Research implications
Firstly, the trial reported in this thesis needs replication including an active control group and longer follow-up period. This thesis also paves the way to further investigate the influence of MBCT on current depression, including patients having more severe depressive episodes. By using a multi-centre design, generalizability might be improved. Of interest is a multi-centre trial that been conducted in The Netherlands by Huijbers et al. (2012), investigating the combination of MBCT and maintenance anti-depressant medication.
Another area of interest is the increasing attention for chronic depression as a specific subtype of depression. Based on our results, MBCT is expected to be effective in this group of patients.
Future studies could also further investigate the working mechanism of MBCT, focussing on the role of rumination and attentional processes of emotional laden information. Adding repeated measurements during MBCT enables conclusions about causality.
147
Summary and general discussion
Experience sampling methods (ESM), using many short repeated measurement over a period of time could be a method to investigate how different processes change over time (Csikszentmihalyi & Larson, 1987; Geschwind et al., 2011).
Clinical implications
The most far reaching implication of this thesis is that recurrent depressive patients having mild to moderate severe depressive symptoms need no longer be excluded from MBCT. This is important information since health insurance companies in The Netherlands restrict payment of MBCT to patients with three or more depressive episodes and in current remission.
In addition, rumination seems to be a vulnerability factor on the long term after MBCT, independent of depressive status. The interplay between Acceptance and rumination is interesting, since rumination seems to play a key role in the course of depressive symptoms since Acceptance seems to protect against the influence of depression maintaining processes like rumination. Room to improve MBCT therefore might be offering booster sessions with a focus on self-compassion (e.g. Gilbert, 2014; Raes, 2010) as a way to maintain and deepen mindfulness skills like Acceptance. The role of compassion training on recurrent depression is under study in the Radboud University Nijmegen Medical Centre for Mindfulness in The Netherlands.
Follow-up reunions sessions perhaps supported by the formation of online health communities (e.g. Kuckertz et al., 2014) could also be explored as ways to improve the results of MBCT, meeting also the perceived importance of group member support. Finally, a next step in improving MBCT might be personalizing MBCT training, taking for example the role of gender, previous meditation experience, level of mindfulness skills, but also religious background into account.
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