Mindfulness-Based Treatment For Bipolar Disorder: A Systematic Review of The Literature

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Mindfulness-Based Treatment for Bipolar Disorder: A Systematic Review of

the Literature
Article in Europe's Journal of Psychology · February 2017

DOI: 10.5964/ejop.v13i3.1138
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Europe's Journal of Psychology
ejop.psychopen.eu | 1841-0413
Literature Reviews
Mindfulness-Based Treatment for Bipolar Disorder: A Systematic Review

of the Literature
Sanja Bojic a, Rodrigo Becerra* a
[a] School of Psychology & Social Science, Edith Cowan University, Perth, Australia.
Abstract
Despite the increasing number of studies examining the effects of mindfulness interventions on symptoms associated with Bipolar Disorder
(BD), the effectiveness of this type of interventions remains unclear. The aim of the present systematic review was to (i) critically review all
available evidence on Mindfulness Based Cognitive Therapy (MBCT) as a form of intervention for BD; (ii) discuss clinical implications of
MBCT in treating patients with BD; and (iii) provide a direction for future research. The review presents findings from 13 studies (N = 429)
that fulfilled the following selection criteria: (i) included BD patients; (ii) presented results separately for BD patients and control groups
(where a control group was available); (iii) implemented MBCT intervention; (iv) were published in English; (v) were published in a peer
reviewed journal; and (vi) reported results for adult participants. Although derived from a relatively small number of studies, results from the
present review suggest that MBCT is a promising treatment in BD in conjunction with pharmacotherapy. MBCT in BD is associated with
improvements in cognitive functioning and emotional regulation, reduction in symptoms of anxiety depression and mania symptoms (when
participants had residual manic symptoms prior to MBCT). These, treatment gains were maintained at 12 month follow up when
mindfulness was practiced for at least 3 days per week or booster sessions were included. Additionally, the present review outlined some
limitations of the current literature on MBCT interventions in BD, including small study sample sizes, lack of active control groups and
idiosyncratic modifications to the MBCT intervention across studies. Suggestions for future research included focusing on factors
underlying treatment adherence and understanding possible adverse effects of MBCT, which could be of crucial clinical importance.
Keywords: mindfulness, literature review, Bipolar Disorder, Mindfulness Based Cognitive Therapy
Europe's Journal of Psychology, 2017, Vol. 13(3), 1–99, doi:10.5964/ejop.v13i3.1138

Received: 2016-03-02. Accepted: 2017-03-05. Published (VoR): 2017-08-31.
Handling Editors: Vlad Glăveanu, Webster University Geneva, Geneva, Switzerland; Steven Hertler, Psychology Department, College of New Rochelle,
New Rochelle, NY, USA
*Corresponding author at: School of Psychology and Social Science (Room 30.129), Faculty of Computing, Health and Science, Edith Cowan
University, 270 Joondalup Drive, Joondalup Perth, WA 6027, Australia. E-mail: [email protected]
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Psychological interventions implementing mindfulness, such as mindfulness-based cognitive therapy (MBCT;

