It’s cards on the table time: I’m no expert on mindfulness. Sure, I’ve read a few mindfulness studies and written and edited a number of blogs, so I have a reasonable idea about what’s going on in terms of research. I’ve also tried out a few simple mindfulness exercises myself, having skimmed a couple of the best books and watched a few YouTube videos.
So it was with a little trepidation that I accepted the offer to appear on the BBC Radio 4 All in the Mind show today, to offer my thoughts on the recent Mindful Nation report and to discuss the current state of mindfulness research in general.
This blog is a summary of the Mindful Nation report, which was published last month by the Mindfulness Initiative. It was written by the Mindfulness All-Party Parliamentary Group, which was set up to:
- Review the scientific evidence and current best practice in mindfulness training
- Develop policy recommendations for government, based on these findings
- Provide a forum for discussion in Parliament for the role of mindfulness and its implementation in public policy.
We have blogged about some of the evidence cited in the report (see my Evidence for Mindfulness blog from May 2015 for a good summary of our work), so it’s interesting to compare the recommendations in the report with our conclusions having critically appraised the same studies.
The Mindfulness Initiative website says:
The recommendations in this report are evidence-based, sourced directly from experienced implementers, who report notable success in their respective fields and urge policymakers to invest resources in further pilot studies and increase public access to qualified teacher trainers.
Eight parliamentary hearings took place from 20th May to 9th Dec 2014 and each looked at mindfulness in relation to a specific population or setting. Two of the hearings focused on mindfulness in the workplace and the others covered mindfulness and mental health, health (covering physical pain and NHS staff), the criminal justice system, education, policing and gangs.
A brief appendix in the report lists the chairs and some of the included speakers from these hearings. The list from the mental health hearing looks like a mix of service users, researchers, clinicians and commissioners. There’s no information about how speakers were selected and invited, or what perspective these different people are coming from. My hunch is that they are mostly mindfulness experts and researchers, or people who have been involved in local initiatives that are being used as case studies in the report. Either way, as ‘converts’ to mindfulness I suspect that their opinions come with certain biases.
The report cites at least 10 studies that investigate the effectiveness of mindfulness based interventions for mental health conditions (mostly RCTs, systematic reviews and meta-analyses) . It is unclear how this evidence was selected for inclusion and whether other studies were excluded and for what reason. Clearly, this report is not an evidence-based guideline, but it does make recommendations for future health service delivery and research, so it would be helpful to see the methodology used to produce the report in order to have confidence in the final content. This level of detail may be available on the Mindfulness Initiative or Mindfulness All-Party Parliamentary Group websites, but I couldn’t find it.
The executive summary of the report says early on (paragraph 2) that while mindfulness “is not a panacea, it does appear to offer benefit in a wide range of contexts”.
The report then goes on to make a number of recommendations for health, education, workforce and criminal justice. I will focus here on the health recommendations, which I’ve paraphrased below:
Health service delivery
- Mindfulness based cognitive therapy (MBCT) should be made available to everyone who is at risk of recurrent depression (that’s 580,000 adults each year). The suggested ‘first step’ is to offer MBCT to 15% of this group (87,000 adults) by 2020
- The IAPT programme should be funded to train 100 new MBCT teachers every year for the next 5 years, which would mean that by 2020 we would have 1,200 trained MBCT teachers to deliver the above recommendation
- MBCT should be offered to everyone living with a long-term physical health condition and a history of recurrent depression
- NICE should review the evidence for mindfulness based interventions (MBIs) in relation to irritable bowel syndrome, cancer and chronic pain.
The report recommends that the NIHR invites bids to study:
- MBCT to prevent recurrent depression in young people
- Mindfulness based stress reduction (MBSR) for long-term physical health conditions
- Lower intensity mindfulness based interventions as public health preventative interventions for people at higher risk of mental illness.
So where’s the evidence to support these recommendations? Well let’s take MBCT for recurrent depression as an example. That seems to be the most well researched area and one where the evidence is strongest.
Mindfulness based cognitive therapy for depression
The uptake of Mindfulness based cognitive therapy (MBCT) within the NHS has been relatively slow since it was recommend for treatment of recurrent depression in the NICE 2004 depression guideline (the 2009 update of that guideline continued to make this recommendation, but NICE has not yet recommended mindfulness based interventions for any other mental or physical health condition). The report quotes a study (Cavanagh, 2014) which suggests that nearly three quarters of GPs want to refer patients to NHS mindfulness courses, but only 1 in 5 have access in their area.
The evidence cited in the report for MBCT for recurrent depression is a 5-year old systematic review (Piet & Hougaard, 2011). Newer studies have provided further evidence that show MBCT in a positive light for preventing recurrent depression, including the PREVENT RCT (Kuyken et al, 2015), which we covered on the Mental Elf back in April and the recent meta-regression by Karolien et al (2015).
The report says that MBCT is a cost effective treatment for depression, but I cannot find a reference for this statement. The PREVENT RCT suggests that MBCT has, at best, a 52% probability of being more cost effective than antidepressants.
Mindfulness for other mental health conditions
The report also cites a few other studies described as “emerging evidence supporting the use” of MBCT and MBIs. We’ve blogged about some of these papers over the last few years and did not always have quite such positive conclusions, e.g.
