Accessibility and implementation in the UK NHS services of an effective depression relapse prevention programme: learning from mindfulness-based cognitive therapy through a mixed-methods study

Implementing a new clinical service - what's your elevator pitch?

BACKGROUND

People with multiple sclerosis (PwMS) identify emotional well-being as a key unmet care need. Mindfulness-based interventions (MBI) can improve emotional well-being in PwMS; however, there is a lack of information on their implementation in routine care. Healthcare policy influencers may provide critical insight as to the implementation process. The aim of this study was to explore the needs and priorities of healthcare policy influencers for implementing MBIs for PwMS in Canada.

METHODS

A qualitative descriptive approach was adopted using semi-structured interviews with an inductive thematic analysis. Healthcare policy influencers (e.g., senior clinical leaders, provisional health service commissioners, healthcare policymakers) in various settings across Ontario were recruited.

RESULTS

Twelve individuals with an average age of 51.1 ± 8.9 years participated in the semi-structured interviews. Interviews ranged from 12 to 60 min. Four themes were identified in thematic analysis: (1) Need for evidence with a personal connection is foundational; (2) People Power: Need for Implementation champions; (3) Finding its place: Need for embedding interventions into existing systems; and (4) Sustainability: Need for focus on long-term impact.

CONCLUSION

Our study provides novel insight into complex factors which affect implementation of new interventions, such as MBIs for PwMS, into the healthcare landscape in Ontario. Six key steps were identified for implementors to consider when seeking to implement a new intervention: (1) identify the problem and the need for intervention, (2) establish evidence highlighting evidence of effectiveness for an intervention, (3) build a team of implementation champions, (4) pilot the novel intervention to establish proof of concept, feasibility, and ecological integration within current landscape, (5) identify decision makers for intervention implementation, and (6) develop an 'elevator pitch' for decision makers. The implementation process is convoluted and can lack clarity. This is a major challenge for implementers. We have identified six key steps for implementers to consider, making this process more transparent and hopefully more successful. Future research should explore, test, and bridge the gaps in the implementation pathway we have identified, as this may be critical in closing the gaps that exist in our healthcare systems.

Center M Pilot Trial: Integrating Preventive Mental Health Care in Routine Prenatal Care

INTRODUCTION

Perinatal depression is a leading cause of preventable US maternal morbidity and mortality. Although Mindfulness-Based Cognitive Therapy for Perinatal Depression (MBCT-PD) is highly effective, it faces significant scalability challenges. Center M, a brief, group-based, mindfulness-based cognitive behavioral therapy (CBT) intervention, is an adaptation of MBCT-PD designed to overcome these challenges. The purpose of this pilot study was to evaluate Center M's preliminary acceptability, feasibility, mechanisms of action, and efficacy.

METHODS

In this mixed-methods pilot study, data were collected from 99 pregnant people at 3 time points: preintervention, postintervention, and 6-weeks postpartum (Clinical Trials no. NCT06525922). Participants engaged in 4 one-hour, weekly group telehealth Center M sessions facilitated by social workers. Participants strengthened mindfulness CBT skills using home practice materials between group sessions. Data included self-report measures evaluating depressive symptoms, mindfulness skills, and emotion regulation. Satisfaction was assessed via focus groups or surveys.

RESULTS

Depressive symptoms significantly decreased preintervention to postintervention (Patient Health Questionnaire-8 score: preintervention mean [SD] 5.02 [3.52], postintervention mean [SD] 4.23 [2.84]; P = .03), and mindfulness capacity significantly increased preintervention to 6 weeks postpartum (Five Facets of Mindfulness Questionnaire score: preintervention mean [SD] 125.56 [18.68], 6 weeks postpartum mean [SD] 130.10 [17.15]; P = .004). Linear regression analyses indicate that higher mindfulness at 6 weeks postpartum significantly predicted fewer depression symptoms at 6 weeks postpartum (β, -0.07; 95% CI, -0.123 to -0.021, R2 = 0.22; P = .006). Reduction in the use of maladaptive emotion regulation was significantly associated with decreased depressive symptoms at 6 weeks postpartum (β, 0.21; 95% CI, 0.048 to 0.376, R2 = .21; P = .012). Qualitative themes indicated high Center M acceptability and appeal.

