Scottish NHS Mindfulness Network

An audit of mindfulness therapy within NHS Scotland

Authors: C. Mitchell & N. Rothwell

Written: December 2020

Funded by NHS Education for Scotland (NES)

Note: the information collated here refers to activity before the start of the Covid-19 pandemic. At the time of writing, most mindfulness courses for patients have been suspended, pending the establishment of a secure platform to deliver courses online. However, many areas continue to run courses for staff.

Executive Summary

Mindfulness-based interventions (MBIs) such as Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR), have a strong evidence base for the treatment of recurrent depression and other psychiatric and physical illnesses. MBIs are an effective treatment compared to compared to CBT and anti-depressants for  recurrent depression. They may provide successful cost-benefits by reducing demand for crisis and inpatient services. 

The aim of this project is to:

1.      Collate information regarding the population, demographic and outcome measures used with MBIs in NHS Scotland.

2.      Evaluate the effectiveness of MBIs in NHS Scotland.

3.      Make recommendations for future delivery.

There are four main findings of this report:

1.      MBIs across Scotland are being carried out for mental health, chronic pain, physical rehabilitation, addictions, stress and wellbeing, as well as NHS staff populations.

2.      Substantial changes were found in pre-post intervention outcome scores using the HADS, CORE-10 and FFMQ-FS.

3.      The age range of participants completing MBIs varied greatly, with there being no upper age limit.

4.      Across NHS Scotland, a total of 17 different outcome measures are being used to evaluate MBIs

This report provides evidence in support of the need for maintenance and expansion of mindfulness within NHS Scotland.

Introduction

Mindfulness-Based Cognitive Therapy (MBCT) is one of two psychological therapies recommended in The National Institute for Health and Care Excellence (NICE) guidelines for recurrent depression and has gathered a substantial evidence-base. Kuyken et al (2016) found that MBCT significantly reduces risk of depressive relapse by almost 50% when compared to Cognitive Behavioural Therapy (CBT) and pharmaceutical interventions. This has significantly improved the quality of life for those with recurrent depression. Therefore, the effective delivery of evidence-based recommended treatments such as MBCT, may have a positive long-term cost-benefit. MBCT may also reduce the demand for services which typically provide care for people experiencing a depressive relapse such as crisis management and inpatient admissions. Clinical guidelines such as the NHS Scotland  MATRIX, SIGN  and NICE recommend MBCT as a treatment to reduce relapse among people with recurrent depression (NICE, 2009; SIGN, 2010; NHS Education for Scotland, 2014).

Subsequently, MBCT and the closely related Mindfulness-Based Stress Reduction (MBSR) are the most widely practised mindfulness-based interventions (MBIs) within NHS Scotland. The difference between these interventions can be summarized as: MBCT incorporates elements of CBT to facilitate shifts in negative thinking styles whereas, MBSR typically focuses on stress management strategies (Crane et al., 2012). These eight-week group interventions have been shown to benefit a range of mental and physical health conditions. A recent meta-analysis carried out examining the effects of MBI on disorder-specific outcomes found positive results. This analysis showed that MBIs had a superior effect on not only depression but also other psychiatric and physical conditions such as anxiety, schizophrenia, eating disorders, chronic pain and addictions (Goldberg et al., 2018). This was in comparison to no treatment controls and alternative evidence-based treatments.  Furthermore, Grossman et al (2004) found that mindfulness therapy enhances coping with stress and disability in everyday life.

Throughout Scotland, MBCT and MBSR are available in all 11 main land health boards to varying degrees. Following the growing interest, demand, and evidence for MBCT and MBSR to treat a range of mental and physical health conditions, this project has been funded by NHS Education for Scotland (NES). The aim of this project is to illustrate and evaluate how MBIs are being delivered throughout Scotland, and to make recommendations for future delivery. All materials and data have been provided by the mindfulness leads for each NHS Scotland health board.

Report questions

1.      Who are mindfulness therapists?

2.      What populations are being treated using MBIs?

3.      What measures are being used to evaluate MBI groups?

4.      How effective are these MBIs?

5.      What recommendations can be made?

Mindfulness therapists

Mindfulness-based therapists (MBTs) should have a Health or Social Care qualification, recognised by a professional body such as the Health and Care Professions Council (HCPC) and a well-established personal practice of mindfulness. These professionals must then attend a formal mindfulness development course to become an MBT. The Therapist Development Pathway was developed by NES and includes a set of structured and systematic requirements for becoming an MBT. There are eight existing guidelines developed to provide recommendations for the minimum requirements to become an MBT (Rothwell & Freir, 2014). These guidelines specifically require that MBTs have previous experience working with the client group they have taught MBIs to. Within NHS Scotland, qualified MBTs come from a range of backgrounds and professions such as clinical psychologists, psychiatric nurses, occupational therapists, public health practitioners, dieticians, and other allied health professionals.

