Introduction
Depression is one of the most common mental health conditions globally (World Health Organisation, 2022). Although a range of effective treatments are available for depression, it remains a highly recurrent disorder (Keller et al., Reference Keller, Lavori, Mueller, Coryell, Hirschfeld and Shea1992) which consequently poses major clinical, economic, and public health implications. For example, in the UK the total cost of adult depression has been estimated at over £9 billion by 2026, of which £3 billion relates to direct treatment (McManus et al., Reference McManus, Bebbington, Jenkins and Brugha2014). It is important to note that the large part of the overall cost is due to lost productivity from people with depression and the burden on unpaid informal carers. In terms of employment, approximately 110 million working days are lost per year through depression, with a predicted cost to the UK economy of £12.2 billion by 2026 (McManus et al., Reference McManus, Bebbington, Jenkins and Brugha2014). The majority of patients (90%) with major depressive disorder report functional impairment (Kessler et al., Reference Kessler, Berglund and Demler2003) and are often characterised by high health service use and costs (McMahon et al., Reference McMahon, Buszewicz and Griffin2012). Related to this, mental health problems contribute to approximately 40% of work-based absenteeism, while depression has been estimated to account for over 4% of UK unemployment (Layard and Clark, Reference Layard and Clark2015).
Recently, interest has been shown for interventions that can bring a reduction in depression relapse rates. Mindfulness-based cognitive therapy (MBCT) is a psychosocial intervention that has been purposefully developed to help individuals at risk of depressive relapse (Teasdale et al., Reference Teasdale, Segal, Williams, Ridgeway, Soulsby and Lau2000). MBCT is included in health guidance for patients in depression remission who are at significant risk of relapse or have residual depressive symptoms, or new and less severe depression (National Institute for Health and Care Excellence, 2022). MBCT provides patients with therapeutic skills to prevent future episodes (Rycroft-Malone et al., Reference Rycroft-Malone, Gradinger and Griffiths2019). Meta-analytic evidence has shown MBCT to be effective for reducing depression relapse rates by 50% compared with treatment as usual for patients with three or more depressive episodes (McCartney et al., Reference McCartney, Nevitt, Lloyd, Hill, White and Duarte2021). Kuyken et al. (Kuyken et al., Reference Kuyken, Hayes and Barrett2015) completed a comprehensive randomised controlled trial (RCT) focusing on the clinical and cost-effectiveness of MBCT compared with maintenance anti-depressant medication. They discovered that both MBCT and prophylactic anti-depressants were highly effective in the prevention of depressive relapse, and cost-effective in the reduction in care utilisation and productivity losses related to depression.
Lau et al. (Reference Lau, Colley and Willett2012) indicate that depression increases the likelihood of absenteeism and a reduction of productivity within the workplace and argue MBCT may provide a viable and cost-effective option for employees who have a history of depression. Despite this, little empirical research has investigated the possible benefits of MBCT for clients with recurrent depression within the workplace. Parallel to the MBCT literature there has been a growing body of evidence that mindfulness can increase the wellbeing of employees, job satisfaction, productivity and reduce absenteeism (Michaelsen et al., Reference Michaelsen, Graser, Onescheit, Tuma, Werdecker, Pieper and Esch2023; Vonderlin et al., Reference Vonderlin, Biermann and Bohus2020); however, this has not specifically focused upon employees with recurrent depression and the focus has been on stress and burnout.
The NHS Improving Access to Psychological Therapies (IAPT) programme in England provides evidence-based treatments for common mental health problems. In 2016, an IAPT-MBCT curriculum was developed to train NHS High Intensity CBT therapists to teach MBCT. In 2018, training in MBCT was commissioned by Health Education England to make MBCT more accessible through IAPT services (Oxford Mindfulness Centre, 2017). Mindfulness interventions have since been demonstrated to be feasible for implementation across large samples of patients in routine IAPT care settings, and effective for treating a variety of mental health conditions (Tickell et al., Reference Tickell, Ball and Bernard2019).
An NHS Talking Therapies team within Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust provides talking therapies to adults in the Northwest of England. A previous internal audit of patient notes (n=220) indicated that 25% of patients had at least one depressive episode, 19% had reported two, and 55% had three or more. The latter high rates of multiple depressive episodes led to the development of a pilot intervention of MBCT.
Given the utility for MBCT in preventing depression relapse, the current study was an exploratory investigation to examine how MBCT group intervention may enhance economical and clinical outcomes for patients who have recently been treated for depression.
