Evaluating Compassion–Mindfulness Therapy for Recurrent Anxiety and Depression

Abstract

Objective:

To evaluate the effects of compassion–mindfulness therapy (C-MT), an adapted version of mindfulness-based cognitive therapy that integrates compassion training.

Method:

Individuals aged 17–69 with recurrent depressive and anxiety symptoms were recruited from a community mental health service unit. Half of the participants were randomized to an 8-week C-MT program (n = 41) and the other half to a wait-list control condition (n = 41).

Results:

Intent-to-treat analyses showed significant improvements in all measures in the treatment group. The effect sizes for depression and anxiety were 1.11 and 1.10, respectively, and those for physical distress, daily functioning, positive affect, and negative affect ranged from 0.71 to 1.04. All improvements were sustained at the 3-month follow-up.

Conclusions:

The results provide preliminary support for C-MT as a viable treatment option for individuals with recurrent depression and anxiety symptoms. Time-limited treatments such as C-MT should be promoted in social work practice.

Keywords

mindfulness training compassion depression anxiety treatment

Effective, time-limited treatments for depression and anxiety are in huge demand. Epidemiological studies have found that anxiety and mood disorders are common, with the lifetime prevalence of both ranging from 14.5% to 28.8% in the United States and European countries (Alonso & Lepine, 2007; Kessler et al., 2005). Studies in other developed countries have found similarly high rates of anxiety and depression (Kessler et al., 2007; Murray & Lopez, 1996).

Clinical trials have shown that psychotherapy is effective in reducing anxiety and depressive symptoms, with comparable results to medication (Cuijpers et al., 2013; Hollon & Ponniah, 2010). Reviews have reported moderate to large effect sizes for psychotherapy for anxiety disorders (0.73) and major depressive disorder (MDD; 0.68), indicating that the changes after treatment should be clearly observable (Cuijpers, van Straten, Bohlmeijer, Hollon, & Andersson, 2010; Hofmann & Smits, 2008; Portney & Watkins, 2009). However, many people with depressive and anxiety disorders are unable to complete treatment, and many completers fail to achieve clinically significant improvements (Taylor, Abramowitz, & McKay, 2012). For example, Taylor, Abramowitz, and McKay (2012) reported that the dropout rate from cognitive behavior therapy (CBT) for anxiety was 16%, and 35% of the completers were classified as nonresponders who are defined as people who did not achieve a clinically significant improvement. Similar rates have been reported in studies of treatment for depressive disorders (DeRubeis et al., 2005; Westen & Morrison, 2011).

Identifying the best research evidence is only the first step in evidence-based social work practice. The validity and limitations of such evidence should be considered together with the practitioner’s clinical expertise, the client and population’s characteristics, state, needs, values, and preferences, and the environmental and organizational context (Thyer, 2007; Thyer & Pignotti, 2011). For example, an outcome study on CBT in a Chinese population reported that people with higher levels of physical distress and cognitive and interpersonal impairment were less likely to benefit from a well-validated intervention program than those with lower levels of these symptoms (Lo, Epstein, Ng, Chan, & Kwan, 2011). As psychotherapeutic approaches for depression and anxiety seem to have minimal or nonsignificant positive outcomes, alternative intervention approaches that satisfy client characteristics and the environmental context should be explored so that people can benefit from these new and advanced evidence-based practices (Thyer, 2007; Thyer & Pignotti, 2011).

In response to the quest for innovative practice approaches, mindfulness training, originating from the ancient Buddhist meditative tradition, has been introduced into clinical and health care with growing empirical support (Kabat-Zinn, 1990; Williams & Kabat-Zinn, 2011). Two well-established mindfulness-based treatment protocols—mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT)—teach people to direct their attention nonjudgmentally to their body, feelings, and thoughts in the present moment (Kabat-Zinn, 1990; Segal, Williams, & Teasdale, 2002). Meta-analyses have demonstrated that mindfulness training can effectively relieve emotional symptoms and improve overall functioning in people with physical and mental health issues (Grossman, Niemann, Schidt, & Walach, 2004; Hofmann, Sawyer, Witt, & Oh, 2010).

