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Outcomes of Online Mindfulness-Based Cognitive Therapy for Patients With Residual Depressive SymptomsA Randomized Clinical Trial

Educational Objective
To evaluate the effectiveness for treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only.
1 Credit CME
Key Points

Question  Can web-based treatment of residual depressive symptoms lead to incremental benefits for adults when added to usual depression care?

Finding  In this randomized clinical trial of 460 participants with residual depressive symptoms, those who received an online version of mindfulness-based cognitive therapy in addition to usual care had greater reductions in depressive and anxiety symptoms, higher rates of remission, and higher levels of quality of life compared with participants who received usual care only.

Meaning  The findings support the value of online mindfulness-based cognitive therapy as an adjunctive, scalable approach for the management of residual depressive symptoms.


Importance  Patients with residual depressive symptoms face a gap in care because few resources, to date, are available to manage the lingering effects of their illness.

Objective  To evaluate the effectiveness for treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only.

Design, Setting, and Participants  This randomized clinical trial was conducted in primary care and behavioral health clinics at Kaiser Permanente Colorado, Denver. Adults identified with residual depressive symptoms were recruited between March 2, 2015, and November 30, 2018. Outcomes were assessed for a 15-month period, comprising a 3-month intervention interval and a 12-month follow-up period.

Interventions  Patients were randomized to receive usual depression care (UDC; n = 230) or MMB plus UDC (n = 230), which included 8 sessions delivered online for a 3-month interval plus minimal phone or email coaching support.

Main Outcomes and Measures  Primary outcomes were reduction in residual depressive symptom severity, assessed using the Patient Health Questionaire-9 (PHQ-9); rates of depressive relapse (PHQ-9 scores ≥15); and rates of remission (PHQ-9 scores <5). Secondary outcomes included depression-free days, anxiety symptoms (General Anxiety Disorder–7 Item Scale), and functional status (12-Item Short Form Survey).

Results  Among 460 randomized participants (mean [SD] age, 48.30 [14.89] years; 346 women [75.6%]), data were analyzed for the intent-to-treat sample, which included 362 participants (78.7%) at 3 months and 330 (71.7%) at 15 months. Participants who received MMB plus UDC had significantly greater reductions in residual depressive symptoms than did those receiving UDC only (mean [SE] PHQ-9 score, 0.95 [0.39], P < .02). A significantly greater proportion of patients achieved remission in the MMB plus UDC group compared with the UDC only group (PHQ-9 score, <5: β [SE], 0.38 [0.14], P = .008), and rates of depressive relapse were significantly lower in the MMB plus UDC group compared with the UDC only group (hazard ratio, 0.61; 95% CI, 0.39-0.95; P < .03). Compared with the UDC only group, the MMB plus UDC group had decreased depression-free days (mean [SD], 281.14 [164.99] days vs 247.54 [158.32] days; difference, −33.60 [154.14] days; t = −2.33; P = .02), decreased anxiety (mean [SE] General Anxiety Disorder–7 Item Scale score, 1.21 [0.42], P = .004), and improved mental functioning (mean [SE] 12-Item Short Form Survey score, −5.10 [1.37], P < .001), but there was no statistically significant difference in physical functioning.

Conclusions and Relevance  Use of MMB plus UDC resulted in significant improvement in depression and functional outcomes compared with UDC only. The MMB web-based treatment may offer a scalable approach for the management of residual depressive symptoms.

Trial Registration  ClinicalTrials.gov identifier: NCT02190968

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Article Information

Accepted for Publication: December 4, 2019.

Published Online: January 29, 2020. doi:10.1001/jamapsychiatry.2019.4693

Correction: This article was corrected on March 18, 2020, to fix the Conflict of Interest Disclosures and Additional Contributions sections.

Corresponding Author: Zindel V. Segal, PhD, Graduate Department Clinical Psychological Science, University of Toronto Scarborough, Room SY144, 1265 Military Trail, Toronto, ON M1C 1A4, Canada (zindel.segal@utoronto.ca).

Author Contributions: Dr Segal had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

Concept and design: Segal, Dimidjian, Beck, Boggs, Felder.

Acquisition, analysis, or interpretation of data: Dimidjian, Beck, Boggs, Vanderkruik, Metcalf, Gallop, Levy.

Drafting of the manuscript: Segal, Boggs, Vanderkruik, Gallop.

Critical revision of the manuscript for important intellectual content: Dimidjian, Beck, Boggs, Vanderkruik, Metcalf, Felder, Levy.

Statistical analysis: Vanderkruik, Gallop, Levy.

Obtained funding: Segal, Dimidjian, Beck.

Administrative, technical, or material support: Beck, Boggs, Vanderkruik, Metcalf, Felder, Levy.

Supervision: Dimidjian, Beck.

Conflict of Interest Disclosures: Dr Segal reported being a codeveloper of Mindfulness Based Cognitive Therapy (MBCT) and receiving royalties from Guilford Press for the MBCT treatment manual and patient books; reported presenting keynote addresses at conferences, and MBCT clinical training workshops where he has received a fee, including from the Mind and Life Institute, the Omega Institute, and the University of California San Diego Center for Mindfulness; reported receiving revenue from online MBCT therapist training tools available on mindfulnoggin.com; and reported being a cofounder of Mindful Noggin, Inc, which supports online dissemination of MBCT. Dr Dimidjian reported receiving royalties from Guilford Press for a book based on MBCT for new and expectant mothers; reported presenting at conferences where she received a fee, including from the Mind and Life Institute and Becoming Jackson Whole; reported receiving revenue from online MBCT therapist training tools available on mindfulnoggin.com; and reported being a cofounder of Mindful Noggin, Inc, which supports online dissemination of MBCT. Dr Beck reported receiving grants from the National Institute of Mental Health during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was funded by grant MH102229 (Dr Segal) from the National Institute of Mental Health.

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: Brian Knudson, NogginLabs, worked on the design of Mindful Mood Balance, and Leslie Wright, MA, Angela Plata, MS, Institute for Health Research, Kaiser Permanente Colorado, and Natalie Coleman, BA, Renée Crown Wellness Institute, helped with patient recruitment, tracking, and study management. These individuals were compensated as grant personnel working on this project.

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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

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