Date: 03 June 2016
Depression causes untold human suffering, affecting as many as one in five people throughout their life. People often have a first episode in adolescence or early adulthood, and for many it tends to recur.
A recent survey from the MQ charity suggests that our top research priority for depression should be finding ways to prevent it. Mindfulness-based cognitive therapy (MBCT) was developed precisely for this reason, as an intervention for people with a history of depression to learn skills to stay well in the long term. There is a compelling body of evidence to show that MBCT is an effective psychological approach to recurrent depression, and some of that evidence is discussed in this Highlight.
As such, both the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network endorse MBCT for people with recurrent depression. However, even though MBCT has a compelling evidence base, appears to be acceptable to those who experience it, and is in national guidance, its value will be determined by its implementation in service delivery and local practice. This gap from evidence to practice was described in a recent commentary as an ‘implementation cliff’; a large body of work to develop the intervention and evaluate its effectiveness is done; now we need to build a bridge to practice.
This background prompted us to ask a question about the current state of accessibility and implementation of MBCT in the UK’s health services – the NIHR funded ASPIRE project. Specifically we wanted to know what the facilitators and barriers are to implementing MBCT, what critical factors enhance its accessibility and routine use in the NHS, and what would support the NHS in implementation?
Our study involved interviews with more than 200 participants including MBCT practitioners, managers, patients and commissioners, and case studies at 10 sites across the UK. The study will publish later in 2016
Our emerging findings show that people’s access to MBCT is patchy, and in some cases very fragile. A mixed picture emerges from the data, suggesting a variety of MBCT implementation journeys. Analysis is ongoing and whilst these journeys are particular to the participants telling their stories, they share some common features.
MBCT is not an intervention that provides ‘a quick fix’ and as such, in many cases it was perceived to contrast with the pace and pressure of current health services. MBCT also aligns with a model of care that places people as active agents in their own recovery and promotes mental health and well-being, rather than a medical model.
Services that found creative ways to ‘fit’ MBCT within their contexts were most likely to have successful and sustained implementation. This often meant using the NICE recommendations for MBCT as a starting point for making the case but then flexibility adapting the MBCT programme to fit the local context and client groups. The alignment of MBCT with other service initiatives (such as IAPT), management interests, resources, and with a recovery ethos was often perceived to be a factor in implementation.
In the absence of a more strategic and/or commissioner led initiation of MBCT, our data is saturated with examples of enthusiastic and passionate individuals who have acted as local implementers. The starting point for implementation in all sites was the presence of these ‘champions’.
Most implementers had initially worked alone in championing the intervention and as such services had grown organically from the ground up. Data show that these implementers had particular skills in pushing and driving the implementation; they were constantly spreading the word, developing supportive networks, writing business cases, and delivering taster sessions to give others a ‘taste’ of MBCT. The position or seniority of the implementer was also perceived to make a difference in initiating and accelerating MBCT implementation. Developing a critical mass of implementers was facilitated through internal training and supervision arrangements, which led to internal apprenticeship models, and supportive networks.
The implementation of MBCT was more successful in contexts that were receptive to the intervention, and of the implementer’s activities. In addition to how MBCT ‘fits’ as an intervention into the pace and ethos of the NHS, wider contextual factors such as access to resources including finance (to fund and support MBCT training and service delivery), human (having dedicated leads and practitioners) and practical (physical space to deliver sessions) were important facilitators.
Where MBCT was not part of a service’s strategy, reorganisations, changes in service structures, the introduction of new targets, competing priorities and a lack of support from senior level managers disrupted the potential for a focus on implementing MBCT. Often in these cases, implementers worked ‘under the radar’ to ensure some level of service continued to be provided. In cases where the context was more conducive, a synergy of this bottom up and top down implementation was perhaps optimally supportive of sustainable implementation.
In all case studies it was possible to describe an ‘implementation journey’ and interestingly these were often marked by ‘tipping points’. In sites where MBCT appears to have been more successfully implemented whereby there was a more sustained delivery of the intervention, participants described factors and facilitators that cumulatively, and over time, enabled more widespread use of the intervention.
Our next steps are to complete the ASPIRE analysis, collaboratively run dissemination events with stakeholders and provide guidance that NHS providers can use to sustainably implement MCBT within their service contexts.
The research team comprised Dr Felix Gradinger (University of Exeter) and Heledd Owen (Bangor University). Professor Stewart Mercer (Glasgow University), Andy Gibson ( University of the West of England) and Rebecca Crane (Bangor University) are co-investigators. Professor Rob Anderson (University of Exeter was a collaborator).
What are the barriers to implementing Mindfulness-based cognitive therapy and what could enhance its accessibility and routine use in the NHS?