Because MBCT has been recommended as a relapse prevention program for MDD (Teasdale, Segal, & Williams, 2003), most rigorous MBCT studies have focused on relapse prevention and included only people in full or partial remission of MDD (Kuyken et al., 2008; Ma & Teasdale, 2004; Segal et al., 2010). Three meta-analyses have reviewed the outcomes of mindfulness training for people with recurrent depression and anxiety, yet each suffered from various limitations. Hofmann, Sawyer, Witt, and Oh (2010) reported average effect sizes of 0.97 for anxiety and 0.95 for depression, suggesting that mindfulness-based therapy has strong effects for people with anxiety and depressive symptoms. However, their analysis included studies for people with physical disorders such as cancer or pain and elevated levels of anxiety or depression. McCarney, Schulz, and Grey (2012) included 11 studies of depression, but only 2 of them were randomized controlled trials (RCTs) that included people in full or partial remission of a mood disorder. Vøllestad, Nielsen, and Nielsen (2011) included 15 studies of mindfulness training for anxiety disorders, excluding acceptance-based approaches, but only 4 of them were RCTs and the sample sizes were small, ranging from 26 to 53. The efficacy of mindfulness training for people with recurrent depression and anxiety is still unclear due to limitations such as different inclusion criteria (inclusion of people with physical disorders or a restrictive inclusion of full or partial remission of MDD only in previous meta-analyses), small samples, and uncontrolled trials. More studies are needed to verify the effectiveness of mindfulness training, including its application in people with moderate to severe depression, treatment satisfaction, attrition rate, and so on, so that treatments for people with depression and anxiety can be improved.

Compassion meditation is another traditional practice that can help people to cultivate a caring response to their own suffering and the suffering of others (Feldman, 2005; Hanh, 1998). Compassion can be defined as a behavior or an intention to nurture, guide, protect, and offer feelings of acceptance and belonging to benefit another person (Gilbert, 2009). Clinicians often use self-compassion as a starting point for developing compassion for others. Self-compassion is positively associated with happiness, optimism, and positive affect and negatively associated with negative affect and neuroticism (Neff, Kirkpatrick, & Rude, 2007). Gilbert (2012) further asserted that the capability for self-compassion and compassion can reduce the tendency to focus on threat and safety seeking and promote an affiliative-focused, soothing well-being.

Compassion is beneficial for people experiencing distress in their interpersonal relationships, which is a common feature among people with anxiety and depression (Addis & Jacobson, 1996; Lo et al., 2011). Recent preliminary evidence suggested that self-compassion may be a more robust predictor of symptom severity and quality of life in depression and anxiety than mindfulness (Van Dam, Shappard, Porsyth, & Earleywine, 2011). Another study found that self-compassion mediated a reduction in cognitive reactivity after MBCT (Kuyken et al., 2010). Although some treatment programs are designed to develop compassion alone, our research team investigated the outcome of compassion–mindfulness therapy (C-MT), an adapted mindfulness training program, by incorporating compassion training onto the proven and related success of MBSR/MBCT. This is also one of the first studies to test the use of mindfulness training for active depression and anxiety with a larger sample size and a control group.

The purpose of this study was to investigate the effectiveness of C-MT in reducing the symptoms of people with recurrent depression and anxiety in a community mental health setting. It aimed to verify the hypotheses that participating in C-MT could (1) reduce depressive symptoms, (2) reduce anxiety symptoms, (3) reduce physical distress, (4) improve daily functioning, (5) increase positive affect, and (6) reduce negative affect. To further investigate the efficacy of C-MT, it was expected that the attrition rate of the program would be less than 20% and the effect size for all outcome measures would be higher than 0.4.

Method

Design

This study adopted an RCT design. Participants were randomized into a treatment group and a wait-list control group. Participants from the wait-list control group were offered C-MT after the treatment group had completed the intervention. A 3-month follow-up was arranged for the treatment group.

Participants

Participants were recruited from the general public in Hong Kong, China, between late 2008 and mid-2010. Information about the program was promoted through mental health services and the family service center. The C-MT and research project were listed on the website www.mindfulness.hk, where most local MBSR/MBCT instructors post regular program updates. The study was based on a community sample, and although some participants were referred by professionals from mental health and family service units, all joined the study on a voluntary basis. People who were receiving pharmacological treatment were not excluded, but the use of drug and/or counseling services at pretreatment was recorded. As this was the first clinical trial of C-MT, the effect size was estimated by referring to two RCTs of MBCT, which have reported effect sizes of 0.5. Based on an expected effect size of 0.5 with 80% power, the required sample size was estimated as 80, with an attrition rate of 20% (Cohen, 1988; Cuijpers, van Straten, & Warmerdam, 2007; Zu et al., 2014).

One hundred and seventeen people indicated their intention to participate in the study. The inclusion criteria were (i) no current diagnosis of psychosis and (ii) a total score of 8 or above on the Hospital Anxiety Depression Scales–Anxiety (HADS-A) subscale (Zigmond & Snaith, 1983) and/or a total score of 15 or above on the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996). Screening was arranged through individual interviews, as a result of which 35 applicants were excluded: Twenty-nine of them had low scores on the BDI or HADS-A, two were no longer interested in joining the program after the screening interview, one reported a diagnosis of bipolar disorder, and three did not attend the screening interview and could not be contacted afterward. Once an applicant was accepted for the study, he or she was assigned a study number. An appointed administrative clerk who did not know the identity or background of the participants allocated them to either the treatment group or the wait-list control group using a random number table.

