According to a report commissioned by the Centre for Mental Health (Cardoso & MacHayle, 2024) the total cost to the economy of depression in 2022 was £300 billion. This comprises economic costs (£110bn), human costs (£130bn) and health and care costs (£60bn). Many treatments are, therefore, researched not just for their effectiveness, but also for their cost-effectiveness (you can read more in these Mental Elf Blogs).
Many first-line treatments such as talking and drug therapies are chosen for both their treatment effectiveness and their cost effectiveness. It is estimated however that around 50% of people using NHS talking therapies for depression will continue to have symptoms that remain above the clinical threshold, and for around 20-30% of these, repeated established treatments fail to relieve symptoms (Cuijpers et al., 2023). These people are considered to have ‘hard-to-treat depression’ (or else known as ‘treatment-resistant depression’).
This study considers whether a Mindfulness Based Cognitive Therapy offers a potentially beneficial ‘next option’ for those whom first-line treatments have not worked, even when they have fully engaged with the treatment programme and, equally, if such a treatment is economically viable.
If standard treatments for ‘hard-to-treat’ depression fall short, could mindfulness-based approaches provide a cost-effective alternative?
Methods
In this randomised controlled superiority trial, 234 participants with hard-to-treat depression were randomly assigned to either mindfulness-based cognitive therapy plus treatment as usual (MBCT+TAU) or simply treatment as usual (TAU) to see if the addition of MBCT to TAU was a potentially viable and cost effective further-line treatment.
Participants were selected from sites in Devon, London and Sussex (both rural and urban). They had all had at least 12 sessions of NHS Talking Therapy high intensity sessions (but not MBCT) without success (i.e. still showing symptoms at a clinical level), so considered to have hard-to-treat depression. Other criteria for inclusion were:
- Within six months of treatment ending
- Coming from services that offered typical NHS therapy services, with typical recovery rates (>45%).
- At least 18 years old.
Various exclusion criteria were also applied including history of psychotic symptoms, current mania, alcohol or substance use disorder within the past 3 months, any other clinically significant condition that might have put them at risk or affect the results of the trial. Importantly patients taking medication for depression were not excluded, but this was documented for statistical analysis. Of the 4,830 contacted by NHS Talking Therapies, 277 completed the baseline measures (Patient Health Questionnaire – PHQ-9 & Mini International Neuropsychiatric Interview – MINI 7.0.2). Of these, 234 participants were then randomly assigned to either MBCT+TAU group or TAU alone group.
Though the participants, assessors and therapists were not blind to which condition the participant was allocated, the statistical analysis was done blindly. Both groups also followed treatment as usual; following any regimes that were suggested by their GP. The only exception was those in the MBCT+TAU group who did not take part in any other psychotherapy during the time the MBCT sessions were running. The MBCT+TAU group received 8 weekly online (Zoom) group based sessions. The course initially teaches mindfulness skills and then how to use these skills to help participants manage difficult emotions. The minimum dose for effectiveness was considered to be 4 sessions. The group size was between 8-16 people. Treatment fidelity was assessed.
In the MBCT+TAU group, 106 completed the 10 week follow-up and 101 completed the 34 week follow-up. In the TAU group, 108 completed the 10 week follow-up and 102 completed the 34 week follow-up.
The primary outcome was the depression score as measured by the PHQ-9 at 34 weeks after randomisation. Further secondary outcomes included:
- PHQ-9 score at 10 weeks post- randomisation
- Other clinical outcomes at 10 and 34 weeks post- randomisation (inc. GAD-7, WSAS & WEMWS)
- Dichotomous outcomes:
- Recovery vs reliable recovery
- Reliable improvement
- Deterioration vs reliable deterioration
- Adverse events.
Finally, health economic analyses were calculated to assess cost-effectiveness of the treatment.
