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Time to adopt Mindfulness-Based Cognitive Therapy (MBCT) as a public health intervention to ease depression?

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As near­ly 10,000 fresh­men and trans­fers arrived on cam­pus at the Uni­ver­si­ty of Cal­i­for­nia, Los Ange­les, last fall, they were invit­ed to try some­thing nev­er before offered dur­ing stu­dent ori­en­ta­tion: depres­sion screen­ing.

The hope, admin­is­tra­tors explained, is that by iden­ti­fy­ing their risk for depres­sion, stu­dents can get the sup­port they need before they face the rig­ors of acad­e­mia and the dis­ori­ent­ing expe­ri­ence of liv­ing away at col­lege. There’s rea­son for the con­cern. In 2016, a record high of almost 12 per­cent of UCLA fresh­man report­ed “fre­quent­ly” feel­ing depressed in the past year. And a report from Penn State, draw­ing data from 139 uni­ver­si­ty and col­lege men­tal health ser­vices, found that in the 2015–2016 year, use of these ser­vices increased by 30 per­cent, although enroll­ment grew by just 5 per­cent. This includ­ed “a per­sis­tent increase in ‘threat-to-self’ char­ac­ter­is­tics such as non­sui­ci­dal self-injury and sui­ci­dal ideation.”

The screen­ing initiative—which will be extend­ed to the entire stu­dent body eventually—is part of the UCLA Depres­sion Grand Chal­lenge, a land­mark effort to under­stand one of the most per­va­sive and debil­i­tat­ing health con­di­tions in the world, one that affects an esti­mat­ed 350 mil­lion peo­ple and con­tributes to the sui­cides of 800,000 peo­ple, includ­ing 40,000 Amer­i­cans, every year.

The uni­ver­si­ty launched the chal­lenge in 2015 as a mul­ti­year, inter­dis­ci­pli­nary study to devel­op bet­ter meth­ods of under­stand­ing the genet­ic and envi­ron­men­tal caus­es of depres­sion and to improve detec­tion, eval­u­a­tion, and treat­ment. The goal is ambi­tious: to cut the glob­al depres­sion rate in half by 2030.

This comes at a time when pub­lic health offi­cials around the world strug­gle to get their hands around what is con­sid­ered the lead­ing cause of dis­abil­i­ty among adults, cost­ing some $210 bil­lion in med­ical and long-term care and lost pro­duc­tiv­i­ty hours each year.

That depres­sion has not been iden­ti­fied as our num­ber-one health issue astounds me,” UCLA chan­cel­lor Gene Block said in announc­ing the cam­pus screen­ing pro­gram in Sep­tem­ber 2017.

Unpacking the blues

While men­tal health experts are cau­tious about call­ing depres­sion an “epidemic”—citing bet­ter screen­ing and greater under­stand­ing and accep­tance of the con­di­tion as pos­si­ble rea­sons for increased diagnosis—the num­bers are still star­tling: 350 mil­lion suf­fer­ers world­wide. Accord­ing to UCLA, if you haven’t expe­ri­enced depres­sion your­self, you know some­one who has.

It is also now rec­og­nized as being at the core of numer­ous men­tal health con­di­tions, from bipo­lar dis­or­der (pow­er­ful swings between high and low mood) to post­par­tum depres­sion, just to name a few.

Many of the symp­toms of depres­sion are famil­iar: per­sis­tent low mood, exhaus­tion, loss of appetite and sex dri­ve, an inabil­i­ty to enjoy life or cope with every­day activities—like social­iz­ing or even get­ting out of bed. But some may not be as obvi­ous, such as dis­or­dered and dis­tort­ed think­ing, agi­ta­tion, phys­i­cal aches and pains, and insom­nia.

Yet despite how much we now know about what depres­sion is, we still don’t real­ly know what caus­es it. What we do know is that a vari­ety of wide-rang­ing fac­tors seem to influ­ence a person’s risk of devel­op­ing depres­sion, includ­ing child­hood adver­si­ty; genet­ic make­up; chem­i­cal changes in the brain and body; cer­tain unhelp­ful styles of think­ing and relat­ing; and social, eco­nom­ic, and cul­tur­al depri­va­tion.

The truth is, there are like­ly myr­i­ad inter­re­lat­ing caus­es involved in each case. “We’re all vul­ner­a­ble in a sense because we all have fac­tors that con­tribute to that vul­ner­a­bil­i­ty,” says Zin­del Segal, a pro­fes­sor of psy­chol­o­gy at the Uni­ver­si­ty of Toron­to who spe­cial­izes in depres­sion.

Fur­ther com­pli­cat­ing mat­ters, depres­sion doesn’t always act the same way from indi­vid­ual to indi­vid­ual, or from episode to episode, which can range from mild to severe. An episode can last from a few days to weeks, months, or even years.