All participants completed the pretreatment assessment at the community mental health service unit before the screening interview. The posttreatment assessment was distributed in a sealed envelope at the final session, and participants were asked to complete the questionnaires at their convenience and to return the questionnaires to the service unit within 2 weeks. All accepted participants were required to pay approximately US$38 to enroll on the program, but half of the fee was waived for those who were currently on welfare or had a low income. Participants who completed all of the assessments received a cash coupon worth about US$25 as an incentive to complete all of the measures at follow-up.

Procedure

C-MT is a group-based program delivered in 8 weekly sessions and lasting for 20 contact hours. The development of C-MT was based on the work of the first author. During the pilot stage, feedback from participants and consultation with a senior mindfulness instructor in Hong Kong were used to refine the practice protocol. Both the feedback from participants and the outcomes of an earlier simple pretest–posttest comparison study were positive (Lo, Chan, & Ng, 2007). The updated protocol is available from the first author upon request. Table 1 shows an outline of the session themes.

Table 1.

Session Themes of Compassion–Mindfulness Therapy (C-MT).

Session	Content
1	Introduction
2	Mindfulness of body sensations
3	Mindfulness of feelings
4	Mindfulness of thoughts
5	Aversion and acceptance
6	Compassion for self
7	Compassion for others
8	Review

C-MT begins with the major mindfulness practices taught in all MBSR and MBCT programs. Participants are guided to perform a body scan, mindful yoga, mindful sitting, and other informal practices to develop awareness of the body, feelings, and thoughts (Kabat-Zinn, 1990; Segal, Williams, et al., 2002). Participants are encouraged to develop a nonjudgmental awareness of their difficulties that serves as a foundation for the compassion practice in the later stage of the program (Germer, 2009; Kristeller & Johnson, 2005).

Compassion practice focuses on cultivating an empathic and balanced relationship with the self and others. Participants are guided to send compassionate blessings to the self, then to a compassionate image, a neutral person, and a difficult person (Feldman, 2005; Germer, 2009). The compassionate blessings include four parts: may I (you) be at peace, may I (you) be happy, may I (you) be healthy, and may I (you) be at ease and able in self-care. These four phrases are based on the traditional loving-kindness meditation, with minor modifications to make the practice more suitable to the needs of people experiencing emotional distress (Feldman, 2005). Self-compassion practice is introduced in the sixth session, and compassion for others is taught in the seventh session. The phrases are repeated 4 times during the compassion exercise, allowing people to explore their inner experiences and interpersonal relationships openly and mindfully. Participants are frequently reminded to respond to their limitations in practice with patience and acceptance, especially toward a difficult person. The practice aims to cultivate a deeper empathic understanding of the self and others by transforming interpersonal conflicts and problems as they emerge over time.

Each C-MT session lasted for 2½ hr. In each group, 10–12 participants were recruited, which also included 3–5 participants without emotional symptoms. A larger group size and the relatively heterogeneous background of the participants helped to open up an interactive dialogue between practitioner and participants which covered different experiences apart from those closely related to depressive and anxiety symptoms (Segal, Teasdale, & Williams, 2013). However, the outcomes of participants without emotional symptoms were not included in this study. All participants were required to practice for at least 30 min 3 times a week at home using guided audio compact disks of mindfulness and compassion practices.

All C-MT programs were conducted between early 2009 and late 2010 in a community mental health service unit located in North Point, Hong Kong. Four treatment groups were organized for the study. The wait-list control group participated in a C-MT program about 3 months after the completion of the C-MT treatment groups, but their posttreatment changes were not included in the analysis. Two experienced mindfulness training instructors were responsible for conducting the C-MT programs, and each was responsible for conducting two treatment groups. One had been conducting mindfulness training programs in Hong Kong for 10 years and the other for 4 years, and both had received extensive training in MBSR and MBCT.

No extra funding source was sought for the study and the project expenditure was absorbed into an existing mental health project run by the Hong Kong Family Welfare Society. The study received formal approval from the Human Research Ethics Committee for Non-Clinical Faculties, The University of Hong Kong (ref: EA090108), and the Hong Kong Family Welfare Society. The study was registered at the Chinese Clinical Trial Registry (ref: ChiCTR-TRC-11002988).