Results
The primary outcome showed that MBCT+TAU was more effective in reducing depressive symptoms than TAU alone at the 34 week follow up, seeing a greater reduction in the PHQ-9 scores, with an effect size of Cohen’s d -0.41. The PHQ-9 scores showed absolute rates of recovery at 34 weeks were 27% of those in the MBCT+TAU and 15% of the TAU alone group. Across the secondary continuous outcomes, except the WSAS and Phobia scale, at both 10 and 34 weeks MBCT+TAU was superior to TAU alone.
For the secondary dichotomous outcomes, significantly more patients reached recovery, reliable recovery and reliable improvement in the MBCT +TAU group, than the TAU alone group, at 10 and 34 weeks based on the PHQ-9 scores.
No treatment related adverse events were recorded, and deterioration was minimal in both groups.
The cost of the session was estimated to be £10.12 per person per session. Over the 34 weeks of the trial those who received MBCT+TAU accessed fewer health and social care services, which again reduced costs. The QALYs data at the 34 week strongly suggests MBCT+TAU both costs less and works better than usual treatment. There was a 95% chance it would be considered cost-effective if the healthcare system was willing to pay less than £5,000 for each unit of improvement in health. This increased to a 99% at the £20,000–30,000 threshold, which is usually used by NICE.
At 34 weeks, 27% of patients in the MBCT+TAU group recovered compared to 15% with usual care, and the therapy proved cost-effective at just £10 per session.
Conclusions
The results are promising: it appears that MBCT+TAU (delivered by Zoom group sessions) is superior to TAU alone, both in effectiveness and cost, for those who struggle with hard-to-treat depression. The small to moderate benefits are maintained for up to 6 months. Economically, the reduced use of health and social care services easily offset the additional cost of the treatment making it cost-effective.
The clinical sample in this trial presented with complex and hard-to-treat depression. This was typically characterised by relatively early onset of symptoms, multiple recurrences, comorbidity and multiple treatment attempts (70% of the sample were on antidepressants). The authors suggest that with each new treatment, successful remission decreases. Therefore with any successive treatment fewer patients will benefit and cost-effectiveness will play an important role in decisions about whether to treat these patients. Compared to other psychological therapies, such as psychodynamic and interpersonal psychotherapy, MBCT+TAU seems to be more beneficial, even though the benefits are only seen in just over 1 in 4 patients.
For treatment resistant depression, MBCT+TAU delivered online achieved remission in just over 1 in 4 patients and remained cost-effective by reducing wider service use and healthcare costs.
Strengths and limitations
The trial was rigorously conducted, following a published protocol and governed by a trial steering committee. As a pragmatic, randomised controlled superiority trial, it enabled the evaluation of both clinical effectiveness and cost-effectiveness in real-world settings (i.e., NHS services in the UK), where such treatments are provided and funded. Research questions were developed in conjunction with Patient and Public Involvement (PPI). A variety of standardised and validated measures (i.e., PHQ-9), widely used to evaluate the severity of depression, were used to assess both treatment and economic outcomes. Where possible, researchers were blinded to treatment conditions to avoid bias. Participant attrition was relatively low and therefore the results were based on relatively high numbers. The design itself also enhances the external validity, making the findings more likely to be applicable to the NHS Talking Therapies programme.
Notably, one of the big strengths of the study is the focus on a service user population with persistent depressive symptoms, despite receiving high-intensity psychological therapy, addressing a significant clinical need. The authors also analysed the cost-effectiveness, which could inform policymakers and commissioners to improve an already stretched and resource-constrained healthcare system, like the NHS with appropriate resource allocation. Lastly, the inclusion of different sites across the UK (Devon, London, Sussex) increases the likelihood of the findings becoming generalisable across different regions.
However, all strengths discussed, as with many trials on mental health and psychological therapy evaluation, the follow-up was only at two, relatively short, time intervals; 10 weeks and 6 months. To truly understand if this intervention was cost effective it would be helpful to know how long the effects of the treatment lasted beyond this point.