All of these fac­tors make treat­ment dif­fi­cult, because each suf­fer­er will need some­thing dif­fer­ent. Indeed, treat­ment for depres­sion is a bit of a guess­ing game, with only a 50 per­cent suc­cess rate with the first inter­ven­tion tried. Anti­de­pres­sants work some­times, but not always. Talk ther­a­pies help some peo­ple, but not oth­ers. Some­one may feel bet­ter with increased social con­tact, a change in rela­tion­ships, or a new job. For oth­ers, becom­ing less busy or start­ing an exer­cise regime is what makes the dif­fer­ence. Some­times the pas­sage of time is what helps. Unfor­tu­nate­ly, because depres­sion plays hav­oc with the capac­i­ty to see things accu­rate­ly, it’s hard for a depressed per­son to know what they need.

And while most peo­ple recov­er from a depres­sive episode, it’s a chron­ic, relaps­ing con­di­tion, with recur­rence ever more like­ly each time it strikes. It’s com­mon­ly accept­ed that if you expe­ri­ence even one depres­sive episode, you have a 50 per­cent greater chance of expe­ri­enc­ing anoth­er.

Dodging the wrecking ball

At this point you might be think­ing, “Now you’re going to tell me that this is where mind­ful­ness fits in.” After all, doesn’t the prac­tice of pay­ing atten­tion to the present moment enhance our abil­i­ty to see clear­ly, sta­bi­lize the mind, and be freed from unskill­ful pat­terns of think­ing and behav­ior? Doesn’t it have salu­tary effects on the mind, brain, and body?

Well, yes. But, also, no.

Psy­chol­o­gists wide­ly agree that mind­ful­ness has an impor­tant role to play in man­ag­ing the condition—as a self-care prac­tice, and by help­ing us to tune in to the nat­ur­al ebbs and flows of ener­gy and mood.

In fact, hav­ing a reg­u­lar mind­ful­ness prac­tice may help some­one who strug­gles with depres­sion to notice when they’re at risk, allow­ing them to take appro­pri­ate action, if not to avoid an episode, then to at least min­i­mize its impact.

I think some­body who has a mind­ful­ness prac­tice and a his­to­ry of depres­sion will know them­selves whether they need rest, or whether it would be bet­ter to walk the dog or go to work,” says Willem Kuyken, a pro­fes­sor of clin­i­cal psy­chol­o­gy at the Uni­ver­si­ty of Oxford, and direc­tor of the Oxford Mind­ful­ness Cen­tre, which has pio­neered mind­ful­ness-based treat­ments for depres­sion. “What’s so beau­ti­ful and trans­for­ma­tive about mind­ful­ness is that it places the wis­dom in the per­son and their own prac­tice. They have a sense of ‘what’s hap­pen­ing with my mind and body at the moment?’ and how to shift from auto­mat­ic pilot to more of an expe­ri­en­tial present-moment mode. From that place they can judge what feels skill­ful and dis­cern­ing.”

One mod­el in par­tic­u­lar, Mind­ful­ness-Based Cog­ni­tive Ther­a­py (MBCT), which offers mind­ful­ness train­ing in con­junc­tion with cog­ni­tive-behav­ioral ther­a­py, appears to be par­tic­u­lar­ly effec­tive. “We’ve got 10 ran­dom­ized con­trolled tri­als sug­gest­ing that for peo­ple with a long his­to­ry of depres­sion, MBCT does much bet­ter than usu­al care,” Kuyken says.

He explains that depres­sion makes some­one more like­ly to react to life’s set­backs with neg­a­tive, judg­men­tal think­ing, which can low­er their mood and trig­ger a new episode. Mind­ful­ness helps cre­ate men­tal space around these thoughts, enabling peo­ple at risk to observe, with kind­ness, the pat­terns of the mind that might oth­er­wise drag them down.

He shared the exam­ple of a for­mer client. “She was a young moth­er who was push­ing her tod­dler son on a swing. It was a hap­py moment, but then a thought popped into her head: ‘I don’t deserve to be hap­py, and this hap­pi­ness won’t last.’ We all have thoughts like this, but for some­one who’s vul­ner­a­ble to depres­sion, those shards of neg­a­tive think­ing can quick­ly spi­ral into a whole bunch of oth­er neg­a­tive thoughts, asso­ci­at­ed emo­tions, and behav­iors.”

For this woman, he says, the thoughts came in the form of “I’m a rub­bish moth­er” and the inter­nal thrash­ing that typ­i­cal­ly fol­lowed. Pri­or to MBCT, he says, going down that path “might have led her to do a ‘duvet dive’ and hide away from the world,” result­ing in more rumi­na­tion and fur­ther­ing the down­ward spi­ral. Instead, she was able to rec­og­nize the destruc­tive pat­tern forming—what she called “wreck­ing-ball thoughts”—and take a side­ways step, allow­ing the thought to pass through her mind with­out being knocked over by it.