Measures

The primary outcomes were levels of anxiety and depression. Secondary outcomes included body–mind–spirit well-being, with subscales in physical health and mental health from positive and negative dimensions.

Hospital Anxiety Depression Scale—Anxiety Subscale (HADS-A)

This study used the 7 anxiety items from the HADS-A for measuring anxiety (Zigmond & Snaith, 1983). This study only used the 7 items for assessing anxiety. The items are measured on a 4-point scale, with a maximum score of 21. The HADS-A displays sound psychometric properties; its internal consistency for anxiety subscale ranged from .76 to .93 in studies across Europe, Canada, and Asia (Bjelland, Dahl, Haug, & Neckelmann, 2002). The authors of the HADS-A proposed the following cutoff points: 8–10 mild, 11–14 moderate, and 15 or above severe. The HADS-A has sound psychometric properties; internal consistency ranged from .76 to .93 in studies across Europe, Canada, and Asia (Bjelland et al., 2002). The maximum scores of HADS-A is 21.

Beck Depression Inventory (BDI-II)

The BDI, second version (BDI-II), is one of the most widely used self-report measures for depression (Beck et al., 1996). It comprises 21 items measured on a 4-point scale, and the scale has undergone extensive validation. The maximum score on the BDI-II is 63, and the cutoff scores are as follows: 1–10 normal, 11–16 mild, 17–20 borderline, 21–30 moderate, 31–40 severe, and 41 or above extreme (Beck et al., 1996).

Body–Mind–Spirit Well-Being Inventory (BMSWBI)

The BMSWBI was developed to assess both physical and mental health (Ng, Yau, Chan, Chan, & Ho, 2005). The BMSWBI includes items to measure both negative symptoms and positive functioning. Four subscales were selected for this study: physical distress (14 items), daily functioning (10 items), positive affect (8 items), and negative affect (10 items), with all items assessed on a 10-point scale. For physical distress and negative distress, high scores reflect poor well-being, while for daily functioning and positive affect, high scores reflect good well-being. The internal reliability of the selected subscales ranges from .87 to .92 (Ng et al., 2005).

Clinically significant changes in the primary outcome measures were assessed by two criteria. (1) The reliable change index (RCI) was used to examine whether the change experienced by each participant was reliable (Jacobson & Truax, 1991). The RCI is computed as the difference between scores at T0 and T1 divided by the standard error. Values exceeding 1.96 are considered to indicate improvement while values lower than −1.96 indicate deterioration. (2) A reduction of 50% or more in participants’ symptom scores.

Treatment Adherence

All of the weekly sessions of the C-MT treatment groups were audio-recorded. Four independent clinicians with previous experience of delivering the C-MT program rated 10% of the sessions randomly selected from the four groups and eight weekly sessions. The MBCT Adherence Scale (MBCT-AS) was modified to assess treatment fidelity for this study. Some modifications were made to the original 17 items for this specific application (Segal, Teasdale, Williams, & Germar, 2002). Five items were removed because they covered CBT techniques related to relapse prevention which was not covered in the C-MT programs. Two items (provision of rationale for compassion practice and review of compassion practice) were added. Raters were required to score the items from 0 (no evidence of adherence) to 2 (definite adherence). The mean score for the 14 items was 1.64, with interrater reliability of .85, indicating that both therapists strongly adhered to the core components of the C-MT program.

Statistical Analyses

All missing values were imputed using the last observation carried forward method. All analyses were conducted according to the intention-to-treat approach (Hollis & Campbell, 1999; Moher et al., 2010).

The intervention effect was evaluated by comparing the treatment and control groups. Repeated measures analysis of variance (ANOVA) with time (pretest and posttest) as the within-subject variable and group (treatment group and control group) as the between-subject variable was used to detect the effects of time, group, and the Time × Group interaction for each of the outcome measures. In the case of significant results, a simple effect analysis was used to test where the differences occurred. T-tests were used to examine the program’s maintenance effect. All analyses were performed in SPSS 20.0.

Results

Demographics

Figure 1 shows the flow of participants through each stage of the trial. The participants (N = 82) were predominantly female (73.2%), and their average age was 44.44 years (standard deviation [SD] = 10.8, range 17–69). Based on the information provided by participants in the screening interview, 56.8% had a diagnosis of either a major depression or an anxiety disorder, and the same proportion was on medication at the time of randomization. Altogether 20.7% had previous meditation experience. Table 2 summarizes the results of the t-tests and chi-square tests comparing age, sex, marital status, religious background, psychiatric diagnoses, and forms of treatment received between the treatment and the control groups. None of the differences were significant (all ps > .05), indicating that the randomization was successful.

