Assessment of mindfulness trait in treatment-resistant depression: a cross-sectional studyABSTRACT
Introduction Treatment-Resistant Depression is a significant challenge in clinical practice, as it is associated with high levels of psychological suffering and functional limitations. Mindfulness has been proposed as a promising complementary approach to improve symptoms in these patients. However, the prevalence of mindfulness practice and its relationship with anxiety and depression still require investigation.
Objective This study aimed to investigate the prevalence of mindfulness traits in patients with Treatment-Resistant Depression receiving treatment at a research outpatient clinic at the psychiatry institute of a public Latin American federal university.
Method A cross-sectional study was conducted on 44 patients, aged between 18 and 65 years, from March 2022 to September 2023. The participants completed inventories measuring depression, anxiety, and mindfulness. The scores were analyzed for correlations using Spearman’s rank correlation coefficient.
Results The analysis showed that there were significant negative correlations between MAAS scores and BAI (rs = -0.502; p < 0.001) and between MAAS and BDI (rs = -0.442; p = 0.003). This indicates that higher levels of mindfulness are linked to lower levels of anxiety and depression.
Conclusion The findings suggest that mindfulness traits may be associated with a reduction in symptoms of anxiety and depression in patients with Treatment-Resistant Depression, supporting the use of mindfulness-based interventions as a complementary approach. However, the results are limited by the small sample size and the absence of a control group, indicating the necessity for future studies with broader scope and greater methodological rigor.
Keywords Anxiety, Treatment Resistant Depression, Mindfulness.
KEYWORDS:
Anxiety; Depression; Present-Moment Awareness; Mindfulness; Treatment-Resistant Depression
RESUMO
Objetivo Avaliar a presença do traço de mindfulness em pacientes com depressão resistente ao tratamento (DRT).
Métodos Este estudo transversal investigou traços de mindfulness em pacientes com Depressão Resistente ao Tratamento atendidos no IPUB/UFRJ, entre março de 2022 e setembro de 2023.
Resultados Pacientes com Depressão Resistente ao Tratamento demonstraram menor capacidade em viver no momento presente, o que reflete um comprometimento em aspectos fundamentais do mindfulness.
Conclusões A redução nos traços de mindfulness pode estar associada à gravidade e à resistência da depressão ao tratamento, sugerindo a relevância de intervenções baseadas em mindfulness para esse grupo.
PALAVRAS-CHAVE:
Mindfulness; Depressão Resistente ao Tratamento; FFMQ; Saúde Mental; Terapia Cognitiva
INTRODUCTION
Depression is one of the most impactful psychiatric disorders. An increasing number of researchers are seeking out innovative treatment methods, as approximately 30% of individuals being treated for a depressive episode do not achieve remission after two or more trials of first-line antidepressant treatment 1,2. These individuals may persist with depressive symptoms for a period of over two years and are diagnosed with Treatment-Resistant Depression (TRD) when they fail to respond to at least two different antidepressant treatments of adequate dose and duration 1,2.
In the treatment of TRD, several therapeutic approaches have shown promise, including pharmacotherapy, electroconvulsive therapy, transcranial magnetic stimulation, deep brain stimulation, vagus nerve stimulation, phototherapy, and sleep deprivation 3. Psychotherapeutic treatments also demonstrate significant effectiveness in managing depressive disorders 3. The importance of psychotherapeutic interventions is emphasized in situations where pharmacotherapy is not recommended or has limitations. This includes cases involving potential risks of side effects, pregnancy, breastfeeding, or an inability to adhere to medication 3. The patient’s medical history, especially if there has been a previous positive response to psychotherapy, supports the recommendation for this approach. Psychotherapy may be an even more promising option when the patient demonstrates agreement with this approach, motivation for change, and the ability for self-analysis and self-control. These are crucial elements for the treatment’s success 3.
