Depression is a relatively common mental health condition affecting 6-20% of people in their lifetime (Kessler & Bromet, 2013; GBD, 2018). It’s a relapsing and remitting condition, meaning people have episodes of depression and episodes of being well. On average, people who have one episode of depression, tend to go on to have 7-8 episodes.
It’s recommended that people with recurrent depression should take antidepressants even when they’re well in order to prevent relapse (NIHR, 2009). Taking antidepressants is a useful way to prevent a recurrent episode, but there are also many reasons people would like to come off their antidepressants (e.g. wanting to find out their ‘real self’, side effects and uncertainty about whether they need to take them).
Psychological therapies are also useful in helping people to recover from depression (NIHR, 2009). They can work well alongside people tapering off their medication (slowly reducing the dose and eventually stopping completely). There has been research looking at people’s experiences of psychological therapy and of discontinuing antidepressants, but not of both together.
Tickell et al. (2020) in this study aimed to look at the experiences of people with recurrent depression who had mindfulness-based cognitive therapy (MBCT) with advice about discontinuing their antidepressants.
Depression affects 6-20% of people at some point in their lives and antidepressants can prevent relapse, but what about people who would rather not take medication?
Methods
Tickell and colleagues (2020) interviewed people who had been part of PREVENT trial (Kuyken, 2015), which we previously blogged about here. In that trial, participants who had depression and were taking antidepressants to prevent relapse, received MBCT and guidance on how to reduce their antidepressants.
MBCT is a psychological therapy using mindfulness, which involves teaching people to have a non-judgemental awareness of their thoughts and feelings. In the PREVENT trial, participants attended eight weekly sessions of MBCT in groups, and four refresher sessions offered in the following year. In these sessions, the MBCT was adapted to include support for stopping antidepressants and preventing relapses of depression.
Participants had recurrent depression, but were currently in remission and they were taking antidepressants to prevent relapse. All had at least three previous episodes of depression and were invited for an interview only if they attended four or more sessions of MBCT. The researchers deliberately selected a diverse group of patients who varied in terms of:
- Level of child abuse
- How well they have previously responded to treatment
- Whether they tried to stop antidepressants
- Whether they have successfully stopped antidepressants
- Whether they reduced but did not stop their antidepressants
- Whether they stopped but then restarted their antidepressants
This led to a sample of 42 participants with a range of different experiences. Participants were mostly female, all white, and had an average age of 52.
Participants were given the opportunity to provide feedback in booklets during the study and take part in in-depth structured interviews. The booklets contained questions about patients views and experiences of the treatment and were given out at the end of the 8-week treatment period and 24 months later. Similarly, the interviews explored their experiences of MBCT and what the two years following treatment had been like for them. All interviews were conducted face-to-face around two years after finishing treatment.
The researchers analysed the content of the booklets and interviews using thematic analysis in order to understand individual experiences and perspectives of MBCT and stopping antidepressants.
Results
1. Beliefs about the causes and treatment of depression
Participants had differing beliefs about the cause of their depression. Many participants believed their depression was caused by a chemical deficiency (usually serotonin) in the brain and that antidepressants were needed to correct that imbalance. For some patients, this belief discouraged their views that a psychological treatment like MBCT would be helpful. They felt a chemical treatment would be needed to treat a chemical problem. Patients also talked about how their beliefs changed during the treatment and they were open to a more psychological as opposed to biological understanding of depression and treatment. They felt confident that it could help them stop their antidepressants. Some people maintained their beliefs in a biological model during treatment. In particular, people whose symptoms worsened during MBCT endorsed a biological model while those who felt improvements believed in a more psychological model. For some participants, the two models worked well together. For example, they felt that MBCT and the techniques it teaches were another way of increasing serotonin. People who believed this saw antidepressants as another useful way to support their recovery rather than seeing antidepressants and MBCT as competing ideas.
2. Personal agency
This theme describes participants who felt that MBCT gave them a greater sense of agency over their ability to prevent relapse. This increased sense of agency was related to feelings of being in control of one’s depression as a result of the MBCT; though for some patients, antidepressants were considered a way of being in control of their symptoms. Learning new skills in MBCT helped them to feel confident in stopping antidepressants as they had a ‘toolbox’ they could use to prevent relapse. With this came an increased awareness and ability to recognise the early signs of relapse. This increased feeling of personal agency also made participants feel more responsible for their depression. For many, this was seen as a positive, where recovery is something they have achieved. However for others it came with feeling that they were at fault if they experienced symptoms of depression. The sense of control that came with MBCT was not considered stable by participants who found it hard to keep up with the mindfulness practices at home.