DISCUSSION

Our findings support the feasibility, acceptability, and appeal of Center M. Results suggest Center M may be effective in reducing depression and enhancing mindfulness skills. Future research must confirm these initial findings to more widely address Center M implementation capacity and sustainability.

A Systematic Review Exploring the Effectiveness of Mindfulness for Sexual Functioning in Women with Cancer

Sexual intimacy is a basic human need that is associated with quality of life whereby its absence can significantly impact both interpersonal and personal wellbeing. This systematic review aimed to provide an up-to-date evaluation of the available literature on mindfulness treatments for sexual functioning in women diagnosed with cancer. Electronic searches including PubMed, PsycINFO, Web of Science and registered clinical trials yielded 10 studies that met the inclusion criteria. The results showed that treatment intervention designs varied and included mixed methods, randomised clinical trials, single arm non-randomised trials and those with the absence of any control. Furthermore, both brief and longer-term mindfulness interventions were trialled across different sexual domains. Whilst inconclusive, mindfulness-based interventions appear to support sexual function and quality of life in both early- and post-cancer survivors. However, in some instances, there were outcome inconsistencies in sexual desire, arousal and orgasm. This review has identified a current shortage in research on the effectiveness of mindfulness-based treatments for supporting sexual functioning in women with cancer; and so far, no research has been conducted in palliative care. This unmet need in supporting sexual functioning in women with cancer, including palliative care, carries important implications for both psychosexual and oncological healthcare services as sexual intimacy does not end with cancer diagnosis or prognosis.

A rowing-specific mindfulness intervention: Effects on mindfulness, flow, reinvestment, and performance

Mindfulness can benefit athletes’ mindset and performance. These benefits may be enhanced by sport-specific mindfulness interventions. Accordingly, our objectives were 2-fold: first, to develop a rowing-specific mindfulness intervention, and second, to investigate its effects on mindfulness, flow, reinvestment, and rowing performance. Rowers were randomly assigned to either a 6-week rowing-specific mindfulness intervention (n = 23), which included generic and rowing-specific practices, or a control group (n = 21). Rowers completed pre-test and post-test measures of performance, mindfulness, flow, and rowing-specific reinvestment. Lastly, rowers completed an evaluation form following the intervention. The results demonstrated that the intervention group increased flow, mindfulness, and improved performance, additionally conscious motor processing decreased from pre-test to post-test. However, the intervention did not preferentially change mindfulness or reinvestment compared to control. Participants provided favorable feedback and evaluated the intervention positively. Our 6-week rowing-specific mindfulness intervention promoted flow, encouraged mindfulness, and aided performance. Thus, we provide preliminary explorative evidence that a sport-specific mindfulness intervention can benefit athletes. We recommend that future research, with large sample sizes and improved home practice, should examine mediators and moderators of the mindfulness-performance relationship.

From many to (n)one: Meditation and the plasticity of the predictive mind

How profoundly can humans change their own minds? In this paper we offer a unifying account of deconstructive meditation under the predictive processing view. We start from simple axioms. First, the brain makes predictions based on past experience, both phylogenetic and ontogenetic. Second, deconstructive meditation brings one closer to the here and now by disengaging anticipatory processes. We propose that practicing meditation therefore gradually reduces counterfactual temporally deep cognition, until all conceptual processing falls away, unveiling a state of pure awareness. Our account also places three main styles of meditation (focused attention, open monitoring, and non-dual) on a single continuum, where each technique relinquishes increasingly engrained habits of prediction, including the predicted self. This deconstruction can also permit certain insights by making the above processes available to introspection. Our framework is consistent with the state of empirical and (neuro)phenomenological evidence and illuminates the top-down plasticity of the predictive mind. Experimental rigor, neurophenomenology, and no-report paradigms are needed to further understanding of how meditation affects predictive processing and the self.

Training School Teachers to Deliver a Mindfulness Program: Exploring Scalability, Acceptability, Effectiveness, and Cost-effectiveness

BACKGROUND

There is growing research support for the use of mindfulness training (MT) in schools, but almost no high-quality evidence about different training models for people wishing to teach mindfulness in this setting. Effective dissemination of MT relies on the development of scalable training routes.

OBJECTIVE

To compare 4 training routes for school teachers wishing to deliver MT differing in intensity and potential scalability, considering teaching competency, training acceptability, and cost-effectiveness.