Figure 1.

Flow diagram of the process for this randomized trial.

Table 2.

Pretreatment Evaluation between Treatment Group and Wait-List Control Group.

	Treatment (n = 41)	Control (n = 41)	t	χ²	p
Mean age (SD)	44.2 (8.9)	44.4 (11.2)	0.13	—	.90
Sex (female)	32 (78.0%)	28 (68.3%)	—	0.99	.32
Educational			—	1.95	.58
Primary	2 (4.9%)	2 (4.9%)
Secondary	17 (41.5%)	23 (56.1%)
Tertiary or above	22 (53.7%)	16 (39.0%)
Marital status			—	0.22	.90
Single	13 (33.3%)	12 (30.8%)
Married	20 (51.3%)	20 (51.3%)
Divorced/separated	6 (15.4%)	7 (17.9%)
Psychiatric diagnoses			—	0.68	.71
Major depressive disorder	10 (24.4%)	9 (22.0%)
Anxiety disorders	8 (19.5%)	4 (9.8%)
Mixed anxiety depression	8 (19.5%)	7 (17.1%)
Other treatment received
Medication	24 (58.5%)	22 (53.7%)	—	0.20	.66
Counseling	19 (46.3%)	17 (42.5%)		0.12	.73
Depression mean score (SD)	27.15 (9.39)	28.08 (11.73)	0.39	—	.70
Mild	5 (12.8%)	6 (15.4%)		0.59	.96
Borderline	5 (12.8%)	5 (12.8%)
Moderate	15 (38.5%)	13 (33.3%)
Severe/very severe	14 (35.9%)	15 (38.5%)
Anxiety mean score (SD)	12.40 (2.53)	11.83 (3.68)	0.81	—	.42
Mild	9 (22.0%)	11 (26.8%)		5.64	.13
Moderate	25 (61.0%)	16 (39.0%)
Severe	5 (12.2%)	11 (26.8%)
Religion			2.41		.49
No religion	21 (52.5%)	25 (61.0%)
Christian	7 (17.5%)	7 (17.1%)
Catholic	6 (15.0%)	2 (4.9%)
Buddhism	6 (15.0%)	7 (17.1%)

Note. SD = standard deviation.

Attrition and Participants’ Comprehension

As shown in Figure 1, eight participants dropped out from the treatment group and three from the control group. Attrition rates for the treatment and control groups were 19.5% and 7.3%, respectively. The reasons for attrition in the treatment group included personal factors (such as a time clash with another commitment) and technique factors (such as an inability to follow the practice instructions). As more than half of the dropouts could not be contacted by the research team, the reasons for attrition were not analyzed. The attrition rate for the treatment group was similar to the rates reported in CBT studies, while the lower attrition rate in the control group may have been due to the expectancy effect of the wait-list (Hofmann & Smits, 2008).

Participants’ understanding of the program was assessed after they had completed the C-MT. A 13-item comprehension scale was designed, on which each participant was asked to rate how useful the different practices and ingredients of the C-MT program were in helping them to manage their emotions and stress. The items were rated on a 6-point scale (0 = not useful at all, 5 = extremely useful). Twelve of the items measured the practices and ingredients of C-MT, such as body scan, mindful sitting, compassion practice, practice review during sessions, and course notes, and 1 item provided an overall rating for the program. Thirty-two participants returned the completed comprehension scale, with a response rate of 97.0%. The overall rating for the course was 3.89 (SD = .94). Three-min breathing practice was rated the highest (M = 4.00, SD = 1.13) and homework the lowest (M = 3.63, SD = 1.16). The score for compassion (M = 3.91, SD = 1.15) was close to the mean of the 12 items (M = 3.90, SD = .87), and such difference was not statistically significant (t = .06, p = .96).

Changes in Depression and Anxiety

The ANOVA results are presented in Table 3. Anxiety symptoms showed a Time × Group interaction, F(1, 79) = 7.72, p = .009. Simple analyses revealed a significant decrease in HADS-A scores at posttest in both the treatment group, t(39) = 6.21, p < .001, and the control group, t(40) = 2.34, p = .024.

Table 3.

