Mindfulness and Depression The integration of contemplative practices into mental health care has helped many, but much remains to be done. By Sona Dimidjian

Yucca brevifolia. I was practicing walking meditation among them in Joshua Tree National Park in the winter of 2010 while co-leading a residential five-day retreat workshop on Mindfulness-Based Cognitive Therapy (MBCT) with Zindel Segal. With the 30 clinicians attending, we shared the principles and practices of MBCT to prevent depressive relapse and invited them to learn through practice and feedback how to facilitate MBCT in the healthcare settings to which they soon would return. We also invited them to immerse in deep personal practice such as this mindful walking. I watched these 30 clinicians walking, surrounded by the silence and dignity of the Yucca brevifolia and nearly 800,000 acres of desert. It was beautiful and inspiring… and profoundly inadequate.

The World Health Organization estimates that, globally, 280 million people struggle with depression and that fewer than 25% of people in low- and middle-income countries receive treatment. Could walking with the Yucca solve this problem?

Effective and accessible interventions are needed to address the persistent and pervasive mental health needs in our world. As clinical scientists and practitioners, this need compels us to wake up each day ready to use the tools of science to discover, design, and evaluate the most precise and powerful interventions possible—and to go to sleep each night asking if we have done right by the 280 million. The integration of mindfulness and contemplative practice with mental health care has made an important and sustained contribution over the last 35 years, but our work is far from done.1

Exploring Uncharted Territory: The Nature of Depression and Mindfulness

I came to graduate school at the University of Washington to study the clinical science of depression and worked closely with my advisor, Neil Jacobson, until he died suddenly and unexpectedly of a heart attack at the end of my second year in the program. I had been introduced to contemplative practice in high school, but it emerged as a much more prominent part of my life after he passed, as I struggled to care for the people in our community, continue our work, and make sense of his death. At that time, I also began working closely with Marsha Linehan who, in 1993, had established mindfulness as a core part of Dialectical Behavior Therapy2 for people with chronic suicidal behaviors. In each of our meetings, Marsha would ask me, “Why aren’t you focusing on mindfulness in your research on depression when you clearly care about it so much?”

I started reading some of the work of John Teasdale, Mark Williams, and Zindel Segal, and their conversations about mindfulness with Jon Kabat Zinn. Their work offered critical insights about how mindfulness practices might be relevant for depression,3 suggesting that this simple and powerful practice directly addressed the ways in which people who have recovered from depression continue to be vulnerable.4 Specifically, formerly depressed people are different from those who have never been depressed in terms of their susceptibility to ‘buy into’ the negative thoughts that are common in depression. Zindel Segal’s studies found that these thoughts can be re-activated5 even when people are no longer depressed, simply by asking people to listen to sad music or recall sad times in their lives. In addition, the more reactive a person was to this ‘emotional challenge’ in the lab, the more likely that they would become depressed again in the future.6

This research was groundbreaking in that it looked “under the hood” of depression to begin to pinpoint specific ways in which people were vulnerable, and that provided clues for intervention. Since it was not possible, nor desirable, to eliminate all sadness from people’s lives, Teasdale, Williams, and Segal began to explore the extent to which mindfulness practice could reduce reactivity. Could mindfulness provide the protection needed so that the emotion of sadness would not settle into enduring states of depression? Could mindfulness practice help people regulate their attention and hold thoughts and emotions in a wider space of awareness with less reactivity? The data from their first randomized clinical trials indicated yes.7

Could mindfulness provide the protection needed so that the emotion of sadness would not settle into enduring states of depression?

Their approach (MBCT)8 combined mindfulness with tools from cognitive behavioral therapy: an 8-week program, delivered in-person in a group setting, focused on developing skills for preventing depression relapse and promoting wellness. The core practices followed a very specific and intentional gradient of attentional focus, which critically started with sensations in the body and daily activities, like eating, then moved over time to thoughts, including those difficult thoughts that could be triggers for relapse. The intent was to build the capacity to watch and observe one’s thoughts as if they were leaves floating down a stream.

I was fascinated by their work and decided Marsha was right. I needed to be studying this! I called Zindel Segal out of the blue and asked if he would supervise me so I could learn MBCT. Amazingly, he agreed. I also convened a panel discussion including Zindel and other experts, and was preparing to moderate their discussion at a conference in November 2001. I recall my first prenatal care appointment that spring, and asking if there was any possibility that I would be able to attend the conference in the fall. My midwife laughed. “No chance,” she said. “You’ll be giving birth that weekend.” Little did I know that the integration of pregnancy, mental health, and mindfulness would become central in my life for the next twenty years, despite missing the conference.

Growing Evidence of Benefit: Reason for Optimism, or Not?

