Review Article
Indications for Mindfulness Based Therapy
in Psychiatric Illness
Alexandra Perel-Winkler
12 Heytesbury St. Garden Apt.
Dublin 8
Ireland
+(353) 86 218-2703
aperelwinkler@rcsi.ie
Abstract
Background: Mindfulness has been successfully incorporated into therapeutic programs for physical
illness and stress reduction. Recently Psychiatric studies have considered the benefit of Mindfulness
Based Cognitive Therapy (MBCT) in the treatment of severe and/or chronic psychiatric disease. This
review synthesizes the most recent and relevant research on Mindfulness Based Cognitive Therapy
and its role in psychiatric treatment.
Methods: PubMed, CochraneReviews and TRIPDatabase were searched for relevant and recent
psychiatric studies examining the effects of mindfulness and related therapies on depression, bipolar
disorder, anxiety, personality disorders and substance abuse. Limits were placed on the initial
search to find meta-analyses to look for papers with the highest level of statistical power.
Results: Evidence based research findings suggest that adjunctive MBCT to standard care results in
improved measures for many different classes of psychiatric patient. Decreased rates of relapse and
control of residual symptoms in affect disorders, and improved control in personality disorders and
substance abuse were consistently reported. However, many studies had low power, with small
sample sizes and lack of randomization.
Conclusion: Mindfullness Based Cognitive Therapy is a cost effective, well tolerated method of
improving the management of psychiatric disorders. More research is needed to improve on
methodological shortcomings.
Mindfulness Based Cognitive Therapy (MBCT) is a psychological intervention that has
integrated aspects of Cognitive Behavioural Therapy (CBT) with Mindfulness Based Stress Reduction
(MBSR) programs. The concept of mindfulness is understood as the process of ‘paying total attention
to the present moment with non-judgmental awareness’. [1] Mindfulness based stress reduction
programs have been shown to be beneficial for physical and mental ailments – boosting immune
function, decreasing pain sensation, increasing cognitive function among many described benefits.
[2] Studies have pointed to the potential uses of Mindfulness based stress reduction to optimize
standard practice as an adjunctive therapy for a multitude of medical specialties. [3]
Recent Psychiatric research has endeavoured to explore the potential of mindfulness based
therapies, particularly MBCT, and its effect in Major Depression, Generalized Anxiety, Personality
Disorders and Substance Abuse, yielding positive results. The 8 week MCBT program attempts to
increase patient’s awareness of their thoughts, feelings and physical experience while recognizing
these things as transient events. [1] By focussing solely on the present moment, participants learn to
avoid becoming overwhelmed with their internal mental phenomena and emotional experiences.
This allows people to observe and detach from habitual ruminations and fixed dysfunctional
patterns.
While treatment for psychiatric illnesses has improved vastly since the development of modern
antidepressant and the application of CBT, significant numbers of psychiatric patients are left with
residual symptoms, relapses, or are resistant to the current best practice efforts .[1] MCBT has been
shown to be most successful as an adjunctive therapy when treating major psychiatric disorders.
Improvements in remission rates, time spent in remission, reduction of residual symptoms and
prevention of relapse are the major findings.
Mindfulness in Major Depression
Depression is considered one of the top contributors to morbidity worldwide by the World
Health Organization.[4] Individuals suffering from depression have a 33% risk of relapse after
multiple trials with pharmacologic treatments and an increased rate of death by suicide.[1]
Depression is a chronic condition, and as such is an emotional, social and economic burden for
patients, families and their community. It has been suggested that the process of ‘rumination’,
the continual thinking about one’s feelings and symptoms of depression, is a central cause of
the perpetuation of the depression itself. MBCT teaches participants to observe thoughts and
feelings through the practice of meditating on a neutral experience in the present moment,
such as breathing.[4]
Several studies have looked at MCBT in patients with three or more episodes of serious
depression, examining the efficacy of standard care with and without an 8 week intensive
MCBT course. Results were positive – fewer patients with adjunctive MBCT relapsed in the
following 12 months (32% v 60% in the control group). Other studies have shown that
adjunctive MBCT is significantly better at lowering residual depressive symptoms in comparison
to anti-depressants alone. [1] Using the Beck’s Depression Index to assess depressive
symptoms objectively and in a comparable manner, studies showed significant change in
depression scores, particularly the items including suicidality, sadness, loss of interest, guilt and
lack of pleasure.[1]
Mindfulness in Generalized Anxiety
Generalized Anxiety Disorder (GAD) is a chronic disease currently treated with Cognitive
Behavioural Therapy and anxiolytic pharmacotherapy. This chronic disease is characterised by
relapse, high rates of sympathetic strain causing physical morbidity in addition to the longterm, extreme worry. As the basis of GAD is rooted in intense, repetitive worry about
uncontrollable events, it has been proposed that MBCT would be indicated in order to help the
person develop a more detached and objective view of the contents of their thoughts.