Segal, Williams, & Teasdale, 2002) and mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990), have
gained popularity over the last 15 years. Mindfulness is defined as “paying attention in a particular way: on
purpose, in the present moment, and nonjudgementally” (Kabat-Zinn, 1994, p. 4). Mindfulness meditation is
postulated to be one of the ‘active ingredients’ of MBCT and involves conscious awareness of the breath or
body while noticing thoughts and feelings without judging them or attempting to alter them in any way (Kabat-
Zinn, 1990; Segal et al., 2002).
MBCT has been reported to reduce symptoms associated with emotional regulation difficulties in a number of
psychological disorders including, major depressive disorder (Kumar, Feldman, & Hayes, 2008) and
Mindfulness-Based Treatment for Bipolar Disorder 2
generalised anxiety disorder (Hofmann, Sawyer, Witt, & Oh, 2010; Kabat-Zinn et al., 1992) and these
improvements were maintained over a 3 year follow-up (Miller, Fletcher, & Kabat-Zinn, 1995). Furthermore
MBCT significantly reduced the risk of depressive relapse over a period of 12 months in those with three or
more prior episodes of major depressive disorder (Ma & Teasdale, 2004; Teasdale et al., 2000).
MBCT has also been associated with decreased rumination of unpleasant emotions (Keng, Smoski, & Robins,
2011) such as worry, anxiety (Chiesa & Serretti, 2009; Jain et al., 2007), feelings of distress (Carlson, Speca,
Patel, & Goodey, 2003; Shapiro, Astin, Bishop, & Cordova, 2005), and decreased emotional reactivity (Chiesa,
Brambilla, & Serretti, 2010; Chiesa, Calati, & Serretti, 2011) with consistently strong effect sizes (Grossman,
Niemann, Schmidt, & Walach, 2004). Furthermore, there is a body of literature supporting MBCT interventions
in enhancing self-compassion, positive emotions (Keng et al., 2011), quality of sleep (Brand, Holsboer-
Trachsler, Naranjo, & Schmidt, 2012; Carlson & Garland, 2005; Shapiro, Bootzin, Figueredo, Lopez, &
Schwartz, 2003), levels of attention, memory, executive functions (Becerra, D’Andrade, & Harms, 2016; Chiesa
et al., 2011) and improved emotional regulation abilities (Chiesa et al., 2010; Segal et al., 2002). Additionally,
MBCT has been shown to have equivalent results to a course of antidepressant medication maintained over a
one-year follow up (Kuyken et al., 2008).
In contrast, a recent comprehensive meta-analysis of 209 studies found that mindfulness interventions were not
more effective than traditional CBT and were associated with lower attrition rates (16.25%) compared to CBT
interventions (22.5%) (Khoury, Lecomte, Fortin, & Hofmann, 2013). Another review of 24 studies found that
almost half of the studies did not find any significant interactions between mindfulness practice and treatment
outcome (Vettese, Toneatto, Stea, Nguyen, & Wang, 2009). In addition, it has been reported that mindfulness
interventions is unrelated to reduction of symptoms of anxiety and depression (Ramel, Goldin, Carmona, &
McQuaid, 2004) or reduction in depression severity (Jermann et al., 2013; van Aalderen et al., 2012; Williams,
Teasdale, Segal, & Soulsby, 2000). Others reported that mindfulness interventions did not contribute to
improvements in depression, anxiety or impulsivity in patients with Borderline Personality Disorder (Sachse,
Keville, & Feigenbaum, 2011) and failed to achieve reduction in worry levels required to meet standard
recovery criteria for people with generalised anxiety disorder (Craigie, Rees, Marsh, & Nathan, 2008). These
mixed findings about the effectiveness of mindfulness interventions in reducing symptoms associated with
various psychological disorders requires further research.
Bipolar Disorder (BD) is a chronic mood disorder characterised by episodes of depression and/or mania
(Johnson, 2005; Trede et al., 2005), emotional regulation difficulties (Green, Cahill, & Malhi, 2007; Gruber,
Eidelman, & Harvey, 2008) and high comorbidity with anxiety disorders (approximately 62%) (Simon et al.,
2005). A number of recent studies have investigated the effectiveness of MBCT on reduction of some of the
symptoms associated with BD. Despite several psychological interventions for BD and effective maintenance
medication, 50% of BD patients relapse within the first year (Rush et al., 2006) and 70-73% relapse within five
years (Gitlin, Swendsen, Heller, & Hammen, 1995; Perry, 1999). Clinical and epidemiological studies have
documented that despite pharmacotherapy, patients with BD often continue to experience residual mood
symptoms even during the euthymic stage (Judd et al., 2008). The high rate of relapse and reported
experienced residual symptoms by many BD patients suggests that there is a gap in current BD treatment. The
National Institute of Clinical Excellence (NICE, 2016) recommends MBCT as a relapse prevention approach for
patients with a history of depressive episodes, which appears to have prompted studies to investigate MBCT in
managing symptoms of BD.

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Bojic & Becerra 3
Mixed findings have been reported on the effectiveness of MBCT in BD, in particular when examining the
effects of MBCT on depressive symptoms. Although the majority of the studies suggest that MBCT is effective
in reducing depressive symptoms associated with BD (Deckersbach et al., 2012, Kenny & Williams, 2007;
Miklowitz et al., 2009; Perich, Manicavasagar, Mitchell, & Ball, 2013b; Van Dijk, Jeffrey, & Katz, 2013; Williams
et al., 2008), others have reported no difference between participants’ pre and post treatment scores (Ives-
Deliperi, Howells, Stein, Meintjes, & Horn, 2013; Perich et al., 2013a). In fact, some studies have reported
worsening of depressive symptoms for certain individuals when comparing their pre and post treatment scores
(Weber et al., 2010).
Given these inconsistent findings, a critical literature review is needed; specifically examining the effects of
MBCT on symptoms associated with BD. Therefore, the aim of the present systematic literature review was to
(i) critically review all available evidence on MBCT in BD, (ii) discuss clinical implications of using MBCT in
treating patients with BD and to (iii) provide a direction for future research.
Method
Data Sources and Search Strategies

