trained practitioner.
- NICE guidance recommends the use of CBT in combination with anti-depressants for people with moderate or severe depression, or who have not responded to previous treatment. The evidence reported here supports this.
- NICE guidance recommends the use of MBCT for people who are currently well, but have experienced three or more previous episodes of depression, and are considered to be at risk of relapse. The evidence reported here supports use of MBCT as an alternative to anti-depressants in these circumstances.
Disclaimer: This report by the NIHR Dissemination Centre presents a synthesis of independent research. The views and opinions expressed by the authors of this publication are those of the authors and do not necessarily reflect those of the NHS or the Department of Health. Where blogs, sound recordings and verbatim quotations are included in this publication the views and opinions expressed are those of the named individuals and do not necessarily reflect those of the authors, the NHS, the NIHR or the Department of Health.
Finn from Bristol experienced severe depression in his early twenties. He was prescribed various antidepressant medications and undertook cognitive behavioural therapy (CBT), but it was only when he was introduced to mindfulness-based cognitive therapy (MBCT) that Finn’s depression really started to shift. Now, he says “Instead of depression setting the agenda in my life, I’m free to follow my aspirations without fear.”
When Finn first visited his GP for his depression after graduating from university, talking therapies were less available than they are today. “I was given one SSRI [selective serotonin uptake inhibitor], and when that didn’t work, another. Then when that one also didn’t do anything, I was prescribed a combination. I ended up on a massive cocktail of drugs that never touched the surface. All it did was give me unwanted side-effects.”
He had already been introduced to CBT as a teenager when seeing a counsellor in NHS mental health services and decided to organise individual CBT privately in his early twenties. “I certainly found benefits from CBT, like the ability to recognise unhelpful thought patterns and especially the behavioural component - keeping active, not isolating yourself and planning small achievable tasks. But overall it really didn’t make a proper difference to my mood. I even remember the therapist saying after six weeks that CBT probably wasn’t for me.”
Finn came across mindfulness in a book, The Mindful way through depression and very quickly recognised himself in the text. “I’d read a few books on depression before, but this was the first time I could genuinely imagine using the techniques presented to deal with the underlying cognitive causes of my low mood, like rumination and self-judgment.”
Finn then booked on to an 8-week MBCT group course privately, mainly because this wasn’t available through NHS services at the time. “I really liked the group element of it, being in it together. Hearing people talk about their challenges in doing the various meditation exercises really helped to keep motivated too, because I realised I wasn’t alone and that although meditating is inherently difficult, it gets easier with practice.
“I saw benefits immediately as well, a sense of distance from the thoughts and emotions that had always pulled me in so much before. I realised it was changing the relationship with thoughts that was the answer for me, rather than constantly trying to change the thoughts themselves, like in CBT”.
Since then, Finn has continued his mindfulness practice beyond the MBCT group and made a daily personal routine. “I’ve found it’s really important to keep up the practice during the good times, where actually you can lay a lot of the groundwork for getting through harder times more easily. It’s easy to think ‘I’m better now, so I don’t need to keep up with mindfulness.’ But that’s when you can really make it count. It’s just like how keeping fit when you’re well will help you get over a virus quicker because you’ll be physically healthy.”
About the author: Patient
Earlier this year, we announced the top ten research priorities for depression, as agreed by those affected by the condition.
Compiled and ranked from a survey that reached over 3,000 participants generating nearly 10,000 questions, these provide guidance to researchers on the issues that could make the greatest impact for people living with or affected by depression.
Depression Top 10
- What are the most effective ways to prevent occurrence and recurrence of depression?
- What are the best early interventions (treatments and therapies) for depression? And how early should they be used in order to result in the best patient outcomes?
- What are the best ways to train healthcare professionals to recognise and understand depression?
- What is the impact on a child of having a parent with depression and can a parent prevent their child from also developing depression?
- What are the best ways to inform people with depression about treatment options and their effectiveness in order to empower them and help them self-manage?
- What are the barriers and enablers for people accessing care/treatment when they are depressed, including when feeling suicidal, and how can these be addressed?
- Does depression impact employment? How can discrimination and stigma of depression in the workplace be overcome, and how can employers and colleagues be informed about depression?
- What are the best ways to help friends and family members to support people with depression?
- Are educational programmes on depression effective in schools for reducing stigma?
- What is the impact of wait times for services for people with depression?
Depression is one of the most common mental health conditions, affecting one in 10 adults each year in the UK – more than six million people. If left untreated, it can have a serious impact on a person’s health, their work and their family life. Most worryingly, it can lead to suicide – the biggest killer of young men in the UK.
It is not surprising then that understanding “what is the best early treatment for depression?” was number two of our Top Ten Depression Priorities.
This is such a great question, with so much potential to help people affected. Researchers can approach it from many different angles too. For example, they could look early in life at treatments that work well for teenagers and young adults, the time when symptoms most often appear or for older people for whom depression is also common.
