A new trial has examined this question: Segal et al. The short answer is that 8 weeks of mindfulness mediation training was just as good as prolonged antidepressant treatment over 18 months. But like all clinical trials, there are some catches.Right mindfulness, sammā-sati, is the 7th step on the Buddha's Nobel Eightfold Path of enlightenment. In its modern therapeutic form, however, it's a secular practice: you don't have to be a Buddhist to meditate here (but it presumably helps).
Mindfulness meditation is also branded nowadays as mindfulness-based cognitive behavioural therapy (MCBT), although how much it has in common with regular CBT is debatable. The technique is derived from the Buddhist tradition.
The essence of mindfulness is deceptively simple: you try to become a detached observer of your own feelings and thoughts. Rather than just getting angry, you notice the feelings of anger, without letting them take over. As I've written before, while this might sound easy, we're not always aware of our own feelings.
MCBT has attracted a lot of attention as a possible way of helping people with depression achieve relapse prevention. The idea is that if you can train people to become aware of depressive thoughts and feelings if they start to reappear, they'll be able to avoid being sucked into the cycle of depression.
The 160 patients in this trial were initially treated with antidepressants, starting with an SSRI, and if that didn't work, moving onto venlafaxine (up to 375 mg, as necessary, which is a serious dose) or mirtazapine for people who couldn't take the side effects. This is a sensible treatment regime, not one relying on low doses and doubtful drugs, as in many other antidepressant trials.
About half of the patients both stayed in the trial and achieved remission. After 5 months of sustained treatment, these 84 patients were randomized into 3 groups: continuation of their antidepressant, placebo pills, or mindfulness. The people who ended up on placebo had their antidepressants gradually replaced by sugar pills over a number of weeks, to avoid withdrawal effects.
Here's what happened:
People on placebo did very badly, with only 20% remaining well 18 months later. People who either stayed on the drugs, or who got the mindfulness training, did a lot better, with 70% staying well, and there were no differences between the two.However here's the catch. This was only true of a sub-set of the patients, the ones who had an "unstable remission", meaning that when they were originally treated with drugs, their symptoms went up and down a bit. The "stable remission" people showed no benefits of either treatment, with the ones on placebo doing slightly better, if anything.
Overall, though, this is a decent study, and shows that, for some people, mindfulness can be helpful. A skeptic could complain that mindfulness was no better than medication, but it might have two advantages: cost, and side effects, though this would depend on the medication you were talking about (some are a lot more expensive, and more prone to side-effects, than others.) The mindfulness meditation also wasn't double-blind, so the benefits may have been placebo effects, but that could be said of almost any trial of psychotherapy.I also wonder whether you'd do even better if you became all mindful and stayed on medication: this study had no combined-treatment group, unfortunately, but this is something to look into...
Segal ZV, Bieling P, Young T, Macqueen G, Cooke R, Martin L, Bloch R, & Levitan RD (2010). Antidepressant Monotherapy vs Sequential Pharmacotherapy and Mindfulness-Based Cognitive Therapy, or Placebo, for Relapse Prophylaxis in Recurrent Depression. Archives of general psychiatry, 67 (12), 1256-64 PMID: 21135325
28 comments:
Another issue with this study may be the interaction with a provider in the mindfulness group. Normally, there are 8 2hr sessions of mindfulness in these kinds of studies, and Kaptchuk et al (2008) showed that interaction with a provider tends to create the largest set of placebo effects, so unless this was equlaised, this study probably needs replication.
If ever there was an open door for placebo effect it's this. Incredible. In fact it is a study confirming the placebo effect is there and effective. The fact that Buddhist nations were/are amongst some of the most oppressive and violent, falsifying the whole concept of the ideology, is already a pretty good indicator that in itself it has no intrinsic value.
Petrossa,
No offence to your ideas, but MBSR is very effective. See Grossman 2004 for a meta-analysis. While the mechanisms and the potential for expectancy effects to be a driver of the benefits has not yet been fully tested, the effect sizes seem too large to be just placebo.