Moreover, the study’s population is defined by ‘non-remission’ following high-intensity NHS therapy, which may have excluded individuals with a different mental health treatment trajectory (i.e., pathway) or different types of ‘treatment resistance’. The NHS stepped-care model further complicates the interpretation, as most often only those with mild-to-moderate symptoms of depression with no active suicidal ideation or self-harming behaviours are eligible for Talking Therapies, while more severe or ‘treatment resistant’ presentations are managed by a secondary mental health service. So, who fits this criterion?
A further limitation acknowledged by the authors is the lack of representativeness of the sample with 71% being female and 86% White. As such, there was no analysis of gender and ethnic sub-groups. Evidently, this raises questions about the accessibility of NHS mental health services to ethnically marginalised groups and service engagement among men.
This rigorous trial evaluated clinical and cost-effectiveness of a mindfulness-based intervention for service users with persistent depression, but was limited by short follow-up and predominantly a White, female sample.
Implications for practice
This trial provides valuable evidence for practicing clinicians in primary and secondary mental health services; those working within the NHS, as well as more specifically in Talking Therapies.
Could MBCT act as a second-line option for those with resistant depression? The findings suggest that this could be a viable and potentially cost-effective option, if the service user has not responded to initial high-intensity therapy. Nevertheless, the study talks about only 27% of service users with remission; what about the other 73% of those that didn’t help? So, yes, it does provide an evidence-based alternative, but findings need to be considered within its limits. Further to this point, service user suitability is something that clinicians would need to carefully consider. Who is more likely to benefit from MBCT based on their background and presentation? As the trial’s sample is limited (White/female), clinicians would need to use their clinical judgment and determine whether this intervention would be suitable. The service user’s individual factors and willingness to engage with mindfulness practices or group-based therapy, readiness would be a good first step. Shared decision-making and a good therapeutic rapport are always the most powerful pillars of therapy.
Lastly, MBCT can be potentially integrated into the stepped care model, purposefully for service users with persistent depressive symptoms; but as with all therapeutic approaches, it would require an investment in training and supervision for therapists to deliver such intervention with fidelity and respect to its cultural roots.
MBCT shows promise as a second-line, potentially cost-effective option for persistent depression, but clinical suitability, diversity, and implementation considerations are key.
Statement of interests
No conflicts of interest.
Links
Primary paper
Barnhofer T, Dunn BD, Strauss C, Ruths FA, Barrett B, Ryan M, Ladwa A, Stafford F, Fichera R, Baber H, McGuinness A, Metcalfe I, Kan DKY, Pooley J, Harding D, Tassie E, Carson J, Rhodes S, Young AH, Connors J, Warren FC. (2025) Mindfulness-based cognitive therapy versus treatment as usual after non-remission with NHS Talking Therapies high-intensity psychological therapy for depression: a UK-based clinical effectiveness and cost-effectiveness randomised, controlled, superiority trial. Lancet Psychiatry. 2025 Jun;12(6):433-446. doi: 10.1016/S2215-0366(25)00105-1.
Other references
Cuijpers P, Miguel C, Ciharova M, Harrer M, Basic D, Cristea IA, de Ponti N, Driessen E, Hamblen J, Larsen SE, Matbouriahi M, Papola D, Pauley D, Plessen CY, Pfund RA, Setkowski K, Schnurr PP, van Ballegooijen W, Wang Y, Riper H, van Straten A, Sijbrandij M, Furukawa TA, Karyotaki E. Absolute and relative outcomes of psychotherapies for eight mental disorders: a systematic review and meta-analysis. World Psychiatry. 2024 Jun;23(2):267-275. doi: 10.1002/wps.21203.
Cardoso, F. and McHayle, Z. (2024). The Economic And Social Costs Of Mental Ill Health Review Of Methodology And Update Of Calculations. Centre for Mental Health (Last Accessed: 06/10/25)