It’s not just about the treatment someone receives. Our survey participants told us that it is also important to have the knowledge and skills to be able to manage their condition in their day-to-day life. In physical health, self-management of symptoms is a common thing – and is backed up by evidence of what works, but when it comes to mental health conditions, like depression, our evidence base is lacking.
This issue was number five in our priority list and it’s clear that further research on self-management is needed if we are going to provide the best opportunities for people with depression to lead fuller, healthier, and happier lives.
People with depression are also looking for meaningful support in their day-to-day lives, whether at home, at school or in the office. At least three of the ten questions in our Top Ten list concerned the need for good evidence on how we can best enable help and support from family friends and peers. The environmental and social aspects of depression cannot be overestimated.
Where do we go from here?
The Top Ten list of questions concerning depression is just a first step toward research that addresses what matters to people most. Research funders and researchers need to work on turning these important questions into realistic and fundable research projects. We are calling on researchers from across disciplines to champion this effort and are working with a range of funders to build support for projects that will help address the Top Ten.
The good news is that research funders like NIHR and MQ are already funding research to tackle these questions head on. Our work to uncover new treatments and improve existing ones will be truly transformative in getting people the care they need at the earliest possibility. But we need your help.
There are many ways you can play a role in helping tackle the issue through research, whether through getting involved yourself, sharing your ideas or even your data , or donating to fund the next new advances.
Depression affects us all - we all can be a part of the solution.
MQ is proud to be the sponsor of the Depression: Asking the Right Questions project in partnership with over 30 organisations and charities. It was independently overseen by the James Lind Alliance , a non-profit making initiative, hosted by the National Institute for Health Research . Visit http://www.joinmq.org and http://www.depressionarq.org to learn more about the project and to work with us in tracking research progress.
Talking therapies can play a big part in helping people to understand, manage and overcome their depression. We spoke to six patients from a mindfulness based cognitive therapy group in Berkshire. All six realised that they had a health problem at different stages of their lives. They all experienced different combinations of anti-depressant medication, cognitive behaviour therapy (online and face-to-face) and mindfulness based cognitive therapy.
Claire’s early adult years were marked by depression and anxiety, treated with counselling and anti-depressant medication. It was only after a major breakdown at the age of 31 that Claire was referred for one-to-one cognitive behavioural therapy (CBT).
“Those ten sessions – backed up with some recommended reading - were extremely beneficial. It was the first time I had learned how my thoughts were impacting on my feelings and behaviours.
"It helped me to feel focussed, to feel that this was something I could use to help myself. It was part of understanding that this is a lifelong illness that I needed to be able to manage.
“I used the CBT techniques for a long time, and it was very helpful, even during a relapse. Later, I was signed up for a computerised CBT programme. It seemed to be a well-developed package but I found it very hard to complete without personal support.”
Claire was then referred for a course of mindfulness based cognitive therapy, working in groups led by a therapist.
“For me, the group work was the key. Working with the group and our excellent therapist depersonalised the depressive illness and I came to understand that I am not my depression, I am not defined by my depression. I use the mindfulness techniques daily and have been able to keep going with my busy and stressful job.”
Louise did not respond to the anti-depressants prescribed for her depression and like Claire found fortnightly one-to-one CBT sessions a constructive way forward.
“I kept a diary of my thoughts and behaviours. The therapist taught me to pick up the patterns of negative behaviour and we would discuss how to change them. Living alone and working hard running my own business, I had little personal support. The CBT gave me a ‘toolbox’ of techniques that I could use to help manage my depression.”
Gill had had mild depression since her teens but this got much worse after she became a mother later in life.
“I found it hard to get my treatment straightened out. It was tricky to find an anti-depressant that suited me and I tried private psychodynamic therapy with only little benefit. When, a couple of years later I became much more unwell I was referred for online CBT. The problem was, there was almost no personal support to this process. I could not make it work for me. I was very tired and I was trying to fight the depression. I needed more help.” Gill has since joined the mindfulness group and has found this therapy helpful."
Andy also tried CBT and found it wasn’t right for him.
“I was in a very stressful job and feeling very anxious. At first I didn’t acknowledge that I was depressed and the first medication I took was to help me sleep. I tried one-to-one CBT but it wasn’t helping. The therapist’s view was that I am a perfectionist and find it hard to let things go. It seemed as though I needed another way forward.”
Andy then undertook a course in mindfulness based cognitive therapy and found learning mindfulness in a group “very powerful”.
“You are not alone and you are not ‘different’. It’s not easy to master at first but it’s a learned skill and it becomes easier. Now I try to practise mindfulness every day. Using it makes me feel more energised. It’s the one thing that has really made a difference to my depression. I wish it had been available to me sooner.”
Caroline’s depression had built up slowly. She tried various interventions (although not CBT) and remedies. She experienced a cocktail of stresses in her life that left her not only depressed but physically ill.
“The anti-depressants weren’t compatible with my physical health problem and at first I tried all sorts of things including acupuncture and faith healing. I had seen a counsellor who was great but what I didn’t realise at that point was that I needed support and I needed strategies.”
