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Major depressive disorder (MDD) is currently ranked the third leading cause of disability in the world. Treatment-resistant depression (TRD) causes the majority of MDD disability. Strikingly, 50% of individuals with MDD will fail to remit with 2 adequate trials of antidepressant medications, thus qualifying as treatment resistant. Current pharmacological and psychotherapeutic treatment strategies for TRD are limited in effectiveness, thus, new interventions are needed. Mindfulness-Based Cognitive Therapy (MBCT) is a new psychotherapeutic treatment with established efficacy in preventing relapse of depression for individuals in complete remission. MBCT is a group-based, 8-week intervention that uses mindfulness meditation as its core therapeutic technique. It teaches people to have a different relationship to depressive thoughts and feelings. Strategies are focused on decreasing rumination, enhancing self-compassion, increasing acceptance, and decreasing avoidance. This modified version of MCBT, which includes the use of metaphor and adaptations of the original intervention, will be discussed through the clinical case of a woman with long-standing TRD. A brief review of the current MBCT literature and future directions for the treatment of TRD are discussed.

BackgroundMajor depressive disorder (MDD) is the leading cause of disability in the developed world, yet broadly effective treatments remain elusive. Up to 40% of patients with depression are unresponsive to at least two trials of antidepressant medication and thus have “treatment-resistant depression” (TRD). There is an urgent need for cost-effective, non-pharmacologic, evidence-based treatments for TRD. Mindfulness-Based Cognitive Therapy (MBCT) is an effective treatment for relapse prevention and residual depression in major depression, but has not been previously studied in patients with TRD in a large randomized trial. Methods/Design The purpose of this study was to evaluate whether MBCT is an effective augmentation of antidepressants for adults with MDD who failed to respond to standard pharmacotherapy. MBCT was compared to an active control condition, the Health-Enhancement Program (HEP), which incorporates physical activity, functional movement, music therapy and nutritional advice. HEP was designed as a comparator condition for mindfulness-based interventions to control for non-specific effects. Originally investigated in a non-clinical sample to promote stress reduction, HEP was adapted for a depressed population for this study. Individuals age 18 and older with moderate to severe TRD, who failed to respond to at least two trials of antidepressants in the current episode, were recruited to participate. All participants were taking antidepressants (Treatment as usual; TAU) at the time of enrollment. After signing an informed consent, participants were randomly assigned to either MBCT or HEP condition. Participants were followed for 1 year and assessed at weeks 1–7, 8, 24, 36, and 52. Change in depression severity, rate of treatment response and remission after 8 weeks were the primary outcomes measured by the clinician-rated Hamilton Depression Severity Rating (HAM-D) 17-item scale. The participant-rated Quick Inventory of Depression Symptomology (QIDS-SR) 16-item scale was the secondary outcome measure of depression severity, response, and remission. Discussion Treatment-resistant depression entails significant morbidity and has few effective treatments. We studied the effect of augmenting antidepressant medication with MBCT, compared with a HEP control, for patients with TRD. Analyses will focus on clinician and patient assessment of depression, participants’ clinical global impression change, employment and social functioning scores and quality of life and satisfaction ratings.