The primary aim was subsequently to examine the possible cost-effectiveness (health utilisation, work absences) of MBCT for depression in patients with three or more previous depressive episodes following treatment, and again at 6-month follow-up. The secondary aims were to investigate changes in clinical outcomes using measures of depression, anxiety, and functioning.
Method
Design
A naturalistic (pre, post and follow-up) evaluation was used to explore the cost and clinical effectiveness of MBCT for reducing relapse in patients who had previously completed a course of psychological intervention for depression with the host service. Primary outcomes included rates of health service usage and days off sick from employment. Secondary outcomes included depression, anxiety, and functioning. The evaluation was conducted between February 2019 and August 2020.
Ethics
The current evaluation was considered as a service improvement project. The project was approved by the CNTW clinical audit team with no further ethical approval required.
Participants
Participants were patients with a history of recurrent depression but who had been recently and successfully treated by CBT and were in remission at the end of treatment. There was a minimum time period of 6 months for patients ending CBT before recruitment for MBCT. We define treatment remission as self-reported depression rating below an established clinical cut-off on the PHQ-9 being less than or equal to 9, and on the GAD-7 being less than or equal to 7, as recommended by the National Collaborating Centre for Mental Health. (2024). The number of previous depressive episodes were determined through clinical notes review. Eligible patients were identified through an electronic patient management system. Patients experiencing mild residual symptoms during the time of assessment and orientation of MBCT were still offered if, when assessed for suitability, it was considered that they were not in an acute depressive episode, and/or did not express suicidal intent or have suicidal plans.
Additional inclusion criteria required participants to be adults (aged 18 years or older) who agreed to undertake up to 1 hour mindfulness home practice 6 days per week for the full duration of the 8-week course to undertake the treatment maintenance (i.e. relapse prevention) programme (i.e. MBCT). Whilst the 1-hour daily practice was recommended, this did not exclude them from the study. Participants were not considered eligible if they: (a) were in an acute depressive episode, (b) had documented organic brain damage, (c) had a history of psychosis/bipolar affective disorder, (d) had substance misuse/dependence, (e) had significant longstanding interpersonal difficulties (e.g. meeting criteria for personality disorder), (f) was in concurrent psychological intervention, or (g) had persistent self-harm/suicide risk taking requiring management.
Procedure
Patients meeting eligibility criteria were sent MBCT invitation letters. An initial orientation appointment (45–60 minutes) was provided for each patient. This appointment consisted of two parts. First, the therapist explored with the patient any triggers, patterns, or early warning signs of depression and reviewed their coping skills. Following this, the patient was provided with information about the MBCT group (e.g. content of sessions, home practice requirements, follow-up session). The final decision about taking part in the MBCT group was made collaboratively between patient and clinician at the end of the appointment.
MBCT delivery was in person and utilised a group format. Groups required between 8 and 15 patients before commencing, as per NICE guidelines (National Institute for Health and Care Excellence, 2022). Two 8-week MBCT programmes were delivered. A third group was originally scheduled; however, this was cancelled due to the onset of the COVID-19 pandemic. Following completion of the group, patients were provided with a 6-month follow-up appointment.
Additional information required for the evaluation was collected at regular intervals; this included patient characteristics (age, gender, employment, depression and anxiety symptoms, functional impairment) and treatment characteristics (concurrent medication, time since prior treatment, completion status, health, and social care service utilisation).
Intervention
MBCT is a manualised group-based skills training programme (Segal et al., Reference Segal, Williams and Teasdale2013) based on the integration of mindfulness-based stress reduction (Kabat-Zinn, Reference Kabat-Zinn1990) with cognitive behaviour therapy for depression (Beck, Reference Beck1979). It is designed to teach people skills that enable them to disengage from habitual negative thought patterns and, therefore, to reduce the future risk of relapse in depression and, eventually, prevent recurrent depression. It aims to achieve this by teaching people to become more aware of the patterns of their bodily sensations, thoughts, feelings and urges to act and to enable them to relate to these experiences in a more compassionate, curious, non-judgemental manner (Segal et al., Reference Segal, Williams and Teasdale2013).