Zin­del Segal, one of the cre­ators of MBCT, agrees. “Qual­i­ta­tive analy­ses show the core take­away from MBCT is I am not my depres­sion. That the self is big­ger than that.”

That’s a source of lib­er­a­tion, because they can choose how they want to act, rather than run­ning to the first solu­tions that the mind offers, which can often be reac­tive,” he adds. “Their symp­toms may not reduce to zero, but their well-being and resilience increas­es as they devel­op a dif­fer­ent rela­tion­ship to them.”

There’s a time and place for mindfulness

For the great suc­cess mind­ful­ness, and MBCT in par­tic­u­lar, has shown for help­ing peo­ple with a his­to­ry of depres­sion to avoid or lessen the impact of those depres­sive dips, there are equal­ly strong caveats against using the prac­tice when you’re in the throes of an episode.

It’s very hard to sit and do for­mal med­i­ta­tion prac­tices when you’re depressed,” Segal says. “The exec­u­tive con­trol net­works of the brain are often com­pro­mised when you’re in an episode of depres­sion, and it’s dif­fi­cult to engage.” In oth­er words, when the world goes dim and life feels bleak, your brain might not have the band­width to be a kind, non­judg­men­tal observ­er to its own thoughts, or to grasp the big­ger pic­ture.

Susan Woods, a psy­chother­a­pist and mind­ful­ness teacher in Ver­mont, goes fur­ther: “If some­body is in a major depres­sion episode, mind­ful­ness is use­less. There’s just no ener­gy there, no abil­i­ty to con­cen­trate for any length of time.”

Even if a per­son with depres­sion is able to engage with med­i­ta­tion, there is a risk that height­ened expo­sure to the unpleas­ant symp­toms of their ill­ness, expe­ri­enced while pay­ing mind­ful atten­tion, could actu­al­ly increase their fear and aver­sion, trig­ger­ing a reac­tive spi­ral of deep­en­ing low mood. “There is some evi­dence that vul­ner­a­ble peo­ple exposed to mind­ful­ness can have quite unset­tling expe­ri­ences,” says Kuyken. “That makes com­plete sense,” he says, because when peo­ple are depressed, the mind “can be quite dark and scary.”

Also, if depres­sion seems more to do with a person’s life sit­u­a­tion, rather than their inner pat­terns of think­ing, feel­ing, and relat­ing, they may need assertive action more urgent­ly than med­i­ta­tion. “If some­one is in cir­cum­stances of tremen­dous adver­si­ty or abuse, they first need to get to a place that’s safe,” adds Segal. “If your house is on fire, you need to get out.”

A mindful exception

There are excep­tions to every rule, of course. I learned to med­i­tate toward the end of a two-and-a-half-year major depres­sive episode, and it was the key that released me from a prison of con­stant­ly fight­ing my inner demons, a pat­tern that kept them run­ning ram­pant.

How­ev­er, by the time I start­ed prac­tic­ing, I had already under­gone inten­sive psy­chother­a­py, begun to make much-need­ed lifestyle shifts, and under­stood some of the ingrained men­tal and behav­ioral habits that were main­tain­ing my low mood. Med­i­ta­tion was a vital piece of the puzzle—a prac­ti­cal skill that helped me dis­cov­er the art of let­ting go—but I also remem­ber how tough it was the first times I tried to sit and focus on my breath. It felt like I was going to explode from the inten­si­ty of the sen­sa­tions inside me. It took a lot of com­mit­ment, a lot of sup­port, and a lot of going gen­tly for the prac­tice to bear fruit. In the ear­li­er phas­es of my ill­ness, I doubt it would have helped so much.

A few small-scale stud­ies sug­gest MBCT can help peo­ple in the midst of an episode, but Segal notes the qual­i­ty of evi­dence is low, and Woods points to the fact that the cours­es in these tri­als were often led by very expe­ri­enced teach­ers, who were also spe­cial­ists in treat­ing depres­sion. Kuyken shares their con­cerns: “With vul­ner­a­ble clients, teach­ers need to be well-trained and very skilled in how they teach mind­ful­ness.”

Because it’s so dif­fi­cult for the depressed mind to dis­cern what it needs, the best first step to well­ness is pro­fes­sion­al sup­port. A com­pe­tent ther­a­pist can act as a guide to skill­ful action, help­ing you form a treat­ment plan. This, accord­ing to Woods, is like­ly to include anti­de­pres­sant med­ica­tion, slow­ly build­ing in self-care activ­i­ties that can help sta­bi­lize and ele­vate mood, and cog­ni­tive ther­a­py to help you under­stand and work with your indi­vid­ual trig­gers. There is mind­ful­ness here, but it comes from the ther­a­pist as a wise, com­pas­sion­ate friend—much need­ed when you can’t locate your own inner com­pass.