And ultimately, if Charles Darwin were an axe murderer the theory of evolution would still be as valid, so i don't really accept your ad hominem argument as possessing validity.
As I said in the post, placebo effects are there, but they are in all psychotherapy trials, and arguably, that's not a problem. Many people would say that the placebo effect is a kind of psychotherapy. So saying that psychotherapy is just a placebo is meaningless.
What I do think you need in trials like these is a therapeutic control. Compare MCBT to another kind of psychotherapy. If they're both equally good, that's evidence that you don't need MCBT specifically.
"The mindfulness meditation also wasn't double-blind, so the benefits may have been placebo effects, but that could be said of almost any trial of psychotherapy."
The same can be said about most antidepressant trials, where some participants can figure out what group they're in based on the side effects/ lack of side effects they're experiencing, and physicians can tell as well. Obviously the blind is still stronger than in therapy trials, but drug trials are certainly not fully "double blind". But again, it doesn't really matter if there is a placebo contribution, as long as it is effective.
What's crucial is to identify subsets of people that will respond positively to treatment. Some people don't respond to meds, and I'm sure that a lot of people wouldn't take MBSR seriously, just like prescribing exercise.
Petrossa I think you meant Confucianism. Tibet is considered peaceful. Meditation addresses the social side to holistic or remedial therapy but it isn't equivalent to meds. It's often used in conjunction with homeopathy, naturopathy for treatment. Controversial area. Pluck meditation out of this context and it may as well be an altered version of CBT.
Frankly this study is not exactly an endorsement of the efficacy of medication for depression. HALF dropped out; HALF stayed and went into remission. But a third stayed better even off meds (and on mindfulness); and 20% of the placebo group stayed better. When you get right down to it, medication wasn't really needed for the majority of subjects to feel better; and it may have led HALF of the original sample to drop out and stop treatment.I think I'll pass on the meds, thank you.
@Disgrunteld
You missed my point. Meditation equals placebo. It's the exact same mechanism just consciously invoked rather then brought on by taking a pill and believing
@veri
No i meant Bhuddism, look here:
http://www.michaelparenti.org/Tibet.html
http://www.class.uidaho.edu/ngier/slrvcol.htm
Hmmm, venlafaxine withdrawn to sugar pills over a matter of weeks. This is a concern.
It took me 9 months to come off venlafxine. The second time I came off it was a month or so, but this was with the help of cross-tapering to fluoxetine.
Given the often horrific nature of withdrawal symptoms, could such an abrupt withdrawal of venlafaxine account for the poor results in the placebo arm.
Furthermore, to ensure informed consent, are participants told what withdrawal symptoms are? If this is the case, then isn't there a high likely hood that those on placebo would have 'broken blind'.
As a meditator for many years, and someone who has taken many different antidepressants, I wonder whether this study looks in enough detail at the process.
It's not easy learning the skill - often it takes a while, and a lot of support from experienced practitioners to get the most out of it. Usually I would expect it to involve personal mentoring for some time. For some people the temptation to introspect rather than do the technique makes it unbearable. If takes some weeks of sustained effort for most people. Let's face it sitting quietly for periods of time is unnatural for most people!
The quality of the teacher/teaching makes a huge difference. There are so many more variables in meditation compared to taking drugs. I doubt you could do a blind test - how would someone be given a placebo meditation?
Placebo relies on believing that you've had an effective treatment - we'd need to know about people's attitudes to meditation before assessing placebo. Did they believe meditation was effective? And why? Clearly @petrossa would not be a good candidate as she has negative preconceptions, for instance.
If I was teaching a meditation class I would think having half continuing after 6 months, and 20% after a year, was good going - so there is another factor. What proportion of well people are able to sustain the rigour of a meditation practice? We have no data on that.
Also if I was teaching someone to meditate I would explain to them how lifestyle affects one's ability to meditate effectively. Most people who take meditation seriously end up making fairly major lifestyle changes. It might be done in a purely secular environment, but I doubt it. To what extent were people given an appropriate context to practice meditation in?
I have friends providing MBSR and CBT for the NHS. Of course they see themselves working wonders, but I wonder whether you can really de-contextualise meditation and it still be effective?