The MBCT programme was delivered in weekly 2-hour training sessions over eight consecutive weeks. The programme included daily exercises that were referred to as ‘home practice’. Participants were required to complete up to an hour of home practice, for at least 6 days per week, and keep a diary on their reflections, all of which were consistently reviewed at each session. This included formal and informal mindfulness practices and exercises that aimed to incorporate awareness skills into daily life. Participants were encouraged to attend all eight sessions. The cut-off number for completion of an MBCT group was four or more sessions, in fitting with established benchmarks (Williams et al., Reference Williams, Fennell, Barnhofer, Crane, Silverton, Segal and Teasdale2017). Patients that attended less than four sessions were excluded from the study.
The MBCT facilitator was an experienced senior CBT psychotherapist and registered as an MBCT teacher with the British Association of Mindfulness-Based Approaches (BAMBA) with substantial experience leading groups for people with recurrent depression using MBCT. Adherence and competency was monitored within ongoing mindfulness supervision through the use of video recording using the Mindfulness-Based Interventions: Teaching Assessment Criteria (MBI:TAC) (Crane et al., Reference Crane, Eames, Kuyken, Hastings, Williams, Bartley, Evans, Silverton, Soulsby and Surawy2013).
Measures
Outcome assessments were taken at the start of MBCT treatment (pre), end of MBCT treatment (post), and at 6-month follow-up. The following measures were employed:
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• Patient Health Questionnaire (PHQ-9): a 9-item, self-report measure of the severity of depressive symptoms. Scores range from 0 to 27. Participants were considered ‘in remission’ if their scores fell below the clinical cut-off (<10). The scale has acceptable levels of internal consistency (Cronbach’s alpha = 0.89) and test–retest reliability (intraclass correlation = 0.84) (Kroenke, Spitzer & Williams, Reference Kroenke, Spitzer and Williams2001).
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• Generalised Anxiety Disorder (GAD-7) questionnaire: a 7-item, self-report measure of worry and anxiety symptoms. Scores range from 0 to 21. Participants were considered ‘in remission’ if their scores fell below the clinical cut-off (<8). The GAD-7 has also demonstrated levels of internal consistency (Cronbach’s alpha = 0.92) and test–retest reliability (intraclass correlation = 0.83) (Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006).
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• Work and Social Adjustment Scale (WSAS): a 5-item self-report-measure of the impact of impairment on everyday functioning. Scores range from 0 to 40. A clinical cut-off of >10 has been recommended (Mundt et al., Reference Mundt, Marks, Shear and Greist2002). The WSAS has acceptable psychometric properties (Mundt et al., Reference Mundt, Marks, Shear and Greist2002).
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• Client Service Receipt Inventory (CSRI) (Knapp and Beecham, Reference Knapp and Beecham1990): is a self-report tool used to collect information on health and social care service utilisation over the previous 3 months. We measured the levels of absenteeism using the item ‘are you in paid employment, and if so, how many days have you had off due to ill health in the last 3 months?’.
Statistical analysis
All analyses were performed using R. Cohen’s d effect-sizes were computed using the metafor package (Viechtbauer, Reference Viechtbauer2010). Patient and treatment characteristics were summarised descriptively. Differences between pre, post and follow-up outcomes were assessed using one-way repeated measures ANOVA. Analyses included all available data. In handling data attrition, it was decided that imputation through last observation carried forward (LOCF) would not be appropriate in this context (i.e. treatment relapse study) as it makes a potentially misleading assumption that patients who drop out have not relapsed.
End of treatment ‘status’ was classified using clinical change indices (Jacobson and Truax, Reference Jacobson and Truax1992). Maintenance was assigned when a patient who began MBCT in remission remained so until intervention end/follow-up. Recovery was assigned when a patient who began MBCT in the clinically depressed range moved to the non-clinical range at post-treatment/follow-up. Finally, relapse was assigned when a patient who began treatment in the non-clinical range moved to the clinical range at post-treatment/follow-up. Reliable change indices were used to determine when a statistically reliable change had occurred, irrespective of treatment status.
Results
Patient characteristics
Fifty-seven patients were considered for MBCT through one-to-one appointments; 43 patients were deemed eligible to participate. Of these, 20 patients declined treatment, citing difficulties in committing to the daily practice and not wanting to undertake therapy in a group format, leaving 23 patients who entered treatment. This raises the question of whether the remaining patients represented a particularly committed group. Characteristics of the patients included in the study are shown in Table 1. Of the patients who entered MBCT, five ended treatment prematurely (13%). There was a female majority (n=17, 73.9%), a mean age of 47.57 years (SD=13.16) and a tendency for patients to be within employment (82.6%). There was a median of 7 months (IQR=6) since previous treatment for depression. There were no statistical differences among variables between men and women accessing treatment.