Measures Over Time for Treatment and Wait-List Control Groups.^a

	Pretreatment M (SD)	Posttreatment M (SD)	Follow-up, M (SD)^b	F (1,78)	p	Cohen’s d ^b	95% CI
Anxiety (HADS-A)
Treatment	12.56 (2.34)	9.10 (3.86)	8.23 (4.62)	7.72	.01	1.10	[0.38, 2.28]
Wait-list	12.54 (3.08)	11.14 (4.13)
Depression (BDI)
Treatment	28.44 (8.51)	17.25 (11.67)	15.56 (11.44)	15.67	<.01	1.11	[−1.50, 4.68]
Wait-list	29.14 (11.34)	27.43 (13.85)
Physical distress (BMSWBI-PD)
Treatment	64.10 (21.69)	42.72 (28.99)	36.77 (23.97)	5.80	.02	0.85	[−5.79, 9.72]
Wait-list	62.61 (27.63)	53.90 (30.11)
Daily functioning (BMSWBI-DF)
Treatment	40.93 (11.57)	55.23 (15.93)	58.63 (18.09)	17.35	<.01	1.04	[4.58, 3.84]
Wait-list	42.03 (15.81)	44.03 (15.51)
Positive affect (BMSWBI-PA)
Treatment	28.54 (12.51)	38.44 (15.48)	38.31 (16.62)	10.33	<.01	0.71	[−4.54, 4.03]
Wait-list	26.28 (15.11)	26.95 (14.92)
Negative affect (BMSWBI-NA)
Treatment	65.32 (12.33)	48.08 (20.24)	46.17 (21.73)	4.39	.04	1.04	[−2.73, 7.24]
Wait-list	60.30 (22.00)	53.70 (24.47)

Note. BDI = Beck Depression Inventory; BMSWBI = Body–Mind–Spirit Well-Being Inventory; DF = daily function; NA = negative affect; PA = positive affect; PD = physical distress; HADS-A = Hospital Anxiety Depression Scales–Anxiety. Cohen’s d is calculated as the effect size from pretreatment to posttreatment. ^a n = 82, except ^b n = 41.

Depressive symptoms also showed a significant Time × Group interaction, F(1, 76) = 15.67, p < .0001. Simple analyses revealed a significant decrease in BDI scores at posttest in the treatment group, t(38) = 5.31, p < .001, and a nonsignificant decrease in the control group, t(38) = 1.68, p = .100.

Changes in Secondary Outcome Measures

As shown in Table 2, there was a significant Time × Group effect on the change in BMSWBI physical distress subscale scores, F(1, 78) = 5.80, p = .002. There was also a significant Time × Group interaction effect on the change in BMSWBI daily functioning subscale scores, F(1, 78) = 17.35, p < .001. There was a significant Time × Group interaction for positive affect , F(1, 78) = 10.33, p = .002, and negative affect, F(1, 78) = 4.39, p = .040.

As reported, the C-MT participants showed significant improvements over time on all of the physical health and mental health measures. Cohen’s d was calculated to measure the magnitude of the treatment effects based on the pretest scores, to estimate changes in the group means. The effect sizes for the outcome measures ranged from 0.71 to 1.11 (Table 3). The effect size was 1.11 for depression and 1.10 for anxiety. The effect sizes for physical distress, daily functioning, positive affect, and negative affect were 0.85, 1.04, 0.71, and 1.04, respectively. In sum, the effect sizes for depression, anxiety, and all secondary measures were high (Cohen, 1988).

Maintenance Effect

A 3-month follow-up was arranged to assess the maintenance effect. Table 3 summarizes the outcome measures for the treatment group. Paired t-tests comparing the differences in mean scores between pretreatment and posttreatment, pretreatment and 3-month follow-up, and posttreatment and 3-month follow-up all showed the same pattern of change.

The differences between pretreatment and posttreatment and pretreatment and 3-month follow-up were all significant (all ps < .00). However, the differences recorded between posttreatment and 3-month follow-up were not significant for all measures (all ps > .05). Overall, the results indicate that there were significant changes between pretreatment and posttreatment and pretreatment and 3-month follow-up. However, there was no difference between posttreatment and 3-month follow-up.

Clinical Significance

Two methods were used to examine whether changes in the primary outcomes were clinically significant and showed slightly different results (see Table 4). All participants with RCI scores exceeding 1.96 were classified as “improved,” those with scores lower than −1.96 as “worsened,” and those who fell between these two values as “no change.” Overall, both the treatment and the control group followed a similar trend, with fewer participants classified as worsened than improved. For changes in depression, 62.5% participants improved and only 7.5% worsened in the treatment group, while only 31.7% participants improved and 17.1% worsened in control group. For changes in anxiety, 67.5% participants improved and 2.5% worsened in the treatment group, while 56.1% participants and 17.1% worsened. Chi-square analysis confirmed that these differences were significant (for depression, χ² = 7.74, p = .02, for anxiety, χ² = 9.96, p = .01).

Table 4.

Number (%) of Participants With Significant Reliable Change Index (RCI) Scores and 50% Reduction in Symptom Scores.

