Published: 09 February 2023
Effective depression treatment limited by poor access
Depression affects up to one in five people during their lifetime and more than half of those will go on to experience at least one more episode. For those who experience several depressive episodes, recurrence rates can be as high as 80% and cause people significant distress.
The most widely used treatment for depression is antidepressant medication, which can effectively treat recurrent depression but needs to be continued to prevent relapse. Mindfulness-based cognitive therapy (MBCT), a type of psychotherapy, can help patients avoid that relapse and subsequent depression.
MBCT is a group-based mindfulness programme that combines learning about mental health, mindfulness practices and cognitive behavioural therapy (CBT) to help people control the negative thought patterns that can lead to a relapse. Many studies have shown it to be a cost-effective and successful treatment for recurrent depression that offers an effective alternative to long-term use of antidepressants. However, despite being recommended by the 2009 NICE depression guideline, patients have not fully benefited from MBCT as its availability varies across the country.
In 2013, the ASPIRE research team led by Professor Jo Rycroft-Malone OBE and Professor Willem Kuyken was awarded £400,000 by the NIHR Health and Social Care Delivery Research Programme to investigate why many patients were unable to access MBCT. They also wanted to understand how the NHS could implement MBCT more widely and consistently, as well as develop guidance to support current and future service providers.
Developing resources to deliver MBCT
The ASPIRE team began by interviewing around 200 NHS staff from across the UK and then analysing how MBCT had been implemented in 10 NHS sites across the UK. Using insights from people who had set up and delivered MBCT services in different healthcare settings, the team built a picture of how a successful “implementation journey” could be made.
While the study was underway, the Mindfulness All-Party Parliamentary Group prepared its 2015 Mindful Nation UK report to make recommendations for the wider use of mindfulness in different settings. This report was informed by Professors Kuyken and Rycroft-Malone’s expert opinion on the use of mindfulness-based initiatives in the NHS, and ASPIRE’s protocol outlining the ongoing research into best practice for NHS-based MBCT was also referred to.
The Group’s report recommended that MBCT should be commissioned in line with NICE guidelines for patients likely to suffer recurrent depression. To fulfil this, they also recommended training 100 MBCT teachers each year, for the following 5 years, through the NHS Improving Access to Psychological Therapies (IAPT) programme training programme.
The IAPT service offers evidence-based treatments for patients with depression, while its training programme teaches staff to deliver those treatments. After a survey of IAPT services showed that over 90% wanted to offer their patients MBCT, an advisory group including Professor Kuyken and other members of the ASPIRE team developed a curriculum to train existing NHS CBT therapists to teach MBCT themselves.
Funded by Health Education England, the first staff were trained using this new curriculum through the IAPT training programme in 2017. ASPIRE’s co-lead Professor Kuyken, Director of the University of Oxford Mindfulness Centre, continues to be involved in delivering MBCT training for NHS staff through the programme.
"The ASPIRE project and this Health Education England-funded MBCT training closes the circle of translational research, ensuring that the millions of people who suffer depression in the UK can access an evidence-based approach to long-term recovery."
Professor Willem Kuyken
Improving patient care through expanded MBCT services
ASPIRE’s results, published in the journal Health Services and Delivery Research in 2017, showed that although patients’ access to MBCT was improving across the UK, access remained inconsistent. The team noted that although fewer than 50% of IAPT services had trained MBCT teachers, there were several areas of excellent implementation. These services had often been developed over several years by individuals who championed the therapy and generated the necessary support and networks.
Their research identified other factors that supported successful MBCT implementation, such as having appropriately trained staff, space and time. Financial pressures and organisational changes were common barriers to offering the therapy. Using these findings, the team developed a framework outlining how healthcare services can successfully implement MBCT.
This framework is now incorporated into new MBCT implementation guidance, which presents a free online plan and related resources to support MBCT teachers, service managers and commissioners who offer or are setting up new MBCT services. As ASPIRE’s subsequent publication in BMJ Open explains, successful implementation can take many years and these resources support the services’ ongoing development.
"We co-designed the implementation resources with those who would be using it to make sure they would be useful and used. It’s therefore positive to know this guidance is helping to have an impact in ensuring the implementation of evidence-informed service delivery."
Professor Jo Rycroft-Malone OBE, Distinguished Professor at Lancaster University (previously at Bangor University during the study period)
Encouraging data from NHS Digital records indicate that patients’ access to MBCT to prevent depression relapse increased more than threefold between 2017 and 2018, with the number of treated patients rising from 1,100 to 3,600. Their treatment will not only have lowered their individual risk of depressive relapse and improved their quality of life, but will also reduce NHS spending on the treatment of recurrent depressive relapses.
You can read more about the impact of ASPIRE’s and NIHR’s wider research into MBCT for recurrent depression in this NIHR impact timeline.
The study was funded by the NIHR Health and Social Care Delivery Research Programme.
More information about the study is available on the NIHR’s Funding & Awards website.
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