Among the psychotherapies that can be utilized, Cognitive-Behavioral Therapy (CBT) is widely accepted and is considered an effective treatment for depression 4. However, relapses remain a relevant problem, leading to the development of new approaches that focus on acceptance and mindfulness. These methods are recommended for chronic cases or patients resistant to usual treatments 4. These treatments, which began in the 1990s, integrated behavioral and cognitive components with new elements like mindfulness, acceptance, and principles from Zen philosophy and dialectical strategies. Dialectical Behavior Therapy (DBT) is based on these principles and has shown effectiveness in treating various disorders, including TRD 5.
In recent times, the introduction of mindfulness-based therapies has significantly contributed to the growing body of scientific literature on effective treatments for depression and anxiety. CBT has experienced significant developments over the years, leading to the incorporation of mindfulness as a key component in the ‘third wave’ of CBT 6. The ‘first wave’ was represented by behavioral therapy, which focused on modifying maladaptive behaviors. The ‘second wave’, cognitive therapy, introduced the importance of thoughts and beliefs in mental health. At present, the ‘third wave’ is broadening the range of treatments by including mindfulness, which involves being aware of the present moment with acceptance and without judgment 6. Several therapeutic approaches illustrate this new perspective, such as Mindfulness-Based Stress Reduction (MBSR), Acceptance and Commitment Therapy (ACT), DBT, Mindfulness-Based Cognitive Therapy (MBCT), and Mode Deactivation Therapy (MDT) 6.
Along with therapies that focus solely on mindfulness, traditional therapies like CBT, systemic therapy, and psychoanalysis have also started to incorporate mindfulness techniques into the range of techniques they offer 7. Among these approaches, MBCT has emerging as a promising therapeutic approach in the treatment of TRD, with strong scientific evidence proving its effectiveness 2,4,7-12 MBCT is a structured eight-week group-based program that integrates formal mindfulness meditation practices with core principles and techniques derived from CBT. During MBCT, participants learn to recognize and break free from harmful automatic cognitive patterns and to develop a non-judgmental and compassionate attitude towards their own thoughts, emotions and physical sensations 2,7 MBCT is an intervention primarily aimed at preventing relapses, and it includes four well-known mediators that can positively affect TRD: mindfulness (referred to as non-judgmental awareness of the current experience of the present moment), reduction of depressive rumination, increased acceptance and self-compassion, and reduction of avoidance 4. Therefore, MBCT can play a central role in diseases like depression, where the psychosomatic component is fundamental and co-occurs with mental symptoms.
In MDT, mindfulness is present in every aspect of the therapeutic process: validation, clarification, and redirection. During the validation phase, the therapist empathetically welcomes the patient’s experiences, acknowledging their perceptions as understandable reactions to their life history. During clarification, the therapist assists the patient in observing and accepting their feelings and sensations in the present moment, without passing judgment. In redirection, the patient is encouraged to explore alternative and positive beliefs that promote the achievement of their goals. If the patient displays emotional reactivity, the therapist utilizes mindfulness techniques to encourage emotional regulation 6. MDT utilizes direct training in mindfulness skills as a crucial intervention in deactivating deeply ingrained maladaptive responses, like emotional dysregulation. It provides a variety of tools for teaching mindfulness skills, such as breathing exercises, guided imagery meditation, visual concentration tasks, nature walks, sensory explorations, and intentionally enjoyable exercises that involve sports and adventure to captivate the interest of young individuals 6. The variety of mindfulness tools provides additional choices for engaging patients and allows them autonomy in selecting the mindfulness exercises they prefer. Since mindfulness exercises are calming in nature, they do not prompt emotional disruptions and reactive opposition 6.
Studies show that incorporating mindfulness into the psychotherapeutic process can effectively alleviate symptoms of stress, anxiety, and depression 4,13. Using mindfulness techniques also increases mindfulness traits, resilience, and quality of life 14. In mindfulness, individuals enter each moment while being aware of everything in it and functioning from that awareness. Patients with TRD often tend to dwell on the past or worry about the future, getting consumed by their anxious thoughts and concerns, and paying attention to everything but the present moment. This difficulty in focusing on the present hinders their ability to accept reality. The constant rumination on the past or future blocks them from recognizing the present and making positive changes 15. A recent study demonstrated that being mindful is linked to lower levels of depression and stress. The study also found that a lack of mindfulness can predict the development of depression and stress. Higher levels of mindfulness are connected to reduced depression and stress and may help to prevent depression in a stressful environment 16.
