Our mental health system is unable to provide care to all who need it: there are too few providers and many clients cannot afford or access it. There is a need to creatively rethink how to offer care to more in need. One way is through self-help workbooks that allow clients to work on problems at their own pace while assisted by limited paraprofessional support.
British National Health Service guidelines currently endorse practitioner-supported Cognitive Behavioral Therapy Self-Help (CBT-SH) for depression. The National Health Service currently offers CBT-SH to over 100,000 clients annually, but the intervention suffers from a high drop-out rate.
Practitioner-supported Mindfulness-Based Cognitive Therapy Self-Help (MBCT-SH) is one possible alternative to CBT-SH, but its comparative efficacy is unknown. Strauss et al. [JAMA Psychiatry] conducted a randomized controlled trial comparing CBT-SH to MBCT-SH on clinical outcomes and cost effectiveness.
The researchers randomly assigned 410 clients with mild-to-moderate depression (62% female; 86% Caucasian; median age = 32) to practitioner-supported CBT-SH or MBCT-SH. Initial diagnosis and level of depression was established by structured clinical interview and self-report.
Participants were handed CBT or MBCT self-help workbooks and provided with six structured face-to-face or telephone 30-45 minute sessions with a psychological well-being practitioner focused on workbook material. “Psychological well-being practitioner” is a paraprofessional designation created through the British National Health Service’s Improving Access to Psychological Services (IAPS) initiative.
The CBT workbook used in this study was one already in wide use in IAPS programs. The MBCT workbook was The Mindful Way Workbook: An 8-Week Program to Free Yourself from Depression and Emotional Distress written by the MBCT co-founders. Participants were given up to 16 weeks to complete the workbook curricula.
Participants were assessed on measures of depression, anxiety, quality of life and mindfulness at baseline, 16 weeks (post-intervention) and 42-week follow-up. Drop-out rates for both groups were similar (28%).
MBCT-SH participants reported greater reductions in depression at post-intervention than CBT-SH participants (d=-0.36) but the group difference was no longer significant at 42 weeks. MBCT-SH participants also reported greater improvement in anxiety than CBT-SH participants at postintervention (d=-0.23), but not at 42 weeks. The absence of significant differences at 42 weeks reflects a continued improvement in depression for both groups.
The direct costs of providing treatment were $209 for MBCT-SH and $202 for CBT-SH. Other health care and social costs were higher for the CBT-SH group ($1,684) than the MBCT-SH group ($923). The increased CBT-SH costs were due to participants receiving more individual psychotherapy outside of the program, receiving more general practitioner visits, and the higher psychotropic medication usage.
The results show MBCT-SH superior to CBT-SH as a treatment for mild-moderate depression in terms of post-intervention mental health outcome and lower health care and social costs. Findings make a case for considering MBCT-SH to be at least as effective as CBT-SH and including it within the IAPS initiative.
Strauss, C., Bibby-Jones, A.-M., Jones, F.,... Cavanagh, K. (2023). Clinical Effectiveness and Cost-Effectiveness of Supported Mindfulness-Based Cognitive Therapy Self-help Compared With Supported Cognitive Behavioral Therapy Self-help for Adults Experiencing Depression: The Low-Intensity Guided Help Through Mindfulness (LIGHTMind) Randomized Clinical Trial. JAMA Psychiatry.
Link to study