3. Acceptance
Before taking part in the trial, feelings of shame around taking antidepressants and inadequacy in dealing with life stresses were reported. The need to take antidepressants was sometimes seen as reinforcing an idea that the person is ‘ill’ or ‘sick’ even if they were not experiencing symptoms at that time. MBCT helped some participants to accept having depression and they were able to identify with other people in the group who had similar experiences. Feeling more able to accept having depression helped some participants to take a more caring approach to themselves. Self-care was seen as a practical means to help with recovery as opposed to something ‘fluffy’. This also meant that some people felt more accepting of the need to continue taking antidepressants. MBCT also helped some people to accept the relapsing and remitting nature of depression. They felt more accepting of the fluctuations in their mood and no longer wanted to use antidepressants to ‘blank out’ negative feelings.
4. Quality of life
Participants talked about how MBCT helped them go from ‘coping’ with life, to experiencing life more fully. For example, some found that they were able to experience and appreciate a full range of emotions now that they were no longer taking antidepressants; both the highs and the lows.
5. Antidepressant tapering/discontinuation
This theme identified participants’ experiences and views of coming off antidepressants. Participants felt it was important to do this at the right time. They felt that antidepressants were useful when they first became depressed, but as time went on, self-management strategies like those taught in MBCT were useful for recovery in the long term and helped patients to understand the difference between relapse and withdrawal.
6. Interactions with GP
Participants talk about how having a GP who was readily available supported them in stopping antidepressants. Participants varied in the extent to which they relied on GP support. In particular if they felt able to self-manage using the tools taught in MBCT, they felt better able to discontinue independently.
Patients who believed in a biological basis of depression were less likely to think that a psychological treatment like mindfulness could help them.
Conclusions
People have different recovery journeys when they have mindfulness-based cognitive therapy with support tapering their medication. However there were six overarching themes that describe the patient journeys: beliefs about the causes of depression, personal agency, acceptance, quality of life, antidepressant tapering/discontinuation and interactions with GP.
In this study, mindfulness-based cognitive therapy was designed to help patients to prevent depressive relapse and support tapering off antidepressants.
Strengths and limitations
This study had a large sample of participants which is useful to understand a range of different perspectives, as the researchers deliberately recruited people with varied experiences on MBCT and tapering. However, the sample was not very diverse in terms of age, gender or ethnicity, so more work is needed to make it more representative of the UK population.
During analysis, four different researchers analysed a part of the data and then compared what they found. Thus, different readings were taken of the data, but the ideas were then agreed and focused on the area of interest. Before continuing with analysis, a coding frame was developed to facilitate the thematic analysis. The researcher who used this coding frame to analyse the data regularly met with the research team to discuss the findings. Using this method prevented a biased analysis.
This study suggests people may find group MBCT helpful, however it can be hard for people to attend these groups and they can be costly. A more accessible format (e.g. online) might be another useful way to support people with greater access and fewer costs. However, the researchers only recruited people who were interested or open to tapering their medication. The experiences of people who are less open to tapering are not represented. It might be that people who are less willing to taper have strong, possibly more negative views about MBCT and tapering support. Therefore, more research is needed with this population.
This was an important piece of work as it highlights people’s views of MBCT and tapering within the trial setting, but it would be also useful to explore the mechanisms through which the MBCT helped people. A qualitative process evaluation would have been helpful to understand how the treatment worked.
Future research should explore the mechanisms through which mindfulness-based cognitive therapy can help people stop using antidepressant medication and remain free of depressive symptoms.
Implications for practice
People may like to have MBCT and tapering support to come off antidepressants, as this may foster personal agency with regards to self-management. However, people’s experiences are varied and further research is needed to understand who in particular will benefit from MBCT and tapering support.
It’s important here to realise that this study alone does not suggest that MBCT with tapering support is effective in helping people come off antidepressants, rather that they liked it and felt that it was helpful. As a qualitative study, it can only tell us about people’s perspectives and experiences. A randomised controlled trial would be needed to demonstrate efficacy (you can read about the PREVENT trial these participants were part of here).
Some people may like to have MBCT and tapering support to come off antidepressants, as this may foster personal agency with regards to self-management.
Statement of interests
Hannah Bowers is currently working on the REDUCE programme, researching the feasibility and acceptability of a digital intervention to support antidepressant withdrawal.
Links
Primary paper
Tickell A, Byng R, Crane C, et al. Recovery from recurrent depression with mindfulness-based cognitive therapy and antidepressants: a qualitative study with illustrative case studies. BMJ Open 2020;10:e033892. doi:10.1136/ bmjopen-2019-033892.
Other references
Kessler RC, Bromet EJ. (2013) The epidemiology of depression across cultures. Annu Rev Public Health 2013;34:119–38.
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. (2018) Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. Lancet 2018;392:1789–858. https://doi.org/10.1016/S0140-6736(18)32279-7
NICE (2009) Depression: The treatment and management of depression in adults (update). National Institute of Health and Care Excellence, 2009.
Kuyken W, Hayes R, Barrett B, 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 2015;386:63–73 https://doi.org/10.1016/S0140-6736(14)62222-4
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