On the other hand, mindfulness has been described in literature as having trait qualities, being an inherent and natural capacity of the human organism 17. The trait of mindfulness is a personal characteristic that reflects the practice of mindfulness. These traits show how a person lives in the present moment consciously and balanced, usually as a result of continuous mindfulness practice. They influence personality and behavior, helping to face experiences with clarity and serenity.
There is an increasing amount of research that demonstrates a strong connection between mindfulness and mental health, particularly in relation to depression 14,18. However, thus far, there have been limited studies investigating mindfulness traits in patients with depression, especially those with TRD. The majority of studies only focus on the effectiveness of treatment. The present study aims to investigate mindfulness traits in a population of subjects with TRD. The relevance of this research is justified, as the findings from this study may enable more professionals in the future to use mindfulness as a treatment option for TRD.
METHOD
Study design
This cross-sectional study examined mindfulness traits in patients diagnosed with TRD at the Institute of Psychiatry (IPUB) of the Federal University of Rio de Janeiro (UFRJ) in Brazil. The study was conducted in the TRD outpatient research group (DERETRAT) from March 2022 to September 2023.
DERETRAT is a specialized research outpatient clinic affiliated with the IPUB/UFRJ, dedicated to the evaluation and follow-up of patients diagnosed with TRD. Patients are referred to the service due to documented non-response to at least two adequate antidepressant trials, according to established clinical criteria. At the time of inclusion in this study, all participants were under regular psychiatric follow-up at DERETRAT.
Population
The initial sample consisted of 55 patients who had already been admitted to and were undergoing psychiatric follow-up at DERETRAT. After their psychiatric evaluation, all patients were invited to participate in the research, and 44 agreed to do so. At the time of data collection, all participants were receiving psychiatric treatment conducted by the outpatient physicians. None of the participants were undergoing psychotherapeutic treatment within the service, as the psychological intervention program had not yet begun. Trained healthcare professionals, who were independent of the study, evaluated all patients using the Mini International Neuropsychiatric Interview (MINI 5.0.0/DSM IV, 2000) for diagnostic evaluation.
The inclusion criteria were: age between 18 and 65 years; a prior clinical diagnosis of TRD, established at DERETRAT based on documented non-response to at least two adequate antidepressant trials; confirmation of current depressive and/or anxiety disorders through the MINI diagnostic interview; and not currently undergoing psychotherapy.
Patients with schizophrenia, bipolar disorder, or difficulties in reading and writing were excluded from the sample. This was evaluated at the time of sending their data in the form. Patients who were already undergoing psychotherapy, either at DERETRAT or in external services, were excluded to ensure that psychological interventions would not influence baseline assessments.
All volunteers followed the instructions regarding the study procedures. The study was approved by CAEE (Certificate of Presentation for Ethical Consideration) Approval Number: 18711419.2.0000.5263. After the psychiatric evaluation, the participants were invited by the psychologist in charge of the research to participate in the study. Those who agreed to participate were taken to a private office, where they received detailed explanations about the research and signed the Informed Consent Form, authorizing the disclosure of the results and understanding that refusal to participate would not result in any harm to their treatment. All instruments were administered on the same day, in a single assessment session, immediately after psychiatric evaluation and prior to the initiation of any psychotherapeutic intervention within the service.
Instruments
The patients completed the Beck Depression Inventory (BDI)19 to measure the intensity of depression, the Beck Anxiety Inventory (BAI)20 to measure the intensity of anxiety, and the Mindful Attention Awareness Scale (MAAS)21 to measure full attention and awareness. The BDI is utilized to assess both the presence and severity of symptoms associated with depression, aligning with the diagnostic criteria for depressive disorders. Beck and colleagues created the BDI in 1961 for the purpose of evaluating the intensity of depressive symptoms. This instrument is self-administered and consists of 21 items that correspond to different categories of symptoms and attitudes representing cognitive, affective, and somatic behavioral manifestations of depression. The total score on the BDI can range from 0 to 63 points, with the following interpretations: a score less than 10 indicates no depression or minimal depression, a score between 10 and 18 denotes mild to moderate depression, a score between 19 and 29 suggests moderate to severe depression, and a score between 20 and 63 points is indicative of severe depression 19. This instrument poses few challenges when it comes to usage, as it is easy for the user to handle.
