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PsychNotes October 2015

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October 27, 2015       

Mindfulness Practice and Relapse Prevention When Using Anti-depressants

by Monica A. Frank, Ph.D.
It has long been shown that discontinuing anti-depressants has a high relapse rate. However, when mindfulness training results in greater emotional tolerance, not only does the relapse rate decline but improvement continues. Learning how to decenter from mindfulness training increases curiosity and the tolerance of thoughts and feelings because they are viewed as temporary events in the mind (Bieling, et al., 2012).

Previous research that examined patients treated with anti-depressants and then randomly placed in groups to either continue with the anti-depressants, receive a placebo, or discontinue anti-depressants to receive Mindfulness-Based Cognitive Therapy (MBCT) found no difference between those who remained on the medication and those who stopped medication and were trained in mindfulness techniques (Segal, 2010).

However, additional research examining the same patients showed that when mindfulness training results in greater emotional tolerance it continues to reduce depression after medication is stopped. Those patients who learned how to decenter from the mindfulness training and increased their ability to observe thoughts and feelings with greater tolerance had lower levels of depression six months after medication was discontinued than those who remained on the anti-depressants (Bieling, et al., 2012).

What does this mean for you? Just learning how to be mindful isn't enough to affect levels of depression when discontinuing medication. It is necessary to get to the point in your mindfulness practice where you can observe your thoughts and feelings from an emotional distance. In other words, when you feel bad, you can recognize you are having a bad day without the judgment: “This is terrible! I can't stand it! I've got to get it to stop” or “I'm so weak. What's wrong with me?” Instead of the judgment and demands to get rid of the depression you can examine it from a more objective perspective: “I'm having a bad day. What do I need to do to best take care of myself?”

This research shows that not only can anti-depressants be discontinued but when you learn to tolerate emotions and approach events with curiosity rather than dread you can continue to improve. As I indicate in my Understanding Mindfulness audios (free to download or read transcripts), step 1 teaches mindful awareness, step 2 teaches mindful awareness with discomfort, and it is not until step 3 that you start learning to develop emotional tolerance. However, these steps build upon one another and you need to take the time to learn each step before you can reduce depression through mindfulness training.

It is the tolerance of emotional discomfort that helps reduce the depressive symptoms. Think of it this way. Imagine that we scale your depression from 1 to 10 and the uncontrollable, physical part of the depression is a 5. But then you also have negative thoughts about your inability to tolerate the depression. Now the depression might be a 7. And then you also have judgmental thoughts about your inability to control the depression. Now the depression might be a 9. This shows that part of the depression is the illness itself but the other part is how your thinking may contribute to increasing the symptoms (this same process is also implicated in other illnesses such as heart disease).

Therefore, mindfulness training increasing emotional tolerance may not rid you of the depression entirely because depression is physically based. However, it can decrease the part of the depression that is due to the intolerance of the symptoms. As a result, the depression becomes more manageable and interferes less with your life.

Bieling, P.J., Hawley, L.L., Bloch, R.T., Corcoran, K.M., Levitan, R.D., Young, L.T., MacQueen, G.M. And Segal, Z.V. (2012). Treatment-Specific Changes in Decentering Following Mindfulness-Based Cognitive Therapy Versus Antidepressant Medication or Placebo for Prevention of Depressive Relapse. Journal of Consulting and Clinical Psychology, 80, 365–372. DOI: 10.1037/a0027483

Segal, Z. V., Bieling, P. J., Young, T., MacQueen, G., Cooke, R., Martin, L., Block, R. and Levitan, R. D. (2010). Antidepressant monotherapy versus sequential pharmacotherapy and mindfulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent depression. Archives of General Psychiatry, 67, 1256–1264. DOI:10.1001/archgenpsychiatry.2010.168


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