The thing with depression seems to be to do everything: eat well, get fresh air and exercise, reduce stress, meditate, and take drugs as well if necessary. But of course this does not help anyone to design and fund a study; or plan and pay for treatments for a nation with an increasing problem with depression.
(@Petrossa - The fact that e.g. Burma is dominated by a repressive military junta doesn't tell us much about the effects of meditation, because the military don't meditate; and nor to the vast majority of Buddhist lay people. Perhaps the situation would be different if they did?)
Jayarava makes excellent points.
Mindfulness meditation is not something wherein one is going to become proficient unless one makes it a lifestyle choice, diving in fully.
The results for the practitioner are utterly profound. It does not merely consist of the academic concept of simply 'observing' cognitive events (repetitive thought patterns, mechanical self-chatter, attendent storms of emotion, chaotic physical impulses, etc.), but involves much more, radically changing one's subjective relationship to thought, emotion, and impulse; resulting in veritable paradigm shifts in perception.
As for whether one can engage effectively in Mindfulness practice while on depression meds, that is an interesting question.
Anonymous: it's not a huge endorsement of meds but:
1. drop-outs are really hard to interpret. In many clinical trials of antidepressants, there are as many drop-outs in the placebo group as the drug group, so it's hard to say that the drugs "made them drop out". People drop out for lots of reasons.
2. We don't know that the people who stayed well on MCBT, were the ones who stayed well on drugs. Maybe they were different people, meaning that the drugs were important for all of the meds people who stayed well; which would imply that meds + MCBT would be even better. Or maybe not. But that's why we need a combined-treatment arm.
Neuro:
With all due respect, I doubt the drop outs did so because they were getting happier. They were ALL getting meds as there was no initial placebo arm to this study. More likely is that they dropped out because they either felt no different, felt worse or got sick of the side effects. Whatever, I agree with your main point about about a combined treatment group for this study. Still, as anyone who toils in the trenches of biological (aka mindless) psychiatry these days, we should realize that the the typical treatment paradigm is: "Open your mouth and here is Lexapro; Oh that didn't work? Well here is Effexor! Oh that didn't work? Well let's try Zoloft. Still no response? Hell have some Pristiq. Oh and let's add a dab of Abilify and maybe some Lamictdal (hope you don't get that nasty rash!). Oh you feel better? Why we finally found the right medication for you!!!!" This is plain CRAP. It is not science. It is not evidence-based medicine. It is "Time shall heal all wounds." And you don't need meds for that outcome! Unless of course you have fallen under the spell (and money) of a Pharma Marketing salesperson!
Petrossa, I see what you're saying and I would agree with you if history and ideologies were that simple.
I read the links. If we look at history, Buddhism was a minor religion and much less bloody than Christianity or Confucianism, dominant religions in Europe and East respectively. There are different types of Buddhism. Buddhism in the East today is a variant of traditional Buddhism which might be mixed with Confucianism. The Tamil conflict like terrorism operates via militia groups purportedly driven by religious ideologies. That’s politics, not religion.
There is a difference between theocracy and culture versus religion.
There's only one recognized theocracy in the world today and that would be the Vatican City. Islamic countries adhering to the Sharia laws are considered autocracies, one of reasons because they have an army, weapons embargos, elected officials etc. same with the Jewish state Israel. Tibet because of China is not considered a theocracy, but like the Palestinians without a state, they are informally recognized as a theocracy under the behest of the Dalai Lama.
Today, theocracies are placed under ‘zones of peace’ plus much more. They engage in peace driven initiatives not warfare, weapons embargos etc.
When religions once ran the world, yes, things were bloody, but that needs to be understood through history. Religion as a political model in the West has been replaced by democracy, capitalism etc. well sovereignty since the Treaty of Westphalia 1648, and subsequent nation-state UN ratifications. Today, religion is personal to people and regarded in the social domain.
Even though terrorists are predominantly considered from Islamic backgrounds, they haven't ejected Islamic persons from the West. Why? Terrorism is not considered a religiously organised network by policy makers.
