Journal of Affective Disorders 168 (2014) 205–209

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Brief report

Mindfulness-based cognitive therapy for seasonal affective disorder:

A pilot study
Joke Fleer a,n, Maya Schroevers a, Vera Panjer a, Erwin Geerts b, Ybe Meesters c
a
University of Groningen, University Medical Center Groningen, Department of Health Psychology (FA 12), P.O. box 30.001,
9700 RB Groningen, The Netherlands
b
University of Groningen, University Medical Center Groningen, School of Nursing and Health, The Netherlands
c
University of Groningen, University Medical Center Groningen, Department of Psychiatry, Groningen, The Netherlands

art ic l e i nf o a b s t r a c t

Article history: Background: The best available treatment for seasonal affective disorder (SAD) is light therapy. Yet, this
Received 17 December 2013 treatment does not prevent recurrence of depression in subsequent seasons. The aim of the study is to
Received in revised form gain preliminary insight in the efficacy of Mindfulness Based Cognitive Therapy (MBCT) in the prevention
30 June 2014
of SAD recurrence.
Accepted 1 July 2014
Available online 11 July 2014
Methods: This is a randomized controlled pilot study, in which SAD patients in remission were randomly
allocated to an individual format of MBCT or a control condition (i.e. treatment as usual). MBCT was given
Keywords: between May and June 2011, when there was no presence of depressive symptoms. The Inventory for
Seasonal affective disorder Depressive Symptomatology Self-Report (IDS-SR), which patients received on a weekly basis from September
Mindfulness
2011 to April 2012, was used to assess moment of recurrence (Z20) and severity at moment of recurrence.
Therapy
Results: 23 SAD patients were randomized to MBCT and 23 to the control condition. Kaplan–Meier survival
Intervention
Randomized controlled trial curve showed that the groups did not differ in moment of recurrence (χ²(1).41, p¼ .52). T-tests showed no
Pilot group difference in mean IDS-SR scores at moment of recurrence (t(31)¼  .52, p¼.61).
Limitations: The results are limited by small sample size (n¼46) and missing data of weekly IDS-SR assess-
ments.
Conclusion: The findings of this pilot RCT suggest that individual MBCT is not effective in preventing a SAD
recurrence when offered in a symptom free period (i.e. spring).
& 2014 Elsevier B.V. All rights reserved.

1. Introduction Terman et al., 1989). Second, 70% of patients have a recurrence of

Seasonal affective disorder (SAD winter type) is a recurrent
depression characterized by the seasonal pattern in the onset (autumn
or winter) and spontaneous remission (following spring or summer)
of the depressive episodes (Rosenthal et al., 1984). In the Netherlands,
3% of the population meets the criteria for the diagnosis of SAD
(Mersch et al., 1999). SAD can be treated effectively with bright light
(Golden et al., 2005), with remission rates up to 80% (Meesters et al.,
1995; Gordijn et al., 2012) when remission is defined as improvement
of at least 50% and a post-treatment score of 8 or below on the
Structured Interview Guide for the Hamilton Depression Rating Scale-
Seasonal Affective Disorder (Wirz-Justice et al., 2013).
There are, however, some limitations to light therapy (LT). First, at
least 20% of SAD patients do not remit with LT (Terman et al., 1996;
n
Corresponding author.
E-mail addresses: j.fleer@umcg.nl (J. Fleer),
M.J.Schroevers@umcg.nl (M. Schroevers), Verapanjer@live.nl (V. Panjer),
y.meesters@umcg.nl (Y. Meesters).
depression in subsequent autumn and winter seasons (Thompson and
Isaacs, 1988). One challenge is, thus, to develop interventions with
enduring effects in the prevention of SAD recurrence (Rohan et al.,
2009). From research in the field of non-seasonal major depressive
disorder (MDD) we know that Mindfulness-based Cognitive Therapy
(MBCT;(Segal et al., 2002)) is particularly effective in the prevention of
recurrence in patients with recurrent MDD in remission (Piet and
Hougaard, 2011). If such outcomes could be generalize to SAD, MBCT
could represent a solution to long-term SAD management.
The primary objective of this pilot study is to gain preliminary
insight in the efficacy of MBCT in the prevention of recurrence of
depression in SAD patients in the following winter. We hypothe-
size that SAD patients who receive MBCT (i.e. treatment condi-
tion), as compared to those who receive treatment as usual (i.e.
TAU condition) will differ in:
1. Moment of recurrence of SAD. We expect patients in the
treatment condition to have a later (if any) onset of SAD than
patients in the TAU condition