Table 1. Pre-treatment characteristics for patients included in the study
Cost-effectiveness
Service utilisation
Data on the utilisation of health services is presented in Table 2. Chi-squared tests demonstrated significant reductions in usage from pre, post, and at 6-month follow-up of general practitioners (p=.023), accident and emergency services (p=.018), and blood tests (p=.016).Footnote 1
Table 2. Total number of visits to health and social care services across participants and average visits per participant before, after, and 6 months after the intervention
N, sample size; n, number of patients with at least one occurrence; Total, total count; M, mean.
Expenditure
The cost of each service visit is based on information provided to IAPT services via the National IAPT long term conditions programme (National Collaborating Centre for Mental Health, 2024). In total, 132 visits to services were made in the period prior to starting MBCT with an estimated total cost of £11,514. For the period up to MBCT completion, 48 service visits were made with an estimated total cost of £3,161, and finally eight service visits were made in the period leading up to the 6-month follow up, with a cost of £475.
Level of absenteeism
At the start of MBCT, 10 patients (of 23) reported at least one illness-related day off from work, with a total of 120 days across patients. At treatment completion, five patients (of 21) reported being off sick for a total of 31 days. Finally, at 6-month follow-up, one patient (of 14) was off sick for a single day. There was a significant reduction in the number of off-sick days between pre-treatment and follow-up (Z=–2.392, p=.017).
Clinical effectiveness
In terms of group mean change, there were no significant differences between assessment points (pre, post, follow-up) for depression (F 2,26=0.835, p=0.44), anxiety (F 2,26=0.873, p=0.43) or functioning (F 2,24=1.904, p=0.17), in line with treatment maintenance. Outcomes for each stage of the study are shown in Table 2.
Depression status
Following MBCT, 14 patients (60.9%) remained in depression remission, three newly entered recovery (13%), three remained in the clinical range (13%), and one relapsed. None of the patients reported severe symptoms of depression (i.e. PHQ-9=>19) following treatment or at 6-month follow-up. Of the 14 patients who attended 6-month follow-up, 10 patients remained in remission, two patients remained in the clinically depressed range, and two patients relapsed.
Anxiety status
Following MBCT, 11 patients (47.8%) remained in anxiety remission, five patients had newly entered recovery (21.7%), and five patients remained in the clinically anxious range (21.7%). No patients demonstrated relapse of anxiety symptoms during treatment. Of the 14 patients who attended 6-month follow-up, 10 patients maintained in remission, one patient remained in the clinically anxiety range, and three patients relapsed.
Discussion
This unique practice-based study evaluated the possible cost and clinical effectiveness of MBCT as a relapse prevention intervention for patients who had responded to psychological treatment for depression. We considered that MBCT may have led to a marked reduction in health service usage and related health care expenditure, and rates of employee absenteeism for clients who had been diagnosed with recurrent depression.
Clinically, there was limited group level change in depression or anxiety over the course of MBCT, fitting with the intended outcome of relapse prevention (Segal et al., Reference Segal, Williams and Teasdale2013). Of the 21 patients who provided post-intervention outcome data, only one person relapsed. Data collected 6 months following MBCT completion demonstrated that treatment gains were maintained (see Table 3 for details). Overall, our hypothesis suggests the possibility that MBCT for relapse prevention can maintain symptomatic improvements achieved by prior interventions while also delivering important additional cost savings through reduced health usage and absenteeism.
Table 3. Treatment scores for patients included in the study
The possibility that MBCT for depression relapse led to additional reductions in health-care usage and absenteeism is an important finding, which adds to an emerging literature regarding the cost-effectiveness of MBCT (Strauss et al., Reference Strauss, Bibby-Jones, Jones, Byford, Heslin, Parry, Barkham, Lea, Crane, de Visser, Arbon, Rosten and Cavanagh2023). The reduction in usage of general practitioners/physicians (see Table 3) is consistent with the findings of Godfrin and Van Heeringen (Reference Godfrin and Van Heeringen2010), who reported a reduction in frequency of visits to GP with depression-related complaints at 8 months following MBCT for depression relapse prevention. These significant reductions in absenteeism are echoed by Nagaoka et al. (Reference Nagaoka, Koreki, Kosugi, Ninomiya, Mimura and Sado2023) who found similar outcomes in a decrease in absenteeism, presenteeism and an increase in productivity for healthy participants who participated within MBCT compared with a wait list group.