The same applies to the Tamil Tigers. They are regarded as militia groups endorsed by terrorist sponsoring states, or private investors, other govts via the CIA, MOSSAD etc. or networked to ‘zones of conflict’. Huntington’s Clash of Civilizations is an interesting theory but impractical for war. Religion has no money to buy weapons.
@veri
This is getting seriously offtopic here. The only thing i wanted to point out is that the Bhuddist ideology has been falsified in its basic tenures so as such it's not a valid scientific mechanism for experimentation. (if an ideology ever could be).
Meditation is just another form of selfhypnosis and as such equal to placebo which does has the same effect.
Whilst i have no proof of this occams razor applied the only logical conclusion can be that any beneficial effects gained from any form of mental influence over corporal effects should have the basic underlying mechanism.
It's not evident to assume that corporal influence on such a basic level can be caused by more then one central mechanism.
It's only the way have to activate that mechanism that differs, whether it be meditation, selfhypnosis, hypnosis or a strong belief in effectiveness of a certain remedy that activates the 'placebo center'
There has still been no convincing study of the additive effects of mindfulness meditation to standard CBT (if any). So how can we know that meditation is the active ingredient?
This smells like the EMDR fad to me...
Petrossa, I'm not sure what it is that you think the placebo effect is or what placebos do.
Despite being commonly described this way in the news and popular science media, placebos don't work through sheer "belief" or "willpower"; it's not as simple as believing a medicine works and then BAM, your "placebo center" is activated and you feel okay.
There are many mechanisms for placebo. For example, someone who is taking pills or enrolled in a trial may feel like they are "doing something" about their illness and undertake other behaviors that help them out. Patients might be conditioned to associate a pill or injection with relief of pain and then still experience it even when given dummy medication. Interacting with a caring health professional and feeling like one is receiving treatment can result in lower stress and anxiety and thus fewer negative symptoms for an illness. Patients might misinterpret their own body cues because they are motivated to report that the treatment worked.
Finally, there is the classic "expectation" cause of placebo effects, but the mechanism by which it operates isn't well known and it interacts with the other causes I mentioned above. A brief google search reveals that the way the brain handles placebo pain medication is different than the way it handles placebo antidepressants is different than placebo alcohol... etc. This makes sense as the effects of the real drugs are much different from each other and the patient's experiences in both real and placebo conditions are different in each case. Further, a placebo analgesic ointment might be administered once or twice in a doctor's office while you're in bad pain, whereas the placebo antidepressant is repeatedly administered at home over several weeks for a condition which waxes and wanes over the long term. I would find it far more surprising to discover that the placebo mechanism was actually exactly the same for both cases.
I would also be extremely surprised to find that meditation was actually a self-induction of the "placebo effect" or equal to self-hypnosis in mechanism because MBCT meditation isn't based on self-suggestion or inducing odd body states. It likely shares some things in common with both as it is intended to reduce anxiety and involves heightened self-awareness. But the main point of it is to be able to observe one's own mental and body states and to become generally more aware of what one is experiencing. The supposed effects of it are also not immediate; they are supposed to build over time as you repeatedly use the different meditation exercises as a coping strategy and as you get better at remaining in a meditative state. If MBCT is a placebo it's probably a placebo only insofar as any treatment can be a placebo, such as through repeatedly interacting with a provider as Disgruntled PhD pointed out.
Anonymous: "as anyone who toils in the trenches of biological (aka mindless) psychiatry these days, we should realize that the the typical treatment paradigm is: "Open your mouth and here is Lexapro; Oh that didn't work? Well here is Effexor! Oh that didn't work? Well let's try Zoloft. Still no response? Hell have some Pristiq. Oh and let's add a dab of Abilify and maybe some Lamictdal (hope you don't get that nasty rash!). Oh you feel better? Why we finally found the right medication for you!!!!" This is plain CRAP. It is not science. It is not evidence-based medicine. It is "Time shall heal all wounds." And you don't need meds for that outcome! Unless of course you have fallen under the spell (and money) of a Pharma Marketing salesperson!"