A systematic search was conducted through PsychINFO, Medline, PubMed, PsycARTICLES, Google Scholar
databases and reference sections of journal articles to obtain relevant literature from the first available date up
to and including January 2015.
Key words used in the search were separated into two groups and joined by “AND’ operators. The first group of
words identified BD patients; “Bipolar”, “Bipolar Disorder”, “Bipolar Depression”, “Manic”, “Mania”, “Manic
Depression”, “Manic Depressive” and “Manic Disorder”. The second group identified Mindfulness;
“Mindfulness”, “Mindfulness*”, “Meditation”, “Mindfulness Based Cognitive Therapy”, “Mindfulness Based Stress
Reduction”, “Mindfulness Training Meditation” and “Breath Counting”.
Inclusion and Exclusion Criteria

Studies were included in the review if they met the following criteria: (i) included BD patients (ii) presented
results separately for BD patients and the control group (where a control group was available), (iii) implemented
MBCT, (iv) were published in English, (v) were published in a peer reviewed journal and (vi) reported results for
adult participants. Only original studies were included in the present review, no studies were included that were
literature reviews. Studies unrelated to the topic under consideration, studies that involved child participants,
duplicate articles across searchers and studies that did not include both BD patients and a mindfulness
intervention were excluded. There were 13 studies that met the selection criteria (See Table 1). A flowchart of
the study selection process is depicted in Figure 1.

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Figure 1. Flow chart of study inclusion/exclusion process.
Data Extraction
The following data were recorded for each study: information about the sample (e.g., the number of
participants, diagnosis of BD and comorbidities); information about the intervention (e.g., duration of treatment,
type of mindfulness treatment and attrition rates); information about the study (publication year and whether the
study was randomized); information about the dependent measures used (e.g., clinical scales that were
administered to compare the pre and post scores and to assess mindfulness); and the main findings of each
study. Comparison of some of the characteristics (e.g., number of participants, length of intervention, main
findings etc.) of the 13 studies included in the present review are presented in Table 1. Studies were grouped
into themes such as studies that found that mindfulness intervention was beneficial in reducing symptoms of
BD and those that found no differences between pre and post test scores on relevant domains. The areas
examined in the present review included effect of mindfulness on major symptoms associated with BD
(emotional regulation, depressive, manic/hypomanic and anxiety symptoms); effects of mindfulness on
cognitive functioning of BD patients; characteristics of mindfulness intervention in BD (e.g., measuring
mindfulness, different changes to the MBCT interventions authors made across studies, attrition rates and
adverse effects); limitations of current research and recommendations for future studies.

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Table 1
Selected Studies Depicting Participants, Groups, Attrition, Clinical Scales, Mindfulness Practice, and Main Outcome
Study Participants Control Group Attrition Clinical Scales Mindfulness Main Outcome
2017, Vol. 13(3), 1–99

• N = 12 • No control group • 25% (3) • Five-Factor Mindfulness Questionnaire • 12 weekly 2h MBCT • Increased mindfulness, lower residual
Bojic & Becerra
Deckersbach et al. (2012)
doi:10.5964/ejop.v13i3.1138
• 12 euthymic BD patients • Compared pre, post (FFMQ) sessions depressive mood symptoms, less attentional