The BAI is a tool used to assess the level and intensity of stress in individuals. It consists of 21 multiple-choice questions that gauge the severity of symptoms related to cognitive, emotional, and physical aspects of anxiety. Participants rate these symptoms on a four-point scale. The total score ranges from 0 to 63, with anxiety levels categorized as minimal (0-7), mild (8-15), moderate (16-25), or severe (26-63)20. BAI played a crucial role in this study because individuals who are anxious tend to focus on future concerns rather than the present. Therefore, high scores on this test indicate that an individual’s thoughts are predominantly centered on future worries that are not relevant in the current moment.
The MAAS is a scale that has been designed to evaluate the key traits of mindfulness availability. This means having an open and receptive awareness of what is occurring in the current moment and focusing attention on it. The original version of the MAAS is a self-assessment tool intended to measure variations among individuals in the occurrence of mental states and consciousness throughout time 21. Although the MAAS requests the respondent to reflect on their daily experiences and how they generally feel, it is classified as a measure of trait mindfulness. This may seem confusing at first, as the scale’s questions focus on the perception of the present moment. 21 However, MAAS is interested in capturing the global trend of individuals experiencing mindfulness throughout their daily lives. Instead of assessing mindfulness at a specific moment, the scale aims to measure an individual’s overall inclination to experience and maintain mindfulness in various situations over time. Therefore, MAAS evaluates mindfulness as a continuous pattern of experience rather than just momentary mindfulness 21. The authors of this scale, Brown and Ryan 22, after evaluating the original 184 items, reduced the total number to 15, to be answered on a six-point Likert scale ranging from (1) almost always to (6) almost never, forming a short unidimensional scale that measures levels of mindfulness. The maximum score a participant can achieve is 90 points and the minimum is 15 points, indicating the maximum and minimum levels of mindfulness. In 2015, this scale was translated, adapted and validated for the Brazilian context 21.
Data Analysis
The sociodemographic data of the patients, along with the test results, was compiled in Excel. This data was presented in a descriptive analysis including age, gender, educational level, marital status, and the scores achieved in the BDI, BAI, and MAAS tests. A correlation analysis was conducted using tests such as the Spearman correlation to examine the relationships between variables. The purpose was to investigate the correlation between MAAS scores with BDI and BAI scores. This allowed us to verify significant associations between the prevalence of mindfulness traits and levels of depression and anxiety.
Statistical tests were performed using SPSS (version 22, OSX, IBM, Armonk, NY, USA). Descriptive analyses were conducted to describe the sample, reporting frequencies and percentages for categorical data and means and standard deviations for continuous variables. Bivariate analyses were conducted by calculating the correlation between the MAAS, BDI, and BAI variables, using the Spearman correlation coefficient. A p-value of <0.05 was selected to determine statistical significance. The data was also analyzed using multiple linear regression to investigate if there was a relationship between the prevalence of mindfulness traits (independent variable) and the intensity of depression (dependent variable) or anxiety (dependent variable). This analysis controlled for potential confounding variables such as age, sex, and educational level. The purpose of this analysis was to explore if levels of mindfulness were linked to the intensity of depression and anxiety in the patients.
RESULTS
The sample consisted of 44 patients diagnosed with TRD and comorbid anxiety disorder, according to the MINI diagnostic interview.
The sociodemographic characteristics of the participants are presented in Table 1. The mean age was 49.32 years (SD = 13.16). The majority of participants were female (70.5%). Regarding educational level, 36.4% had completed higher education, while the remaining participants had varying levels of elementary or high school education. More than half of the sample (54.5%) were unemployed. Concerning income, 31.8% reported having no income, and 40.9% reported earning up to two minimum wages. In terms of marital status, 56.8% were single, widowed, separated, or divorced.