But exactly the same applies to psychotherapy. I had CBT last year. It was a 16 week course. At the start I did a self-report questionnaire and it said I was "moderately depressed". At the end I did another one and it said I was "no longer depressed". This was summarized on my end-of-course report as a success for CBT.
The possibility that I'd have felt better after 4 months whatever I'd done wasn't considered - it's not like mood disorders are episodic or cyclical, right? Er... - nor was the possibility that I was just filling in the form in such a way that I wanted to my therapist feel happy, and nor was the fact that I'd raised my daily dose of Effexor from 150 to 300 mg over the same time period...
So it's not just biological psychiatry. It's psychiatry as a whole. Biological psychiatry is just bigger.
Petrossa I may've gone a bit overboard but I get what you mean now. I hadn't thought about placebo centers before.. sounds highly complex.. I have no idea. Sorry. I should stop stalking Neo's blog and get back to my world. Ciao for a while.
Neo if you ever get depressed please call me. I get depressed too. Life is so hard.
Neuro:
I agree with you. It is not just biological psychiatry it is psychiatry and psychology as a whole. Sure psychotherapy is a target and should be: Years of therapy, countless transference interpretations or if you do CBT, "cognitive restructurings", and PRESTO "I feel good!" I am an old timer. When I was in graduate school at a very prestigious university, we were taught that most mood episodes or disorders remitted over time. That was with or without "treatment" whether it be drugs or therapy. That's what the longitudinal research indicated. But in the 1980's when psychiatry became wedded to Big Pharma and Prozac, all of a sudden this changed! Criteria for mood episodes were changed by committee votes by people with conflicts of interest and lo and behold depression or bipolar episodes NEVER remit without the constant aid of medication or therapy. But mostly it was meds. Whatever. As this mindfullness versus drug study suggests, it may well be that most psychiatric/psychological treatments are non-specific. And that is not what psychiatrists or psychologists want to hear.
@kat
You pose an opinion I disagree with. Let's reduce it to simple logic.
Pain is a emergency signal. An animal having continuous pain is less likely to survive. Less likely to (further) procreate.
If pain can be managed, it can be postponed and if the injury is not incapacitating the animal can seek refuge and heal.
So pain control becomes a survival trait.
Therefore a mechanism must be in place that can used to suppress or deactivate the center which makes pain known since blocking the nerve signals themselves is not feasible.
This mechanism can then be controlled via other means then pure automated reaction.
Hi Neuro,
The acronym is actually MBCT, which stands for Mindfulness Based Cognitive Therapy. You're right, it has little in common with CBT, but no one said that it did.
There are studies running at the moment where the control condition is MBCT without the mindfulness element. That may satisfy the people crying out for a more equivalent placebo.
As for depression, based on my experience, meditation has been my useful anti-depressant. Because when meditating, my mind is free and relaxed so it releases all my anxieties and stress and problems. But I do not undererstimate the power of medications as well. But for me really, I always go with the natural such as meditation. But if something gets worse, of course, medication is our last line of defense!
Perhaps MBCT acts more as a mood stabilzer than an antidepressant.
One name: Jon Kabat-Zinn.
This is a great post, and the comment thread is also very illuminating. Thank you, Neuroskeptic!
I linked to this post in a post of my own, Healing Depression through Meditation.
take care,
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Dear Neuroskeptic,I dont know what kinda neuroscientist you are.But when you refer to your self as a neuroscientist,mostly people will trust your words.Thats why any biased opinion from this blog will harm.I am here as a result of one of my patient's friend's suggestion.He has assumed that antidepressants are not effective and very harmful.As I wont be able to read whole of your content,I just want to share my point of view on this topic.I am also a believer of Buddhist philosophy and its impact on contemporary psychotherapeutic interventions.But the study you are referring clearly states about"role in prophylaxis of recurrent depression".Its not about "Acute severe depression".Most of the patients with acute severe depression can not be helped with any kind of psychotherapy alone.And also often recurrent depression is actually a part of Bipolar mood disorder for which mood stabilizers are the best treatment at least early in therapy.Lastly,the real world of psychiatric drug therapy is far different from claims made during drug trials.
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