http://dx.doi.org/10.1016/j.jad.2014.07.003
0165-0327/& 2014 Elsevier B.V. All rights reserved.
206 J. Fleer et al. / Journal of Affective Disorders 168 (2014) 205–209
2. Severity of recurrence of SAD. We expect that patients in the
treatment condition will experience a less severe recurrence (if
any) than patients in the TAU condition
2. Methods
2.1. Participants
For this randomized controlled trial patients were recruited
through the SAD outpatient clinic of the University Medical Center
Groningen (UMCG), the Netherlands. Eligible patients were patients
Z18 years, with a formal diagnosis of winter SAD (based on the
criteria of the DSM-IV as assessed by means of a M.I.N.I. interview
(Sheehan et al. 1998)), who received LT in the winter of 2010–2011 at
the UMCG. Patients known to have a psychiatric comorbidity (e.g.
schizophrenia, autism) were not approached. The following exclusion
criteria were checked during the recruitment procedure: presence of
depressive symptoms (IDS-SRZ15; (Rush et al. 1996)), receiving
psychological treatment at the time of the study, experience with
mindfulness meditation, and not being able to read and/or
write Dutch.
2.2. Procedure
Because the MBCT training is developed to prevent recurrence
of depression, the training was planned for the spring time
Fig. 1. Participant flow throughout the study.
(April 1–June 30 2011). In March 2011, 152 potentially eligible
patients received a letter inviting them to participate in the study.
In the letter it was explained that half of the patients would be
randomly allocated to MBCT, and half to TAU. An informed consent
form and a pre-paid return envelope were included. Patients were
asked to provide consent for (1) study participation and (2) use of
the data on their depressive symptoms in the coming winter (i.e.
from August 29 2011 (week 35) – April 15 2012 (week 15)). These
data are collected by the SAD outpatient clinic as part of standard
care, in order to monitor the development of depressive symptoms
in their patients during the winter season (see for further
information the description of the TAU condition).
It was asked to return the completed informed consent form
within two weeks. Patients who returned an informed consent
expressing their interest in participation were further screened for
eligibility via a short (5–10 min) standardized telephone interview.
During this interview, patients were asked specifically whether
they (1) received psychological care at that moment and,
(2) whether they had experience with mindfulness meditation.
Thirdly, the interview was used to check whether patients had
sufficient command of the Dutch language. Patients found eligible
during the telephone interview were send the IDS-SR (including
return envelope). Patients who scored Z 15 were excluded from
participation.
Eligible patients were randomised by means of a computerized
randomization program. After randomization, patients were noti-
fied by telephone. Participant recruitment and flow throughout
 J. Fleer et al. / Journal of Affective Disorders 168 (2014) 205–209
the study is presented in Fig. 1. The study was approved by the
UMCG Medical Ethics Committee.
2.3. Treatment conditions
Treatment as usual (TAU) condition. Patients in the TAU
condition received a weekly online depression questionnaire (i.e.
the Inventory of Depressive Symptomatology (IDS-SR) during the
Winter of 2011–2012 (August 29 2011–April 15 2012), in order to
monitor the development of depressive symptoms during the
winter season. Upon first signs of a depressive episode (i.e. IDS-
SR Z20), they received an invitation for a light treatment at the
SAD outpatient clinic consisting of 5 consecutive days of 45 min
morning light (full spectrum without UV, 10,000 lx). The SAD
outpatient clinic of the UMCG developed this treatment procedure
after Meesters et al. (1993) found that administering light at the
occurrence of the first signs of a winter depression prevents it
from developing into a full-blown depression during that the
winter season.
The intervention condition. Patients in the intervention condi-
tion received the MBCT training during the Spring of 2011 (April
1–June 30 2011). The intervention was based on the MBCT
protocol as developed by Segal, Teasdale, and Williams (Segal et
al., 2002). MBCT is usually delivered in a group setting, but we
adapted the standardized treatment protocol for individual ther-
apy (eight weekly sessions of 45 to 60 min). The theoretical