Once mood has sta­bi­lized, mind­ful­ness train­ing can be part of the plan. At this point, says Segal, a mind­ful­ness-trained ther­a­pist might rec­om­mend a mind­ful move­ment prac­tice. Woods sug­gests short sit­ting prac­tices, such as the three-minute breath­ing space, to be prac­ticed sev­er­al times a day and at the begin­ning of a ther­a­py ses­sion. After a few months of sta­bil­i­ty, it might be time to enroll in a group-train­ing pro­gram, such as MBCT.

Moving forward

So, when depres­sion is present, it prob­a­bly isn’t the time to engage in med­i­ta­tion. How­ev­er, there’s cau­tious opti­mism that when mind­ful­ness is devel­oped and prac­ticed while a per­son is feel­ing emo­tion­al­ly sta­ble, it may increase their abil­i­ty to nav­i­gate dif­fi­cult sit­u­a­tions or emo­tion­al upheavals in the future. In this sense, it may be a pow­er­ful buffer against the ups and downs inevitable in every life.

By show­ing peo­ple sad movie clips dur­ing an fMRI scan, Segal and his col­leagues in Toron­to found that mind­ful­ness prac­ti­tion­ers’ brains showed more acti­va­tion in sen­so­ry pro­cess­ing regions, such as the insu­la and somatosen­so­ry cor­tex, but less acti­va­tion in mid­line pre­frontal struc­tures, which are asso­ci­at­ed with the men­tal rumi­na­tion that is often prob­lem­at­ic for peo­ple with depres­sion. This indi­cates that while mind­ful­ness-trained peo­ple feel their emo­tions intense­ly, they are less like­ly to think that sad­ness is a prob­lem to fix, a cog­ni­tive stance that can lead to depres­sion. Also, a key ele­ment of mind­ful­ness may be a shift to enhanced sen­so­ry expe­ri­ence and a cor­re­spond­ing decrease in “liv­ing in your head.”

Evi­dence also shows that prac­tic­ing mind­ful­ness can start an upward spi­ral of mood and behav­ior, enabling peo­ple to become more ful­ly inte­grat­ed in their lives, and bring­ing with it a greater sense of free­dom and flour­ish­ing. “In the longer term, sus­tained prac­tice is a pro­found gen­er­a­tor of com­pas­sion and con­nec­tiv­i­ty,” explains Segal, “and that starts to change how peo­ple inter­act with one anoth­er. It’s at a much broad­er scale than peo­ple just look­ing to deal with their mind dis­or­der, although that is an impor­tant start­ing point.”

This poten­tial for wider social impact hasn’t escaped the notice of politi­cians: A 2015 report by the Unit­ed Kingdom’s Mind­ful­ness All-Par­ty Par­lia­men­tary Group rec­om­mend­ed that MBCT be made more avail­able in the country’s Nation­al Health Ser­vice, and a glob­al group of policymakers—including U.S. Con­gress­man Tim Ryan—has formed to explore the pos­si­bil­i­ties fur­ther. Mean­while, the Oxford Mind­ful­ness Cen­tre has begun a sev­en-year pro­gram of research into teach­ing mind­ful­ness in schools to see if it can help stu­dents’ resilience as they enter the teenage years, a com­mon age for the first appear­ance of men­tal health prob­lems. “Can we take 11 to 14 year olds,” asks Kuyken, who’s lead­ing the project, “and teach them the skills to pre­vent depres­sion from ever occur­ring?”

Pre­vent­ing depres­sion among those at risk is where more mind­ful­ness train­ing could be, as Segal says, “a pub­lic health win.”

It would have a huge impact on the health land­scape, because peo­ple wouldn’t be com­ing back into treat­ment, and they’d be more effec­tive in par­ent­ing, as part­ners, and at work,” he explains. “They could enroll in all sorts of activ­i­ties that would have much-need­ed effects in areas of well­ness aside from men­tal health.”

Based at UC-Berke­ley, Greater Good high­lights ground break­ing sci­en­tif­ic research into the roots of com­pas­sion and altru­ism. Ed Hal­li­well is a mind­ful­ness teacher and writer, based in Sus­sex and Lon­don, UK. He is author of Into The Heart of Mind­ful­nessHow To Live Well By Pay­ing Atten­tionco-authored The Mind­ful Man­i­festo and teach­es cours­es and retreats to pub­lic groups, in orga­ni­za­tions and to indi­vid­u­als, face-to-face and online via Skype. He is also an advi­sor to The Mind­ful­ness Ini­tia­tive, which is sup­port­ing the Mind­ful­ness All-Par­ty Par­lia­men­tary Group to devel­op mind­ful­ness-based poli­cies for the UK. This arti­cle was orig­i­nal­ly pub­lished on Mind­ful, includ­ing first steps to take when feel­ing the blues.

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