‘Mind the gaps’: the accessibility and implementation of an effective depression relapse prevention programme in UK NHS services: learning from mindfulness-based cognitive therapy through a mixed-methods study

Abstract

ObjectivesMindfulness-based cognitive therapy (MBCT) is an evidence-based approach for people at risk of depressive relapse to support their long-term recovery. However, despite its inclusion in guidelines, there is an ‘implementation cliff’. The study objective was to develop a better explanation of what facilitates MBCT implementation.SettingUK primary and secondary care mental health services.Design, participants and methodsA national two-phase, multi-method qualitative study was conducted, which was conceptually underpinned by the Promoting Action on Research Implementation in Health Services framework. Phase I involved interviews with stakeholders from 40 service providers about current provision of MBCT. Phase II involved 10 purposively sampled case studies to obtain a more detailed understanding of MBCT implementation. Data were analysed using adapted framework analysis, refined through stakeholder consultation.ResultsAccess to MBCT is variable across the UK services. Where available, services have adapted MBCT to fit their context by integrating it into their care pathways. Evidence was often important to implementation but took different forms: the NICE depression guideline, audits, evaluations, first person accounts, experiential taster sessions and pilots. These were used to build a platform from which to develop MBCT services. The most important aspect of facilitation was the central role of the MBCT implementers. These were generally self-designated individuals who ‘championed’ grass-roots implementation. Our explanatory framework mapped out a prototypical implementation journey, often over many years with a balance of bottom-up and top-down factors influencing the fit of MBCT into service pathways. ‘Pivot points’ in the implementation journey provided windows of either challenge or opportunity.ConclusionsThis is one of the largest systematic studies of the implementation of a psychological therapy. While access to MBCT across the UK is improving, it remains patchy. The resultant explanatory framework about MBCT implementation provides a heuristic that informed an implementation resource.

The effectiveness of mindfulness-based cognitive therapy for major depressive disorder: evidence from routine outcome monitoring data

“… 5 Notwithstanding this established efficacy of MBCT, there is a large ‘implementation gap’ in research on MBCT. 6 Most of the evidence for the efficacy of MBCT comes from RCTs, which are typically conducted in ‘ideal’ settings (often by the developers of the treatment, with highly qualified teachers) with strict inclusion and exclusion criteria for participant selection, and homogeneous samples as a result. 7 Psychological treatment effect sizes might decrease substantially when translated from research settings into clinical practice.…”

Training School Teachers to Deliver a Mindfulness Program: Exploring Scalability, Acceptability, Effectiveness, and Cost-effectiveness

“…In contrast, research suggests that natural implementation often relies on grassroots champions within schools who have a strong commitment to MT, engage wider staff and train teachers. 7 – 9 . In addition, although the costs and organizational demands of training were borne by the study rather than teachers or school, reducing resourcing barriers, teachers consequently had less flexibility with regards to when they accessed program training, and difficulties with attendance at this training were a significant source of attrition.…”

“…To begin to address these issues, research has recently examined facilitators and barriers to implementation of MT in schools 7 and health-care services. 8 , 9 These studies show that implementing MT within health and education sectors is a journey that requires both bottom-up grass roots efforts (people who act as champions, and “will go the extra mile”) and top-down facilitation (eg, investment of time and financial resources required to train teachers to deliver MT). In schools, implementation of social–emotional teaching generally and MT specifically relies on training enough teachers who can teach these programs.…”

Feasibility and Effectiveness of a Workplace-Adapted Mindfulness-Based Programme to Reduce Stress in Workers at a Private Sector Logistics Company: An Exploratory Mixed Methods Study

“…This might indicate that positive outcomes are harder to improve on under this condition, but it needs to be confirmed and explained with more detail in future research. Only very recently have studies examined the implementation of MBIs in health [92] and education [93]. These studies have used an established theoretical framework to map the key contextual and facilitating factors that support implementation, with some overlap (e.g., the importance of "champions") and some differences (e.g., importance of clinical guidelines in health and "perceptions of mindfulness" in education).…”