underpinning of why we adapted the treatment protocol for
individual therapy, a detailed description of the treatment proto-
col, and first results on the feasibility and effectiveness of the
individually delivered MBCT can be found elsewhere (Schroevers
et al., 2013 [online, 14 august]); (Tovote et al., 2014).
During the Winter of 2011–2012 patients in the treatment
condition received, similar to those in the TAU condition, weekly
online depression questionnaires, and an invitation for LT upon
first signs of a depressive episode.
2.4. Measures
The Inventory of Depressive Symptomatology (IDS-SR) (Rush et
al., 1996) was used to assess depressive symptoms prior to the
intervention, and during the winter period (2011–2012, i.e. when
the questionnaire was send out weekly to the patients by the SAD
outpatient clinic). The IDS-SR is a 30 item self-report question-
naire, scored on a four-point Likert-scale ranging from 0 (no
complaints) to 3 (severe complaints of depression). The total score
on the IDS-SR is calculated by adding up the scores on all
questions. In this study, the reliability of the IDS-SR was good
(α ¼ .74 for the IDS-SR that was administered prior to the
intervention).
2.4.1. Moment of recurrence
According to the IDS-SR a score Z20 is indicative of onset of
winter SAD. Therefore, we consider somebody to experience a
recurrence the first moment he or she obtains an IDS-SR score
Z20 (i.e. following treatment procedure of SAD outpatient clinic,
where LT is offered when patients obtain this score) (Fig. 2).
2.4.2. Severity at moment of recurrence
Severity at moment of recurrence was determined by the IDS-
SR scores at the moment of first recurrence.
2.4.3. Background characteristics
Before the intervention, a written questionnaire was used to
obtain the following demographic and clinical characteristics from
participants: date of birth, marital status, educational level, year of
207
SAD onset, number of SAD episodes in the past five years (i.e. 1–5),
effectiveness of LT (i.e. 1 not at all-5 very much), and occurrence of
other psychological problems for which they received treatment in
the past.
2.5. Statistical analyses
Analyses were performed based on the intention-to-treat
method. Missing values for the weekly IDS-SR questionnaires were
estimated by imputing group (i.e. MBCT or TAU) means. SPSS
Statistics 20 was used for all analyses. Chi-square and t-tests were
used to examine if there were baseline differences between the
two conditions regarding background characteristics and depres-
sive symptoms. Kaplan–Meier survival analysis was performed to
assess moment of recurrence, chi-square tests were used to
compare MBCT and TAU on proportion of patients with a recur-
rence, t-tests were used to compare MBCT and TAU on severity at
moment of recurrence.
3. Results
3.1. Descriptives
There were no significant differences between MBCT and TAU
on any of the background characteristics. Mean age of participants
was about 40 years old (MBCT 39.4 (11.5), TAU 41.6 (12.2),
t(44) ¼  .63, p ¼.53), and the majority was female (MBCT 69.6%,
TAU 78.3%, χ²(1)¼ .45, p ¼ .50). Most participants had a partner
(MBCT 63.2%, TAU 85.7%, χ²(1)¼2.71, p ¼.10), and received higher
education (i.e. college, bachelor or master degree; MBCT 68.4%,
TAU 61.9%, χ²(2) ¼1.91, p ¼.39).
On average, the onset of SAD was over 10 years ago (MBCT 13.0
(11.3), TAU 10.7 (10.6), t(37) ¼  .67, p¼ .51), and participants
reported a SAD episode in 4 of the past 5 winters (MBCT 4.3
(1.0), TAU 4.1 (1.3), t(38) ¼  .60, p ¼.56). LT worked rather well in
previous years (MBCT 3.1 (.8), TAU 3.1 (.7), t(37) ¼  .23, p ¼ .82). As
expected, mean pre-intervention scores on the IDS-SR were clearly
below the cut off of the IDS-SR (MBCT 5.9 (4.3), TAU 6.4 (4.4),
t(44) ¼  .37, p ¼.71).
As for the weekly IDS-SR assessments in the winter of 2011–
2012, it should be noted that, on average, MBCT participants more
often completed the weekly questionnaires than TAU participants
(MBCT 24.5 (7.9), range 6–32; TAU 17.1 (11.0), range 0–32;
t(44) ¼  2.63, p¼ .01). This difference can be explained by the fact
that 3 TAU patients did not complete any of the weekly
questionnaires.
3.2. Moment of recurrence
Fig. 2 shows the Kaplan–Meier survival curve comparing recur-
rence over the 33-week study period for MBCT and TAU conditions.
The survival curves of MBCT and TAU did not differ (Log Rank