Mindfulness was not only to emerge as a core part of my work over the next twenty years; the clinical science of mindfulness grew exponentially around the world. The 2005 XIII Mind & Life Dialogue in Washington, DC was a watershed moment that literally put the clinical application of mindfulness practice at center stage. Clinical science began to address the potential benefits of mindfulness in the treatment and prevention of significant mental health problems: depression, anxiety, disordered eating, substance use, and more.

As this field grew, the trajectory of my own work was guided by the clients with whom I was working in Seattle. At the end of one of the MBCT classes I led, a client thanked me for the powerful benefits she had received and shared how much she enjoyed doing the practices with her toddler. Then she added, “I only wish I could have learned these skills when I was pregnant. It would have spared my family and me a lot of suffering in the postpartum period.”

My emerging dedication to the science that could inform practice with new and expectant moms was ethical, practical, and personal. I was outraged by the fact that pregnant women had been systematically excluded from clinical research; there was little data that guided women in making informed choices between antidepressant medication and non-pharmacological approaches during the perinatal period. Focusing on this period also made good sense because it met the mental health needs of women and helped buffer against future risk for their kids. Having recently experienced pregnancy, a difficult labor, and early parenting, I also knew firsthand how much support parents needed during this time. In our early work, my colleague Sherryl Goodman and I found that pregnant women at risk for depression said that they would vastly prefer a mindfulness approach to taking antidepressant medication if offered a choice.

We adapted MBCT to be sensitive and responsive to the context of pregnancy and early parenting; we focused on adaptations like emphasizing brief, daily practices, integrating prenatal and postpartum yoga practices, and addressing the critical and judgmental attitudes towards mothers in our contemporary context with practices of lovingkindness and behavioral strategies for asking for help and increasing support. We conducted a multisite study in which we randomly assigned pregnant women with a history of depression to MBCT or usual care within large healthcare systems. We found that MBCT provided clear and significant benefit in preventing depression relapse compared to usual care, with 80% of women in MBCT protected, compared to only 50% of women in usual care.

We believed that these data would be a game-changer, and that the program could help pregnant women protect themselves and their families from depression during this important life transition by learning practical skills. And it took just eight 2-hour sessions with women reporting that, on average, they practiced mindfulness about 3 times per week for about 15 minutes each time between sessions.

^{Sona further elaborates on her work to apply contemplative practices to
improve mental health, with a focus on systems of inequality.}

These findings were consistent with other rigorously conducted randomized clinical trials. In one study, Zindel’s team found that MBCT was comparable to antidepressant medication and significantly outperformed placebo among people with unstable patterns of remission. There were important scientific questions that had not been answered definitively, such as what were the mechanisms by which such effects were achieved, and which parts of the intervention were having the effect?

When Amishi Jha and I first met at the Mind & Life Summer Research Institute, we talked late into the night about ways to incorporate her basic research on attention, to identify the mechanisms of the mental health interventions I was studying. These questions are still very much alive, as are the questions of for whom these practices are or are not helpful, and issues around the lack of diversity and representation in the samples recruited for studies—and the scientists who are leading such studies. The power of a community participatory approach to research still has much to offer studies of mindfulness and contemplative practice.

The power of a community participatory approach to research still has much to offer studies of mindfulness and contemplative practice.

Despite these concerns, this emerging field was demonstrating clearly that people had choices for how to care for their mental health, including the pregnant women with whom I worked who faced significant risk of depression relapse. Simple practices could lead to significant and enduring change. We published9 our data in a top tier clinical psychology journal, we gave presentations at national conferences, and we offered trainings for clinicians, just like the one at Joshua Tree National Park.

Our participants saw benefit. From a wider lens, however, little changed.

Addressing Barriers to Access

There are many ways to expand the reach of mental health interventions so that barriers to access are addressed effectively. At the workshop retreat at Joshua Tree National Park, Zindel and I wondered about the potential for digital delivery of MBCT to increase access. Would seeking to replicate the experience of in-person MBCT online degrade the value of the teaching? Would it corrupt the integrity and the impact of the program? We were hesitant to embark on this direction, even skeptical at first. Yet we trusted the empirical process and wanted to rely on the data, so we launched the journey of creating a digital version of MBCT called Mindful Mood Balance (MMB).

We piloted the program in the Kaiser Permanente healthcare system in Colorado, and found significant decreases in depressive symptoms following MMB (compared to a control group). We also found indicators that MMB changed the processes that we were seeking to change, such as ruminative thinking and decentering. Based on these promising initial data, we conducted a randomized controlled trial: one group received MMB in addition to the (already robust) usual care for depression, and the other group received just the usual care. Results10 indicated significant reductions in residual depressive symptoms and anxiety for people who received the MMB program. Secondary analyses11 also indicated that this program was effective for people who experienced suicidal ideation, and specifically reduced suicidal ideation over time. We’ve also developed an adaption of MMB for perinatal women (MMB for Moms), which we’re currently piloting in a number of different populations. These findings will help inform future treatments for many struggling with depression.