Spearman’s rank correlation analysis was performed to examine associations between mindfulness (MAAS), anxiety symptoms (BAI), and depressive symptoms (BDI). A statistically significant negative correlation was observed between MAAS and BAI (rs = −0.502; p < 0.001), indicating that higher anxiety levels were associated with lower mindfulness scores. A significant negative correlation was also found between MAAS and BDI (rs = −0.442; p = 0.003), demonstrating that higher depressive symptom severity was associated with lower levels of trait mindfulness. No additional significant associations were identified.
DISCUSSION
The present findings demonstrate an inverse association between trait mindfulness and the severity of depressive and anxiety symptoms in patients diagnosed with TRD and comorbid anxiety disorder. In this clinically complex population, individuals reporting lower levels of mindfulness also tended to present higher levels of emotional distress. These findings are consistent with previous research reporting negative associations between dispositional mindfulness and symptoms of depression, stress, and anxiety 16,23-27.
The sample analyzed in this study was clinically homogeneous, as all participants were diagnosed with TRD and comorbid anxiety disorder according to the MINI diagnostic interview. This characteristic is relevant because it allows the observed associations to be interpreted within a specific and clinically complex population. Additionally, mindfulness was assessed using the MAAS, a unidimensional instrument designed to measure trait mindfulness, specifically the tendency to maintain attention and awareness of present-moment experiences in daily life. Thus, lower MAAS scores in the present study indicate a reduced disposition toward present-moment awareness among individuals reporting greater symptom severity.
Mindfulness has been described as a psychological resource associated with improved emotional regulation and reduced vulnerability to distress. Higher scores on mindfulness tests can serve as a protective factor against depression, particularly in stressful situations 16. One possible explanatory pathway discussed in the literature involves rumination and repetitive negative thinking, which are frequently linked to both depressive and anxiety symptoms. Lower levels of mindfulness have been associated with greater engagement in such cognitive patterns 24-28, which may help explain the observed associations in the present study. This occurs because mindfulness can reduce involvement in repetitive thoughts (such as worry and rumination), which has implications for anxiety and depression 24.
Importantly, the results should be interpreted within the limitations of a cross-sectional design. Although significant associations were identified, causality cannot be inferred. It is not possible to determine whether lower mindfulness contributes to greater symptom severity or whether higher symptom levels interfere with dispositional mindfulness.
From a clinical perspective, the findings suggest that trait mindfulness may be a relevant variable in the context of treatment-resistant depression. The observed associations support the rationale for further investigation of mindfulness-based approaches as potential complementary strategies alongside pharmacological and psychotherapeutic interventions. However, interventional and longitudinal studies are necessary to clarify the directionality and clinical impact of this relationship.
Some limitations must be acknowledged. The relatively small sample size limits generalizability and may reduce statistical precision. Additionally, the absence of a comparison group prevents evaluation of whether the levels of mindfulness observed are specific to individuals with treatment-resistant depression or reflect patterns seen in other clinical or non-clinical populations. Furthermore, participants were recruited from a specialized outpatient clinic, which may restrict the representativeness of the sample. Future studies should include larger and more diverse populations and incorporate comparative designs to expand understanding of mindfulness traits in this clinical context.
CONCLUSION
This study contributes to the growing body of research examining the role of mindfulness in individuals with treatment-resistant depression. The findings highlight the relevance of dispositional mindfulness as a psychological characteristic that may be related to emotional functioning in this population.
Although causal relationships cannot be inferred, the results support the importance of further investigating mindfulness within the clinical context of treatment-resistant depression. Mindfulness-based approaches may represent a promising complementary strategy to be explored alongside established pharmacological and psychotherapeutic treatments.
Future research should employ larger samples and longitudinal or interventional designs to clarify the mechanisms involved and better understand the potential role of mindfulness in the management of treatment-resistant depression.
ACKNOWLEDGEMENTS
We thank the patients who participated in this study and the IPUB/UFRJ team for their institutional support.
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