METHODS

Schools were randomized to an existing route comprising an 8-session instructor-led personal mindfulness course, combined with 4-day MT program training, or 1 of 3 more scalable, lower intensity, alternatives: an instructor-led personal mindfulness course combined with 1-day MT program training, a self-taught personal mindfulness course (delivered through a course book) combined with 4-day MT program training, and a self-taught personal mindfulness course combined with 1-day MT program training.

RESULTS

Attrition from training was substantial across all routes. The instructor-led course was more effective than the self-taught course in increasing teachers' personal mindfulness skills. Even the most intensive (existing) training route brought only 29% of the teachers commencing training, and 56% of those completing the study protocol, to the required minimum competency threshold (an advanced beginner rating on an adapted version of the Mindfulness-based Interventions Teaching Assessment Criteria). The differences in levels of competency achieved by existing training compared with the more scalable alternatives were modest, with economic evaluation suggesting that the existing route was both more expensive and more effective than lower intensity alternatives, but with no statistically significant differences between routes.

CONCLUSIONS

This research questions the move toward abbreviating teacher training to increase scalability and suggests instead that many teachers require additional support to ensure competency from first delivery of MT in the classroom.

Testing the Efficacy of a Multicomponent, Self-Guided, Smartphone-Based Meditation App: Three-Armed Randomized Controlled Trial

BACKGROUND

A growing number of randomized controlled trials (RCTs) suggest psychological benefits associated with meditation training delivered via mobile health. However, research in this area has primarily focused on mindfulness, only one of many meditative techniques.

OBJECTIVE

This study aims to evaluate the efficacy of 2 versions of a self-guided, smartphone-based meditation app-the Healthy Minds Program (HMP)-which includes training in mindfulness (Awareness), along with practices designed to cultivate positive relationships (Connection) or insight into the nature of the self (Insight).

METHODS

A three-arm, fully remote RCT compared 8 weeks of one of 2 HMP conditions (Awareness+Connection and Awareness+Insight) with a waitlist control. Adults (≥18 years) without extensive previous meditation experience were eligible. The primary outcome was psychological distress (depression, anxiety, and stress). Secondary outcomes were social connection, empathy, compassion, self-reflection, insight, rumination, defusion, and mindfulness. Measures were completed at pretest, midtreatment, and posttest between October 2019 and April 2020. Longitudinal data were analyzed using intention-to-treat principles with maximum likelihood.

RESULTS

A total of 343 participants were randomized and 186 (54.2%) completed at least one posttest assessment. The majority (166/228, 72.8%) of those assigned to HMP conditions downloaded the app. The 2 HMP conditions did not differ from one another in terms of changes in any outcome. Relative to the waitlist control, the HMP conditions showed larger improvements in distress, social connectedness, mindfulness, and measures theoretically linked to insight training (d=-0.28 to 0.41; Ps≤.02), despite modest exposure to connection- and insight-related practice. The results were robust to some assumptions about nonrandom patterns of missing data. Improvements in distress were associated with days of use. Candidate mediators (social connection, insight, rumination, defusion, and mindfulness) and moderators (baseline rumination, defusion, and empathy) of changes in distress were identified.

CONCLUSIONS

This study provides initial evidence of efficacy for the HMP app in reducing distress and improving outcomes related to well-being, including social connectedness. Future studies should attempt to increase study retention and user engagement.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04139005; https://clinicaltrials.gov/ct2/show/NCT04139005.

'Mind the gaps': the accessibility and implementation of an effective depression relapse prevention programme in UK NHS services: learning from mindfulness-based cognitive therapy through a mixed-methods study

OBJECTIVES

Mindfulness-based cognitive therapy (MBCT) is an evidence-based approach for people at risk of depressive relapse to support their long-term recovery. However, despite its inclusion in guidelines, there is an 'implementation cliff'. The study objective was to develop a better explanation of what facilitates MBCT implementation.

SETTING

UK primary and secondary care mental health services.

DESIGN, PARTICIPANTS AND METHODS

A national two-phase, multi-method qualitative study was conducted, which was conceptually underpinned by the Promoting Action on Research Implementation in Health Services framework. Phase I involved interviews with stakeholders from 40 service providers about current provision of MBCT. Phase II involved 10 purposively sampled case studies to obtain a more detailed understanding of MBCT implementation. Data were analysed using adapted framework analysis, refined through stakeholder consultation.