In terms of clinical effectiveness, the current study fits with a growing body of literature indicating that MBCT can maintain clinical improvements and avoid depression relapse in routine practice (Tickell et al., Reference Tickell, Ball and Bernard2019). No significant change in symptoms were reported with regard to depression, anxiety, and functional impairment before, after, and at 6-month follow-up treatment (see Table 3).
The current study was able to provide the possibility of further evidence regarding the cost and clinical effectiveness of MBCT for prevention of depression relapse. The use of follow-up data collection offered the prospect of further confidence regarding the durability of intervention effects. The relatively low levels of attrition provide support for the acceptability of MBCT as an intervention in routine care. Several limitations are noteworthy and provide reason to interpret study findings cautiously.
A notable limitation is that data are not available for the period of depression intervention preceding MBCT. It is therefore not possible to know what level of change was established or maintained between MBCT and earlier parts of the patient care pathway (e.g. start of treatment pathway, end of depression intervention, including medication usage and CBT).
Second, as the current study was observational (i.e. no control group) it is not possible to say what level of change would otherwise been achieved in the absence of MBCT. Given that time had elapsed between previous depression intervention and MBCT relapse prevention commencing (while still maintaining clinical recovery), there is subsequently already evidence that relapse prevention was already being achieved. Despite this, it would be expected that as time progresses following initial recovery some level of deterioration would emerge, whereas patients in this study were symptomatically maintained while also demonstrating additional improvements in health-care usage and absenteeism.
Third, no information about the nature of the problem or the purpose of each healthcare appointment was provided, and therefore it is difficult to deduct that the purpose of each visit was depression related.
Fourth, the measures used in this study were exclusively self-report and may be sensitive to reporting bias.
Fifth, the sample size was small and demonstrated a high-level of attrition at 6-month follow-up (n=9), of which we do not know the reasons why; consequently this may have led to an attrition-related bias within the findings. The sample size of this study substantially limited the power and generalisability of the outcomes. This provided a dilemma for statistical analysis as commonly used imputation methods (e.g. last observation carried forward) in the context of treatment maintenance would assume patients with missing data have maintained recovery, which may well be incorrect. This led to omission of patients without data which may introduce bias. Adequately powered RCTs which examine cost-effectiveness for MBCT are an important step for future research.
Finally, the current study did not explore how mindfulness-specific mechanisms of action influence outcomes. Prior research has demonstrated a reduction in depressive symptoms has been associated with an increase in the levels of mindfulness skills for patients attending a MBCT course for depression (Van Aalderen et al., Reference Van Aalderen, Donders, Giommi, Spinhoven, Barendregt and Speckens2011). The addition of mindfulness-specific measures (e.g. Kentucky Inventory of Mindfulness Skills, Mindful Attention Awareness Scale, Self-compassion Scale; Kuyken, Crane & Williams, (Reference Kuyken, Crane and Williams2012) in future outcome batteries should be considered for research. Future studies could also consider the use of qualitative or quantitative studies that explore key mechanisms of mindfulness such as attention, acceptance and decentring as contributing factors that influence outcomes.
Key practice points
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(1) The current findings offer the possibility that MBCT may establish economical improvements while also maintaining symptomatic relief. Furthermore, outcomes following MBCT appear durable with intervention effect being shown at 6-month follow-up
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(2) Given that patients who enter MBCT are within recovery, additional data capturing of maintenance of symptoms, alongside routine care utilisation collection, could be considered.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1754470X25100408
Data availability statement
The authors confirm that the anonymised data supporting the findings of this study are available upon reasonable request.
Acknowledgements
The authors would like to acknowledge their appreciation for all the clients that participated, and to the senior clinical management and leadership team within First Step, especially to Richard Thwaites for allowing this project to go ahead.
Author contributions
Ryan Askey-Jones: Conceptualization (equal), Formal analysis (equal), Investigation (equal), Methodology (equal), Project administration (equal); Chris Gaskell: Formal analysis (equal); Olga Karagiorgou Johnstone: Data curation (equal), Formal analysis (equal), Investigation (equal).
Financial support
The authors confirm that as this study was a part of an audit, no funding was required.
Competing interests
The authors have no competing interests with respect to this publication.
Ethical standards
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS.
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