Caroline has found this support through the mindfulness-based cognitive therapy group, saying: "It has taught me strategies that I use every day. Things I have spent years fighting no longer bother me."
*Everyone in this group attended therapies provided by the NHS. The courses of mindfulness-based cognitive therapy referred to took place between 2012 and 2014. Some names have been changed.
Depression causes untold human suffering, affecting as many as one in five people throughout their life. People often have a first episode in adolescence or early adulthood, and for many it tends to recur.
A recent survey from the MQ charity suggests that our top research priority for depression should be finding ways to prevent it. Mindfulness-based cognitive therapy (MBCT) was developed precisely for this reason, as an intervention for people with a history of depression to learn skills to stay well in the long term. There is a compelling body of evidence to show that MBCT is an effective psychological approach to recurrent depression, and some of that evidence is discussed in this Highlight.
As such, both the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network endorse MBCT for people with recurrent depression. However, even though MBCT has a compelling evidence base, appears to be acceptable to those who experience it, and is in national guidance, its value will be determined by its implementation in service delivery and local practice. This gap from evidence to practice was described in a recent commentary as an ‘implementation cliff’; a large body of work to develop the intervention and evaluate its effectiveness is done; now we need to build a bridge to practice.
This background prompted us to ask a question about the current state of accessibility and implementation of MBCT in the UK’s health services – the NIHR funded ASPIRE project. Specifically we wanted to know what the facilitators and barriers are to implementing MBCT, what critical factors enhance its accessibility and routine use in the NHS, and what would support the NHS in implementation?
Our study involved interviews with more than 200 participants including MBCT practitioners, managers, patients and commissioners, and case studies at 10 sites across the UK. The study will publish later in 2016
Our emerging findings show that people’s access to MBCT is patchy, and in some cases very fragile. A mixed picture emerges from the data, suggesting a variety of MBCT implementation journeys. Analysis is ongoing and whilst these journeys are particular to the participants telling their stories, they share some common features.
Fitting it in
MBCT is not an intervention that provides ‘a quick fix’ and as such, in many cases it was perceived to contrast with the pace and pressure of current health services. MBCT also aligns with a model of care that places people as active agents in their own recovery and promotes mental health and well-being, rather than a medical model.
Services that found creative ways to ‘fit’ MBCT within their contexts were most likely to have successful and sustained implementation. This often meant using the NICE recommendations for MBCT as a starting point for making the case but then flexibility adapting the MBCT programme to fit the local context and client groups. The alignment of MBCT with other service initiatives (such as IAPT), management interests, resources, and with a recovery ethos was often perceived to be a factor in implementation.
The importance of implementers or ‘champions’
In the absence of a more strategic and/or commissioner led initiation of MBCT, our data is saturated with examples of enthusiastic and passionate individuals who have acted as local implementers. The starting point for implementation in all sites was the presence of these ‘champions’.
Most implementers had initially worked alone in championing the intervention and as such services had grown organically from the ground up. Data show that these implementers had particular skills in pushing and driving the implementation; they were constantly spreading the word, developing supportive networks, writing business cases, and delivering taster sessions to give others a ‘taste’ of MBCT. The position or seniority of the implementer was also perceived to make a difference in initiating and accelerating MBCT implementation. Developing a critical mass of implementers was facilitated through internal training and supervision arrangements, which led to internal apprenticeship models, and supportive networks.
The implementation of MBCT was more successful in contexts that were receptive to the intervention, and of the implementer’s activities. In addition to how MBCT ‘fits’ as an intervention into the pace and ethos of the NHS, wider contextual factors such as access to resources including finance (to fund and support MBCT training and service delivery), human (having dedicated leads and practitioners) and practical (physical space to deliver sessions) were important facilitators.
Where MBCT was not part of a service’s strategy, reorganisations, changes in service structures, the introduction of new targets, competing priorities and a lack of support from senior level managers disrupted the potential for a focus on implementing MBCT. Often in these cases, implementers worked ‘under the radar’ to ensure some level of service continued to be provided. In cases where the context was more conducive, a synergy of this bottom up and top down implementation was perhaps optimally supportive of sustainable implementation.
In all case studies it was possible to describe an ‘implementation journey’ and interestingly these were often marked by ‘tipping points’. In sites where MBCT appears to have been more successfully implemented whereby there was a more sustained delivery of the intervention, participants described factors and facilitators that cumulatively, and over time, enabled more widespread use of the intervention.
Our next steps are to complete the ASPIRE analysis, collaboratively run dissemination events with stakeholders and provide guidance that NHS providers can use to sustainably implement MCBT within their service contexts.
The research team comprised Dr Felix Gradinger (University of Exeter) and Heledd Owen (Bangor University). Professor Stewart Mercer (Glasgow University), Andy Gibson ( University of the West of England) and Rebecca Crane (Bangor University) are co-investigators. Professor Rob Anderson (University of Exeter was a collaborator).
About the author: Jo Rycroft-Malone and Willem Kuyken