	Treatment (n = 41)			Control (n = 41)					Treatment (n = 41)	Control (n = 41)
Scale	Worsened	No change	Improved	Worsened	No change	Improved	χ²	p	50% Reduction	50% Reduction	χ²	p
BDI	3 (7.5)	12 (30.0)	25 (62.5)	5 (12.2)	23 (56.1)	13 (31.7)	7.74	.02	17 (42.2)	3 (7.3)	13.48	.00
HADS-A	1 (2.5)	12 (30.0)	27 (67.5)	7 (17.1)	11 (26.8)	23 (56.1)	9.96	.01	11 (27.5)	5 (12.2)	2.99	.08

Note. BDI = Beck Depression Inventory; HADS-A = Hospital Anxiety Depression Scales–Anxiety.

The level of clinical significance was further assessed by the number of participants reporting a 50% reduction in symptom scores. In the treatment group, 42.2% of the participants reported a 50% reduction in depression scores and 27.5% reported a 50% reduction in anxiety scores. In the control group, only 7.3% and 12.2% of participants reported a 50% reduction in depression and anxiety scores, respectively. Chi-square analysis confirmed that the differences in depression symptom scores between the two groups were significant (for depression, χ² = 13.48, p < .01). The difference in anxiety scores was marginally significant, probably because the lower symptom scores for anxiety at pretest caused a ceiling effect.

Predicting Changes by Symptom Severity, Medication, and Counseling at Pretreatment

In view of concerns about the application of mindfulness training in people with moderate to severe depression, treatment changes by symptom severity were calculated. Based on the symptom severity, and combining the mild and moderate groups into one group for further analysis, a one-way ANOVA was performed to detect significant differences among groups. Table 5 shows that the mild depression group reported the least change in BDI scores (M = 6.83, SD = 10.38), the moderate depression group reported a larger change (M = 13.55, SD = 10.56), and the severe depression group reported the largest change (M = 20.70, SD = 12.39). The difference between groups was nonsignificant (F = 1.68, p = 0.19), and the effect in the mild depression group was limited by the ceiling effect. The analyses of anxiety by symptom severity revealed similar patterns. The mild anxiety group reported the least change (M = 3.10, SD = 3.14), the moderate anxiety group reported a larger change (M = 3.46, SD = 3.36), and the severe anxiety group reported the largest change (M = 4.20, SD = 3.44). Again, the difference between groups was nonsignificant (F = 0.42, p = 0.74). There was no evidence that people with moderate and severe symptoms gained less improvement from the treatment.

Table 5.

Predicting Changes by Symptom Severity, Medication, and Counseling at Pretreatment.^a

		Pretreatment	Posttreatment	Treatment Change
	Measures	M (SD)	M (SD)	M (SD)	t/F	p
Depressive symptom severity	BDI				1.68	.19
Mild		16.30 (2.45)	11.90 (7.11)	6.83 (10.38)
Moderate		25.27 (2.63)	15.33 (10.74)	13.55 (10.56)
Severe		37.29 (5.21)	22.50 (12.82)	20.70 (12.39)
Anxiety symptom severity	BDI				0.42	.74
Mild		9.80 (0.79)	6.70 (3.09)	3.10 (3.14)
Moderate		12.83 (1.01)	9.37 (3.29)	3.46 (3.36)
Severe		16.80 (2.53)	12.60 (5.27)	4.20 (3.44)
Medication	BDI				0.64	.52
Yes		28.13 (9.91)	17.00 (11.92)	11.13 (13.11)
No		24.94 (9.06)	16.29 (11.08)	8.65 (10.42)
Medication					0.40	.69
Yes		12.48 (3.04)	8.91 (4.32)	3.57 (3.64)
No	HADS-A	12.29 (1.69)	9.18 (3.21)	3.11 (3.24)
Counseling	BDI				0.39	.70
Yes		28.06 (8.43)	17.17 (11.10)	10.89 (11.66)
No		25.73 (10.49)	16.32 (11.94)	9.41 (12.43)
Counseling	HADS-A				0.21	.84
Yes		12.22 (3.31)	8.72 (3.30)	3.50 (3.45)
No		12.55 (1.97)	9.27 (4.30)	3.27 (3.51)

Note. BDI = Beck Depression Inventory; HADS-A = Hospital Anxiety Depression Scales–Anxiety; SD = standard deviation. ^a n = 41.