Population of participants

NHS Scotland health boards have reported carrying out MBCT and MBSR in primary, secondary and community settings. Following NICE, SIGN and MATRIX guidelines, mental health populations are the largest proportion of participants within mindfulness groups. All 11 health boards reported that MBIs were being carried out for those with anxiety and/or depression. This included those with mild to moderate symptoms and those with severe and enduring symptoms.

Secondary to this population, 55% of NHS Scotland’s health boards are carrying out MBIs for those with chronic pain. Other populations in mindfulness groups included, addictions (18%), physical rehabilitation (18%), and stress and wellbeing (27%).

MBIs for NHS staff members has been carried out by 63% of NHS Scotland health boards. These groups were carried out with varying consistency as boards reported lack of funding, staff and capacity for regular delivery. For those health boards that have been able to carry out staff mindfulness courses, the delivery has often varied. Some health boards were able to carry out courses consisting of NHS staff members only, others provided space (1 or 2 slots per patient course) for NHS staff or have provided brief mindfulness interventions for staff for limited time periods.

Table 1. Percentage of population undertaking MBI.

Demographics

A snapshot of the demographic characteristics (age, gender) of participants attending mindfulness groups has been provided by NHS Dumfries & Galloway, Fife, Greater Glasgow & Clyde, Highlands, and Lanarkshire. Limited data regarding ethnicity meant this could not be described within this report. As seen in Table 2 and 3, there is a significantly greater uptake of MBI courses by women than men. It can also be observed that MBIs have been widely accepted by adults of all ages, with no health boards reporting an upper age limit.

Table 2. Demographic age of MBI participants.

Table 3. Demographic gender of MBI participants.

Measures

Table 4 outlines the various questionnaires used throughout NHS Scotland to obtain a measure of the effect of MBCT and MBSR interventions on participants. These outcome measures are based on the participants self-evaluation.  A total of 17 outcome measures are currently being used throughout NHS Scotland to evaluate MBIs. Each of the 11 health boards used a combination of these outcome measures at the pre-intervention stage of mindfulness and at the post-intervention stage of mindfulness. The number of outcome measures during a course varied from 1-6. The most frequently used outcome measure, the Hospital Anxiety and Depression Scale (HADS), was used in 55% of health boards across Scotland. The percentage of health boards using the same outcome measure varied from 9-55%.

Table 4. Percentage of health boards using outcome measures.

Effectiveness of MBIs

The outcome measures collected from NHS Ayrshire & Arran, Borders, Dumfries & Galloway, Fife, Grampian, Greater Glasgow & Clyde, and Lothian were collated to indicate how effective MBCT and MBSR has been for participants. These measured were collected from various time points between 2012-2020. The reported findings refer to within subject pre-post comparisons, and the change/difference between these scores after 8 weeks of the MBI. Pre-treatment measures were administered at the first session (week 1) and post-treatment measures were collected after the last session (week 8).

The Hospital Anxiety and Depression Scale (HADS) has two measures showing a score for anxiety and another for depression. The mean difference of the HADS (Anxiety) indicated that there was a substantial difference in pre-post MBI measures. This was derived as the mean pre intervention score equalled 12.77 and the mean post intervention equalled 8.41, indicating a 34% reduction in anxiety.

A mean difference in pre-post MBI measures for the HADS (depression) was also found.  The mean pre intervention score was 9.13 and the mean post intervention score was 5.45, which indicates a 40% reduction in depression.

Using the CORE-10 as a measure for psychological distress, it was found that there was a substantial decrease in the in pre-post MBI scores. For this measure, a mean pre intervention score of 17.27 and a mean post intervention score of 11.8 was found. This represents a mean reduction of 32% in psychological distress.

The Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF) was used to measure dispositional mindfulness. The mean difference seen form the FFMQ-SF indicated a small mean difference between the pre-and post-MBCT measures, suggesting they became more mindful after the MBI intervention. The mean pre intervention score was 32.1 and the mean post intervention score was 38.1, which reveals a 19% increase in mindfulness. It may be that this increase in mindfulness has occurred alongside the participants reduction in anxiety, depression, and psychological distress as a direct result of the MBI.

In addition to these results, NHS Dumfries & Galloway reported that on average, there was a significant difference between pre-post-MBI scores for the CORE-10, t(34) = 10.35, p = <0.000, and this represented a large effect size, d = 1.01.

NHS Grampian also found significant results of paired samples t-tests of the HADS for anxiety and depression. This was shown as Hospital Anxiety, t(85) = 11.39, p = <0.001, with an effect size of d = 1.23, and Hospital Depression t(85) = 11.67, p = <0.001, with an effect size of d = 1.13.

In NHS Greater Glasgow & Clyde, on average there was a small significant difference of the FFMQ-39 between the pre-and post-MBI scores. A Wilcoxon Signed Rank Test was used because data were not normally distributed and indicated that this was a significant difference (Z = -2.27, p = .023).

Qualitative evaluation of services

Throughout NHS Scotland, evaluation forms are regularly given to participants at the end of the 8-week mindfulness course. These forms provide invaluable feedback regarding the MBI.