Increasing awareness of thought patterns is said to allow greater room for integration of coping
strategies, and as a secondary features decreases nervous system arousal and physical stress
symptoms . [5] In a study observing the effects of an 8 week MBCT program for patients with
GAD, both Beck Anxiety Inventory (BAI) and Penn State Worry Questionnaire (PSWQ) were
significantly reduced at the completion of the program. The group described a decrease in their
anxiety, tension, and mood symptoms and also described an experience of increased mindful
awareness in their everyday life. In another study patients in a minimum of a 6 month
remission of GAD after pharmacotherapy treatment were allocated to MBCT or psychoeducation groups. Those that had the mindfulness training reported significantly lower BAI
scores and decreased residual anxiety symptoms than those with the psychoeducation.[1]
Mindfulness in Borderline Personality Disorder
The concept of Mindfulness has been incorporated into a unique form of treatment therapy
called Dialectical Behaviour Therapy (DBT), which has had great success in people exhibiting
Borderline Personality Disorders. DBT is an integration of mindfulness with training programs
aimed to enhance participant’s ability to tolerate distress, affect changes, and regulate
behaviour. Studies have shown treatment with DBT has led to the reduction of self
harm/suicidal behaviours, admissions to inpatient treatment, and measures of anger in
Borderline patients. [3]
Mindfulness in Substance Abuse
Addictive substances impair brain systems causing a deregulation of mesolibic dopaminergic
reward, motivation and inhibitory pathways.[3] These pathways are deeply integrated with all
brain functions and thus have great effect on attention and mood. Cognitive Behavioural
Therapy is currently the cornerstone of addiction treatment aiming to point out stimuli leading
to substance use and supplement new behaviours that are incompatible. Unfortunately,
relapse rates are said to range from 50-90%, 30% of which are believed to be precipitated by
low mood or anxiety. It is known that co-morbid mood or anxiety disorders exacerbate
substance abuse and decrease periods of abstinence.[3] This can be understood as substance
abuse causes an adaption to increased dopamine concentration at the synaptic cleft. Cessation
of substance use causes a sharp drop in dopamine levels initiating the sensations of negative
moods. This experience is most intense at the beginning of abstinence, clarifying why recovery
is so challenging.
It is thought that mindfulness-based approaches may enhance the effectiveness of current
substance abuse therapy by supporting individuals in not resisting negative feelings or
thoughts, but instead recognising them as transient experiences of reality. In doing so patients
are less perpetually focussed on feelings of depression and need, and instead can feel hopeful
that these will pass and different thoughts will follow. Mindfulness blends the concepts of
change intrinsic to CBT as well as adding a component of acceptance to factors that may not
change. [3]
Multiple studies have shown that Mindfulness Meditation is related to both neurochemical and
structural changes within the brain. A meta-analysis prepared by Chiesa and Serretti compiled the
core findings of recent studies which analysed the effects of Mindfulness on the brain in both
healthy and physically and/or mentally ill individuals. EEG studies described electrical activity shifting
towards left-sided frontal cortex activation, a pattern understood to be associated with positive
emotions. Neuro-imaging studies described enhanced ability to use the anterior cingulated cortex
and dorsal medial prefrontal cortex, areas related to regulating attention and cognitive focus. These
cerebral areas involved in attention were measurably thicker in expert meditators compared to
controls. Neuro-imaging studies also show evidence of mindful meditation practices inhibiting the
reduction of grey matter volume, signifying that this practice may be protective against cognitive
decline in aging. [2]
Research on mindfulness is still in early stages of development and more rigorous study designs
are necessary to confidently integrate mindfulness based therapies into psychiatric practice. [3]
Particular problems include small sample sizes, lack of randomization in some studies, and
comparability between studies. Further, most studies examined the overall effects of MBCT and did
not specifying which aspect of this therapy was beneficial.[1] While supporters describe the seated
meditative practice as the focal aspect, it should be considered that attention training or group
relaxation, for example, could yield similar results.
Evidence based research findings suggest that adjunctive MBCT to standard care results in
improved measures for many different classes of psychiatric patient. Depressed patients can benefit
with lower rates of relapse and improved control of residual symptoms; anxious patients can
experience clinically significant decrease in intensive worry and related affect symptoms. The
practice of present moment awareness has seemed to improve emotional control and insight in
many difficult psychiatric disorders including Bipolar Personality, as well as modulating the negative
effects of substance withdrawal and improving abstinence rates in substance abuse. Other benefits
to this therapy that cannot be ignored: it is cost effective, well tolerated and currently no side effects
have been reported. On top of clinically significant results, general improvements in subjective
accounts of quality of life, sleep and cognitive function are consistently reported. While more
research on these therapies should be done to improve methodological shortcomings, current
evidence points to mindfulness based therapies as a useful tool to improve the lives of psychiatric
patients.
Bibliography
1.Chiesa A, Serretti A. Mindfulness Based Cognitive Therapy for Psychiatric Disorders: A Systematic
Review and Meta-Analysis. Psy Research. 2010. In press.
2. Chiesa, A. Serretti A. A Systematic Review of Neurobiological and Clinical Features of Mindfulness
Meditations. Psy Med. 2010; 40: 1239-1252.
3.Hoppes K. The Application of Mindfulness-Based Cognitive Interventions in the Treatment of Cooccurring Addictive and Mood Disorders. CNS Spectr. 2006; 11: 829-851.
4. Kenny MA, Williams JMG. Treatment-resistant Depressed Patients Show a Good Response to
Mindfulness-based Cognitive Therapy. Behaviour Research and Therapy. 2007; 45: 617-625.
5. Evans S, Ferrando S, Findler M, et al. Mindfulness-based Cognitive Therapy for Generalized
Anxiety Disorder. Journal of Anxiety Disorders. 2008; 22: 716-721.