- RCT of mindfulness based cognitive therapy for health anxiety (McManus, 2012) which we concluded was promising, but suffered from a number of limitations which made the findings difficult to apply in practice
- Meta-analysis of mindfulness based interventions for psychosis (Khoury, 2013) which we concluded was interesting, but again very difficult to use in the real world because of significant limitations in the primary research.
Overall I was rather disappointed by the lack of high quality evidence presented in the report. My calculations show that about 600 mindfulness RCTs and 250 mindfulness systematic reviews and meta-analyses were published worldwide in 2014, so it’s surprising that more of this evidence didn’t find it’s way into a report that is clearly trying to persuade the powers that be that mindfulness is worth significant investment.
My take home message from this whole experience is that clinical practice and health policy sometimes change before the evidence is in place (shock horror!). It takes a long time for research evidence to show what treatments are safe and effective, and for which populations and conditions. Guideline producers, policy makers and politicians don’t always have the patience to wait for reliable evidence before they make their recommendations (CBT for psychosis anyone?).
I’m not convinced that the evidence yet exists to support the case made by the Mindful Nation report, but I remain very interested in mindfulness as a practice that we can all learn from. I would like to see more compelling primary studies (with usual care groups and more real world study populations – both things that the PREVENT RCT did not have). Studies should ensure to monitor, measure and report on side effects, and they should also focus on the cost effectiveness of mindfulness. An up to date systematic review of MBCT for recurrent depression wouldn’t go amiss either.
I will continue to highlight evidence about mindfulness based interventions for mental illness. This is clearly an emerging field with more and more reliable studies being published. Perhaps future research will support the Mindful Nation recommendations. Only time will tell.
The advantages of having a more mindful nation
Finally, it’s important that we make the distinction between the kinds of mindfulness based interventions I’ve been talking about in this blog and the every day practice of mindfulness that we can all enjoy.
Mindfulness is about paying attention to the present moment, without getting stuck in the past or worrying about the future. Being conscious of our mind, body and external environment. We all have every day moments of mindfulness. I had one this morning; walking through the woodland (external environment), noticing a cold breeze on my elfin ears (body) and feeling happy with my soon to be published blog and tweets (mind).
There are many positives that we can all take from this simple practice, but also advantages that this may have on a societal level:
Promoting self-care and mental wellbeing
Any practice that promotes mental wellbeing should be encouraged. We all have mental health, but many of us pay less attention to our mental wellbeing than we do to our physical wellbeing. Mindfulness puts the management of our health in our own hands (and minds). Self-care and self-management give the power to the patient, which historically has rarely been the case for people with mental illness.
Mental health prevention
We know that “Mental ill health represents up to 23% of the total burden of ill health in the UK.” (DH, 2011; Campion, 2013) Outcomes are poor for mental health patients once they are ill, so it makes sense to try and prevent illness from occurring or reoccurring if we can. For me, this is where the whole mindfulness movement can have the biggest impact; by helping us all to build resilience in the face of stress and prevent mental illness from taking hold in the first place.
Have you tried being mindful today? If not, why not start with a simple FOFBOC (Feet on Floor, Bum on Chair) practice?
Mindful Nation UK: report by the Mindfulness All-Party Parliamentary Group (MAPPG) (PDF). The Mindfulness Initiative, Oct 2015. http://www.themindfulnessinitiative.org.uk/images/reports/Mindfulness-APPG-Report_Mindful-Nation-UK_Oct2015.pdf
Piet J, Hougaard E. (2011) The effect of Mindfulness-Based Cognitive Therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review. 2011;31:1032–40. [PubMed abstract]
Kuyken W. et al (2015) Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. The Lancet, published online 21 Apr 2015.
McManus F, Surawy C, Muse K, Vazquez-Montes M, & Williams JMG. A randomized clinical trial of Mindfulness-Based Cognitive Therapy versus unrestricted services for health anxiety (hypochondriasis). Journal of Consulting and Clinical Psychology. 2012; 80:817–28. [PubMed abstract]
Khoury B, Lecomte T, Gaudiano BA, Paquin K. Mindfulness interventions for psychosis: a meta- analysis. Schizophrenia Research. 2013;150:176–84. [PubMed abstract]
Cavanagh K, Strauss C, Forder L, Jones F. Can mindfulness and acceptance be learnt by self-help?: A systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions. Clinical Psychology Review. 2014;34:118–129. [PubMed abstract]
No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages (PDF). Department of Health, 2011
Campion J, UCL Partners & SLaM, 6/13 presentation. http://www.nhft.nhs.uk/mediaFiles/downloads/80814779/Dr%20Jonathan%20Campion.pdf
Karolien E.M. et al (2015) Effectiveness of psychological interventions in preventing recurrence of depressive disorder: Meta-analysis and meta-regression, Journal of Affective Disorders, Volume 174, 15 March 2015, Pages 400-410, ISSN 0165-0327, http://dx.doi.org/10.1016/j.jad.2014.12.016. http://www.sciencedirect.com/science/article/pii/S0165032714008027