Benefits of mindfulness

‘It has helped me a lot. I have learnt ways to manage my anxiety. I have learnt how my thoughts affect my mood and body. I am more aware of my negative thoughts and how to stop them spiralling. I have learnt my thoughts don’t have to control me. I have learned the importance of being kind to myself.’

‘It has helped me to look at challenges through a different window. It has not solved them but given me the choice to act differently. I feel better equipped to manage challenging situations- which keeps me calmer beforehand.’

‘Taking a few minutes to “ground” myself and take control is also a great benefit in times of panic and anxiety.’

‘Becoming aware of my body, helps me to make a choice about what it needs rather than what I think I need.’

‘It has helped me to ground myself consciously, and to practice mindfulness as a form of mental exercise, daily, not only as an emergency.’

Recommendations for change

‘I’d like it to have been longer as it’s been very much an introduction. Some more planned regular follow ups would benefit myself to keep motivation levels high and avoid falling back!’

‘Less in short time space or make it a little longer rather than trying to cramp it all in two hours.’

‘Didn’t enjoy complete silence...made me feel agitated’

Limitations

There are several limitations to this report. Firstly, the information shared by NHS Scotland’s health boards provided only a snapshot of mindfulness services, and some of which could not provide demographic information. Consequently, these finding may not be representative of other populations or mindfulness groups. Secondly, the materials provided from NHS Scotland are from varying time points from 2012-2020, therefore it cannot be assumed that these numbers are accurate to date. Lastly, initial positive findings are limited due to the lack of follow up data. This data would enable an evaluation of the extent of improved wellbeing, and reduced anxiety and depression on MBI participants.

Clinical Implications

This report gives clinical evidence for the effectiveness of MBCT and MBSR in primary, secondary and community settings across NHS Scotland. Participants of MBIs show markedly positive changes in wellbeing and reduction in anxiety and depression, as well as providing encouraging feedback regarding these services. MBCT and MBSR is an effective alternative to CBT and pharmaceutical interventions. Therefore, increasing the availability of this intervention could provide more treatment choice to patients. This finding further supports the need for maintenance and expansion of mindfulness within NHS Scotland.

Recommendations

1) MBIs should be continued to be offered as alternative to CBT and/or pharmaceutical treatment for recurrent depression.

2) Further training of staff in the facilitation of mindfulness groups is required to ensure services are routinely available across NHS Scotland.

3) Creating a set of standardised outcomes measures to use in the future would be beneficial for future analysis and evaluation of mindfulness services across Scotland.

References

Crane, R., Kuyken, W., Williams, J., Hastings, R., Cooper, L., & Fennell, M. (2012). Competence in Teaching Mindfulness-Based Courses: Concepts, Development and Assessment. Mindfulness, 3(1), 76-84.

Depression in adults: recognition and management | Guidance | NICE. Nice.org.uk. (2009). Retrieved 8 December 2020, from https://www.nice.org.uk/guidance/cg90/chapter/1-guidance.

Goldberg, S., Tucker, R., Greene, P., Davidson, R., Wampold, B., Kearney, D., & Simpson, T. (2018). Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52-60.

Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits. A meta-analysis. Journal of psychosomatic research, 57, 35-43.

Kuyken, W., Warren, F. C., Taylor, R. S., Whalley, B., Crane, C., Bondolfi, G., Hayes, R., Huijbers, M., Ma, H., Schweizer, S., Segal, Z., Speckens, A., Teasdale, J. D., Van Heeringen, K., Williams, M., Byford, S., Byng, R., & Dalgleish, T. (2016). Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials. JAMA psychiatry, 73(6), 565–574.

NHS National Education for Scotland (2014) The MATRIX Evidence Tables. Adult Mental Health. http://www.nes.scot.nhs.uk/media/3403916/matrix_-_adultmentalhealthtables.pdf NICE (2009).

Rothwell, N., Freir, V. (2014). Training pathway for mindfulness teachers, trainers and Supervision NHS Scotland.  Retrieved from http://knowledge.scot.nhs.uk/ mindfulness/resources-library/resource.

Scottish Intercollegiate Guidelines Network (SIGN) (2010) http://www.sign.ac.uk/sign-114-non-pharmaceutical-management-of-depression.html

Appendix

NHS Scotland mindfulness leads

NHS Ayrshire & Arran - Pat Harris and Kevan Fulton

NHS Borders - Pam Doig and Heather Cunningham

NHS Dumfries & Galloway - Ania Gut-Gofron

NHS Fife - Clare Cassells

NHS Forth Valley - Nick Bell, Wendy Prentice and, Alison Brough

NHS Grampian - Helen Moffat

NHS Greater Glasgow & Clyde – Lucy Gamble

NHS Highland - Wendy Van Riet

NHS Lanarkshire - John Coffey

NHS Lothian - Charlotte Procter

NHS Tayside: Gemma King