Following the pioneering meeting in 2005, Mind & Life continued to hold interdisciplinary dialogues with the Dalai Lama to explore the science of contemplative practice in applied settings. In Dharamsala, in the spring of 2018, I had an opportunity to share some of this research with him.

^{Sona shares her compassion study at the 2018 Mind & Life Dialogue with the Dalai Lama.}

At the end of my presentation, he turned and said: “I think you have a very, very important role. And therefore, with an important role, you also have more responsibility. From 1 person, 10 people, 100 people, 1,000 people, 100,000 people… That is the way to change humanity’s way of life.” Although we had been apprehensive about teaching MBCT online, his message seemed to emphasize just this—the importance of expanding reach and access.

The Road Ahead

Many aspects of our world need to change to ensure long-term and widespread mental health and wellness. We must address blatant and insidious forms of structural and systemic inequality. Increasingly, we also need to address the climate crisis and the health of our planet. We need to experience genuine connection with others and purpose and joy. We need to reduce stigma about mental health so that all people know that it is ok not to feel ok. And we need to make resources easy to access when people need help. The science of the clinical application of mindfulness and contemplative practice suggests that these programs have the power not only to protect people’s mental health and wellness, but also to achieve substantial reach through digital platforms.

We need to reduce stigma about mental health…
And we need to make resources easy to access when people need help.

The National Park Service website says that the Yucca brevifolia “tell a story of survival, resilience, and beauty borne through perseverance.” Mindful walking through the desert will not alone help us realize the charge we have been given, but it may remind us of the importance of persisting, and the power of simple practices. Many lives depend on it.

Have something to share? Email us at insights@mindandlife.org.
Support our work with a gift to Mind & Life. 

Notes

1. 1.

   Dimidjian S, Segal ZV (2015). Prospects for a clinical science of mindfulness-based intervention. American Psychologist 70(7), 593–620. https://doi.org/10.1037%2Fa0039589 [Free full text]

2. 2.

   Linehan MM (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.

3. 3.

   Teasdale JD, Segal Z, Williams JM (1995). How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) training help? Behavior Research and Therapy 33(1):25-39. https://doi.org/10.1016/0005-7967(94)e0011-7.

4. 4.

   Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, Segal ZV (2002). Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology 70(2), 275–287. https://doi.org/10.1037/0022-006X.70.2.275.

5. 5.

   Scher CD, Ingram RE, Segal ZV (2005). Cognitive reactivity and vulnerability: Empirical evaluation of construct activation and cognitive diatheses in unipolar depression.
   Clinical Psychology Review 25(4):487-510. https://doi.org/10.1016/j.cpr.2005.01.005.

6. 6.

   Segal ZV, Kennedy S, Gemar M, Hood K, Pedersen R, Buis T (2006). Cognitive reactivity to sad mood provocation and the prediction of depressive relapse. Archives Of General Psychiatry 63(7):749-55. https://doi.org/10.1001/archpsyc.63.7.749.

7. 7.

   Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy.
   Journal of Consulting and Clinical Psychology 68(4):615-23. https://doi.org/10.1037//0022-006x.68.4.615.

8. 8.

   Segal ZV, Williams JMG, & Teasdale JD (2002). Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse. Guilford Press.

9. 9.

   Dimidjian S, Goodman SH, Felder JN, Gallop R, Brown AP, Beck A (2016). Staying well during pregnancy and the postpartum: A pilot randomized trial of mindfulness-based cognitive therapy for the prevention of depressive relapse/recurrence. Journal of Consulting and Clinical Psychology 84(2):134-45. https://doi.org/10.1037%2Fccp0000068 [Free full text]

10. 10.

    Segal ZV, Dimidjian S, Beck A, Boggs JM, Vanderkruik R, Metcalf CA, Gallop R, Felder JN, Levy J (2020). Outcomes of Online Mindfulness-Based Cognitive Therapy for Patients with Residual Depressive Symptoms: A Randomized Clinical Trial. JAMA Psychiatry 77(6):563-573. https://doi.org/10.1001%2Fjamapsychiatry.2019.4693 [Free full text]

11. 11.

    Dimidjian S, Kaufman J, Coleman N, Levy J, Beck A, Gallop R, Segal ZV (2022). Impact of online Mindfulness-Based Cognitive Therapy on suicidal ideation: A secondary analysis of a randomized trial of Mindful Mood Balance. Journal of Affective Disorders 301:472-477. https://doi.org/10.1016/j.jad.2021.12.051