(Mantel–Cox), χ²(1).41, p¼.52). The proportion of recurrence did not
differ between conditions, with 15 patients in the MBCT condition
experiencing a recurrence (65.2%), and 18 (78.3%) in the TAU
condition (χ²(1).965, p¼ .33).
3.3. Severity at moment of recurrence
At moment of first recurrence, the groups did not differ in
mean IDS-SR scores (MBCT: m ¼26.5, SD¼ 7.0; TAU: m ¼ 25.3,
SD¼ 6.3, t(31) ¼  .52, p ¼.61).
208 J. Fleer et al. / Journal of Affective Disorders 168 (2014) 205–209
Fig. 2. Survival curves comparing recurrence of winter depression for treatment-
as-usual (TAU) and mindfulness-based cognitive therapy (MBCT).
4. Discussion
With this pilot RCT we aimed to investigate the efficacy of
MBCT as a preventive treatment for SAD in the following winter.
We did not find evidence for its effectiveness in preventing a SAD
recurrence. Participants from the two conditions experienced their
first recurrence at approximately the same time, and the recur-
rence was equally severe in both groups.
Our findings are in contrast with evidence from the effective-
ness of MBCT in the prevention of recurrences in major depressive
disorders (MDD) (e.g. (Piet and Hougaard, 2011; Fjorback et al.,
2011)). The American Psychiatric Association considers winter SAD
to be a subtype of MDD or Bipolar Disorder, type I or II (DSM-IV-
TR) with a seasonal pattern. Yet, it has also been argued that
winter SAD has a different underlying pathological mechanism
than MDD. Several studies (e.g.(Young et al., 1991; Lam et al., 2001)
suggest that people with SAD do not only experience the cognitive,
behavioral and affective symptoms associated with MDD, but also
show substantial physiological changes during the winter. This
seasonal component, which is assumed to respond well to light
therapy (Young et al., 1991), may in part explain why MBCT did not
have a similar effect in SAD as in non-seasonal MDD.
Although MBCT might not work as a preventive treatment for
recurrent SAD, it might be valuable to investigate the effectiveness
of MBCT when it is provided at the beginning of the Fall (i.e.
September), when the first signs of winter depression generally
tend to occur. There is increasing empirical evidence that MBCT
not only reduces the risk of recurrent depression in indivi-
duals with previous depressive episodes, but also reduces current
depressive symptoms (Hofmann et al., 2010; van Aalderen et al.,
2012).
This study has several limitations. First, the study has a small
sample size, so the results should be regarded as preliminary and
need verification in larger studies. Second, no patient completed
all 33 weekly assessments (mean is 21 assessments), with three
patients not completing any of the assessments. Although we did
sensitivity analyses (e.g. we did an analysis in which we assumed
that the three participants who did not complete any of the
assessments had a recurrence during week 1 of the weekly
assessments and an analyses in which we assumed that these
participants had no recurrence during the 33 weeks of weekly
assessments) showing the robustness of the data (i.e. these
analyses did not influence outcomes), the missing data may
nevertheless have affected interpretations of the results and led
to biased conclusions about the treatment effects. Third, it should
be emphasized that we examined an individual MBCT training,
rather than the commonly used group format. Although two
recent trials among depressed diabetes patients did show that
individual MBCT was effective in reducing depressive symptoms,
as much as individual cognitive behavioral treatment (Schroevers
et al., 2013 [online, 14 august]; Tovote et al., 2014), there is no
empirical evidence for the differential efficacy of group versus
individual MBCT, nor of the effectiveness of individual MBCT in
other groups than diabetes patients.
In conclusion, the findings of this pilot study suggest that MBCT
is not effective in the prevention of recurrent winter SAD. For
future research we suggest to investigate the effectiveness of
MBCT when it is provided at the beginning of the Winter season.
Role of funding source
This study was not funded by external funding sources.
Conflict of interest
Declaration of Competing Interests: Nothing to declare.
Acknowledgments
The authors would like to thank the Winter Depression Outpatient Clinic of the
University Medical Center Groningen for making it possible to undertake this study.
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