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Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: Randomised controlled trial

  • Jan Sundquist (a1), Åsa Lilja (a2), Karolina Palmér (a2), Ashfaque A. Memon (a2), Xiao Wang (a2), Leena Maria Johansson (a2) and Kristina Sundquist (a1)...

Individual-based cognitive–behavioural therapy (CBT) is in short supply and expensive.


The aim of this randomised controlled trial (RCT) was to compare mindfulness-based group therapy with treatment as usual (primarily individual-based CBT) in primary care patients with depressive, anxiety or stress and adjustment disorders.


This 8-week RCT ( ID: NCT01476371) was conducted during spring 2012 at 16 general practices in Southern Sweden. Eligible patients (aged 20–64 years) scored $10 on the Patient Health Questionnaire-9, $7 on the Hospital Anxiety and Depression Scale or 13–34 on the Montgomery–åsberg Depression Rating Scale (self-rated version). The power calculations were based on non-inferiority. In total, 215 patients were randomised. Ordinal mixed models were used for the analysis.


For all scales and in both groups, the scores decreased significantly. There were no significant differences between the mindfulness and control groups.


Mindfulness-based group therapy was non-inferior to treatment as usual for patients with depressive, anxiety or stress and adjustment disorders.

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Corresponding author
Jan Sundquist, MD, PhD, Center for Primary Health Care Research, Lund University, Clinical Research Centre (CRC), Building 28, floor 11, Jan Waldenströms gata 35, Skåne University Hospital, SE-205 02 MALMö, Sweden. Email:
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J.S. and K.S. from the Swedish Research Council, ALF funding from Region Skåne and The Swedish Research Council for Health, Working Life and Welfare (in Swedish: Forte). The funding agencies had no role in the design and conduct of the study, in the collection, analysis and interpretation of the data; or in the preparation, review or approval of the manuscript.

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Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: Randomised controlled trial

  • Jan Sundquist (a1), Åsa Lilja (a2), Karolina Palmér (a2), Ashfaque A. Memon (a2), Xiao Wang (a2), Leena Maria Johansson (a2) and Kristina Sundquist (a1)...
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MBI and CBT provide comparable benefits in a primary care setting

David S Black, Professor, University of Southern California Keck School of Medicine
14 December 2015

Most patients with mild to moderate psychological ailments are treated in primary care settings where treatment may involve medication and/or a limited number of therapy sessions, most likely using some form of cognitive behavioral therapy (CBT). Therapists can be scarce, however, and one-to-one clinical interventions can be costly.

Sundquist et al. [British Journal of Psychiatry] explored whether a group-delivered mindfulness-based intervention (MBI) offered within a primary care setting might have equivalent outcomes to routine standard treatment.

The authors recruited 215 primary care patients from 16 different Swedish primary care settings. The patients had mild to moderate depressive, anxiety, and adjustment disorders and were seeking therapy. The patients were largely middle-aged, female, and well-educated. Participants were randomly assigned to either a MBI or routine standard care, mainly CBT.

The MBI was an 8-week group treatment modeled after Mindfulness Based Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT) and delivered by primary care psychologists and social counselors who underwent a six-session training.

The three symptom rating scales were administered before and after the 8-week intervention period. Both treatment groups improved significantly on all three scales. There were no significant differences between the MBI and standard care groups over time. The MBI treatment response was dose dependent – patients attending 5 or fewer sessions improved on only one of the three anxiety and depression measures, while those attending 6-8 sessions improved on all three. The equivalence between the MBI and standard care groups persisted even when reanalyzed using only those standard care members receiving CBT.

The findings suggest that 8 sessions of a group-delivered MBI provide essentially the same symptomatic relief as an average of six sessions of individually-delivered CBT when delivered as usual within a primary care setting. There was no long-term follow-up, so it remains to be seen whether this equivalence persists over time.

David S. Black, Ph.D., M.P.H.

Assistant Professor of Preventive Medicine

Keck School of Medicine

University of Southern California

2001 N. Soto Street, Ste. 302D, MC 9239
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Conflict of interest: None Declared

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RE: Mindfulness group therapy in primary care patients with depression, anxiety and stress and adjustment disorders: randomised controlled trial

Ihsan Khadra, Speciality Doctor Psychiatrist, Cumbria partnership NHS foundation trust
05 March 2015


Dr Ihsan Khadra

Specialty Doctor Psychiatrist

Dr Sophia Zaman

Specialty Doctor Psychiatrist

Cumbria Partnership NHS Foundation Trust

Carleton Clinic, Carlisle

We would like to commend Sundquist at el, on undertaking the difficult task of performing an RCT in primary care including a group of patients with depression, anxiety, stress and adjustment disorder and managing them with mindfulness group therapy as compared to treatment as usual.

The study emphasises the efficacy of mindfulness group therapy in this group. It provides a wealth of information about providing management for this group in primary care, but there are few issues which might differ when applying the treatment modality in practice.

The authors used the ICD 10 psychiatric diagnosis for different groups in depression, anxiety, adjustment disorder and stress as the inclusion criteria. However NICE guidance 2009, describes Mindfulness- based cognitive therapy as psychological intervention for relapse prevention “Mindfulness- based cognitive therapy for people who are currently well, but have experienced three or more precious episodes of depression” (, and the study did not seem to a give a breakdown about the number of depressive episodes that patients included have had.

The intervention based on the two mindfulness-based therapies MBCR and MBCT were structured and controlled meditative exercises. All participants received pharmacological treatment if deemed necessary. The control group received TAU which some time included pharmacological treatment and most cases also psychotherapy or counselling. This is not in accordance with clinical equipoise which is the ethical basis for medical research.

Treatment effects cannot be made without attention to treatment fidelity which is necessary for internal and external validity of study. These rules out Type 1 and 2 errors.

The assessment of delivery which means adherence to treatment components and competence to deliver the treatment in the manner specified need to be assessed? The gold standard to ensure that treatment are delivered as specified is to use audio or video tapes for objective verification of delivery, evaluated according to criteria developed a priori. Videotaping enables the evaluation of non-verbal behaviours in both providers and patients. The only disadvantage would be that it is more obtrusive and costly and may increase demand characteristics.

To enhance treatment fidelity for treatment delivery an independent group can be used to review taped sessions and guess the treatment conditions.

1-National Institute For Health and Care Excelence (2009), Depression in adults; The treatment and management of Depression in Adults, (CG90). London; National Institute For Health and Care Excelence.

2-Borrelli B. The Assessment, Monitoring, and Enhancement of Treatment Fidility In Public Health Clinical Trials. J Public Health Dent. 2011 ; 71(s1): S52-S63.

With thanks to Dr Akeem Sule, Consultant Psychiatrist at Cumbria Partnership NHS Foundation Trust for advice.

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Conflict of interest: None Declared

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