Subgroup analyses on the use of medication and individual counseling at pretreatment were performed using t-tests. The medication group reported a larger reduction in BDI scores (M = 11.13, SD = 13.11) than the no medication group (M = 8.65, SD = 8.65), but the difference was not significant (t = 0.64, p = .52). The medication group also reported a larger reduction in HADS-A scores, but the difference did not reach significance. Participants who were receiving counseling reported larger treatment changes, with a larger reduction in BDI scores (M = 10.89, SD = 11.66) than the no counseling group (M = 9.41, SD = 12.43) and a larger reduction in HADS-A scores (M = 3.50, SD = 3.45) than the no counseling group (M = 3.27, SD = 3.51).

Discussion and Application to Social Work

The results of this RCT provided initial evidence of the efficacy of the C-MT program using a community sample. Analyses of both the immediate treatment effects and the maintenance effects revealed significant improvements in participants’ physical and mental health. Tests of clinical significance provided further support for the benefits of C-MT in reducing recurrent depression and anxiety symptoms. C-MT also provided benefits by relieving physical distress and negative affect and by enhancing positive affect and daily functioning. This outcome fits with the conception of the body–mind–spirit intervention model, which assumes that the physical, psychological, and spiritual well-being domains interact as an interrelated system (Lee, Ng, Leung, & Chan, 2009; Raphael, Schmolke, & Wooding, 2005).

Many studies on mindfulness training for depression and anxiety are limited due to poor research designs, such as the lack of a control group and small sample sizes. The results of this study contribute to the emerging evidence on the value of mindfulness training for reducing recurrent depressive and anxiety symptoms by adopting an RCT design with a relatively large sample size. It provides initial support that C-MT, as a form of mindfulness-based intervention, may produce effects comparable to those of CBT and other standard treatments.

As the majority of RCTs on mindfulness training have focused on relapse prevention in people with recurrent MDD and have included participants in partial or full remission, this study examined whether people with moderate and severe depression could also benefit from the program. Participants receiving different psychopharmacological treatments reported positive outcomes, although it is recommended that people with moderate to severe symptoms receive drug treatment at the same time. Further studies should be conducted to compare the outcomes of C-MT and CBT and MBSR/MBCT. Instead of opting for a simple comparison of effect sizes, researchers and practitioners should investigate possible outcome predictors, such as psychiatric history, sources of emotional distress, and treatment preferences.

The C-MT program represents an initial attempt to integrate compassion and mindfulness practice in one treatment program. Many MBSR teachers include compassion practice once or twice in their programs but seldom treat it as a core component. Although some practitioners, including the founders of MBCT, worry that participants with MDD may find compassion practice difficult, the comprehension tests administered in this study reflected that participants found compassion to be as helpful as any other component of the program (Segal, Williams, et al., 2002). More studies should be conducted to investigate the therapeutic value of compassion, both on its own and when integrated with mindfulness training.

In social work practice, depressive and anxiety symptoms are found in mixed populations, and those who present with problems, such as low income and financial difficulties, child care, and family violence, may also exhibit emotional symptoms. The community sample in this study showed improvements in their overall mental health status following a time-limited intervention. Practitioners should consider mindfulness training or C-MT as an evidence-based treatment option so that clients can receive effective help from an intervention that matches the client’s preferences and the practitioner’s expertise.

A few limitations of the study should be noted. First, there are a few weaknesses in the present study design. It is likely that mindfulness and compassion have different effects and mechanisms of change in people with depression and anxiety. The research design did not include a comparison group undergoing an established mindfulness training program (i.e., MBSR or MBCT). Thus, it is still an open question whether compassion adds value to mindfulness training programs. Although gains of treatment group maintained in follow-up, the maintenance effects of C-MT was not uncertain due to the use of wait-list control group and the lack of comparison at the 3-month follow-up period. Second, the study was conducted at a single site using a heterogeneous community sample. All participants were Hong Kong Chinese, so the findings may not generalize to people from other populations and cultures. Further studies should investigate the effectiveness of C-MT in a separate population, and the potential bias due to the use of a developer-administered intervention could be examined. Third, the inclusion criteria were based on self-report scales with cutoff scores, rather than on diagnostic criteria such as Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Future studies should add diagnostic criteria and investigate whether cultural background affects responsiveness to C-MT. Outcome studies should ideally include indicators other than self-administered measures, which may suffer from bias. Finally, the sample size of this study was relatively small. In future studies, the inclusion of clinician-reported measures, other physical, physiological, or neurological tests related to anxiety and depression, larger sample sizes, and a design that can detect possible effects within groups and instructors will help to establish the efficacy of C-MT.

Footnotes

Acknowledgments

The authors thank Dr. Helen S.W. Ma for her assistance in implementing the Compassion–Mindfulness Therapy program in this project and her valuable advice in preparing the manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by the Hong Kong Family Welfare Society, which offered administrative support and assistance in recruitment and data collection.

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