RESULTS

Access to MBCT is variable across the UK services. Where available, services have adapted MBCT to fit their context by integrating it into their care pathways. Evidence was often important to implementation but took different forms: the NICE depression guideline, audits, evaluations, first person accounts, experiential taster sessions and pilots. These were used to build a platform from which to develop MBCT services. The most important aspect of facilitation was the central role of the MBCT implementers. These were generally self-designated individuals who 'championed' grass-roots implementation. Our explanatory framework mapped out a prototypical implementation journey, often over many years with a balance of bottom-up and top-down factors influencing the fit of MBCT into service pathways. 'Pivot points' in the implementation journey provided windows of either challenge or opportunity.

CONCLUSIONS

This is one of the largest systematic studies of the implementation of a psychological therapy. While access to MBCT across the UK is improving, it remains patchy. The resultant explanatory framework about MBCT implementation provides a heuristic that informed an implementation resource.

A maturing mindfulness-based cognitive therapy reflects on two critical issues

Mindfulness-Based Cognitive Therapy (MBCT) is a multimodal intervention that integrates training in mindfulness meditation and the cognitive theory of affective disorder. This hybrid nature may provide an advantage in the prevention field that addresses the critical need for enhancing wellness among people with recurrent mood disorders. Despite the robust evidence base for MBCT, its penetration at the population health level and in routine clinical settings has been limited. Addressing the gap between the science of MBCT and public access requires grappling with two questions: what is the role of home practice of mindfulness skills in realizing the benefits of MBCT? And, what role do digital platforms play in the delivery of mindfulness programs? Addressing these two questions is overdue in the field and the answers generated have the potential to optimize future research and practice on the ways, in which contemplative practices can support agentic self-care.

Mindfulness Training in UK Secondary Schools: a Multiple Case Study Approach to Identification of Cornerstones of Implementation

This paper examined the facilitators and barriers to implementation of mindfulness training (MT) across seven secondary/high schools using a qualitative case study design. Schools varied in level of implementation. Within schools, head teachers, members of school senior leadership teams, and staff members involved in the implementation of MT were interviewed individually. In addition, focus groups were conducted with other members of school staff to capture a broad range of views and perspectives. Across the case studies, several key themes emerged, which suggested four corner stones to successful implementation of MT in schools. These were: people, specifically the need for committed individuals to champion the approach within their schools, with the support of members of the senior leadership teams; resources, both time and financial resources required for training and delivery of MT; journey, reflecting the fact that implementation takes time, and may be a non-linear process with stops and starts; and finally perceptions, highlighting the importance of members of the school community sharing an understanding what MT is and why it is being introduced in each school context. Similarities and differences between the current findings and those of research on implementation of other forms of school mental health promotion programs, and implementation of MT in healthcare settings, are discussed.

The Effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) in Real-World Healthcare Services

Depression is common with a high risk of relapse/recurrence. There is evidence from multiple randomised controlled trials (RCTs) demonstrating the efficacy of mindfulness-based cognitive therapy (MBCT) for the prevention of depressive relapse/recurrence, and it is included in several national clinical guidelines for this purpose. However, little is known about whether MBCT is being delivered safely and effectively in real-world healthcare settings. In the present study, five mental health services from a range of regions in the UK contributed data (n = 1554) to examine the impact of MBCT on depression outcomes. Less than half the sample (n = 726, 47%) entered with Patient Health Questionnaire (PHQ-9) scores in the non-depressed range, the group for whom MBCT was originally intended. Of this group, 96% sustained their recovery (remained in the non-depressed range) across the treatment period. There was also a significant reduction in residual symptoms, consistent with a reduced risk of depressive relapse. The rest of the sample (n = 828, 53%) entered treatment with PHQ-9 scores in the depressed range. For this group, 45% recovered (PHQ-9 score entered the non-depressed range), and overall, there was a significant reduction in depression severity from pre-treatment to post-treatment. For both subgroups, the rate of reliable deterioration (3%) was comparable to other psychotherapeutic interventions delivered in similar settings. We conclude that MBCT is being delivered effectively and safely in routine clinical settings, although its use has broadened from its original target population to include people experiencing current depression. Implications for implementation are discussed.