with moderate residual treatment and 3 month • Hamilton Depression Scale (HAM-D) difficulties, and increased emotion-regulation
symptoms follow up • Young Mania Rating Scale (YMRS) abilities, improved psychological well-being,
• BD I (9) = 7 females, 2 • Penn State Worry Questionnaire (PSWQ) positive affect, and psychosocial functioning.
males • Response Style Questionnaire (RSQ)
• BD II (3) = 2 females, 1 • Emotion Reactivity Scale (ERS)
male • Clinical Positive Affective Scale (CPAS)
• Psychological Well-Being Scale (PWBS)
• The Longitudinal Interval Follow-up
Evaluation –Range of Impaired Functioning
Tool (LIFE-RIFT)
Stange at al. (2011) • N = 12 • No Control condition • 25% • Five-Factor Mindfulness Questionnaire • 12 weekly 2h MBCT • MBCT showed improvement in executive
• 12 Euthymic BD patients (FFMQ) sessions functioning and memory to levels
with moderate residual • Hamilton Depression Scale (HAM-D) comparable with normative samples.
depressive and varying • Young Mania Rating Scale (YMRS) • Improvements in many areas of cognitive
degrees of residual • The Frontal Systems Behavior Scale functioning, particularly memory and task
manic symptoms. (FrSBe) monitoring, were maintained at the follow-up
• The Behavior Rating Inventory of Executive evaluation 3 months after treatment.
Function (BRIEF)
Chadwick et al. (2011) • N = 12 • No control condition • 0 dropped out • Semi structured interview • 90 min MBCT sessions • All participants reported subjective benefits
• 12 BD (7 men, 5 women) for 8 weeks plus 6 week and challenges of mindfulness practice.
experiencing mild to booster session. Seven themes emerged: Focusing on what
moderate depression or (practiced MBCT for at is present; clearer awareness of mood state/
elation symptoms. least 18 weeks) change; acceptance; mindfulness practice in
different mood states; reducing/stabilizing
negative affect; relating differently to
negative thoughts; reducing impact of mood
state.
Williams et al. (2008) • N = 68 • 35 in wait-list control • 18% (15) did not attend • Mini International Neuropsychiatric Interview • 2 hours MBCT sessions • Improved anxiety (specific to BD group).
• 33 Euthymic BD (24 condition (27 unipolar, 8 first assessment (MINI) for 8 weeks • Both BD and MDD groups in MBCT showed
unipolar, 9 bipolar) with a bipolar). • 15% (5) did not complete • Beck Depression Inventory (BDI-II) reductions in residual depressive symptoms
history of serious suicidal • Follow up available for follow up from MBCT • Beck Anxiety Inventory (BAI) when compared to those in the waitlist
ideation/behaviour 27 in wait list condition group and 23% (8) did condition.
• Follow up data was (20 unipolar and 7 not complete follow up
available for 28 bipolar) from wait list condition.
participants in MBCT (21
unipolar and 7 bipolar)
Howells et al. (2012) • N = 21 • 9 healthy control • Not reported-appears to • Structured Clinical Interview (SCID) • 8 week MBCT • Brain activity: individuals with BD showed
• 12 euthymic BD patients participants (7 females, 2 be 0 • Young Mania Rating Scale (YMRS) significantly decreased theta band power,
(10 females, 2 males) males) • Hospital Anxiety and Depression Scale increased beta band power, and decreased
(HADS) theta/beta ratios during the resting state,
eyes closed, for frontal and cingulate
cortices.
• Post MBCT intervention there was
improvement over the right frontal cortex
5
(decreased beta band power) in the BD

group.
• Brain activation: individuals with BD showed
a significant P300-like wave form over the
2017, Vol. 13(3), 1–99

frontal cortex during the cue. Post MBCT
intervention the P300-like waveform was
doi:10.5964/ejop.v13i3.1138
significantly attenuated over the frontal

cortex.
Miklowitz et al. (2009) • N = 22 • No control group • 27% (6) dropped out • MINI International Neuropsychiatric • 2 hour MBCT sessions • Reductions were observed in depressive
• 22 euthymic BD (I = 14; • Compared pre-post Interview for 8 weeks symptoms and suicidal ideation and to a
BD II = 8) patients (16 measures • Hamilton Rating Scale for Depression lesser extent manic symptoms and anxiety.
females, 6 male). (HRSD)
• 16 completed MBCT • Young Mania Rating Scale (YMRS)
• Beck Depression Inventory (BDI-II)
• Beck Anxiety Inventory (BAI)
• Beck Scale for Suicide Ideation (BSSI)
Perich et al. (2013a) • N = 95 • 47 BD- TAU • 29% • Structured Clinical Interview for DSM-IV-TR • 2 h sessions for 8 • There was no significant reduction in time to
• 48 BD (I or II) • 14 (10 dropped out, 4 Disorders (SCID-I) weeks. depressive or hypo/manic relapse, total
did not start MBCT) • Young Mania Rating Scale (YMRS) number of episodes or mood symptom
• 22 (18 drop outs and 4 • Montgomery-Asberg Depression Rating severity at 12 month follow up.
did not start)-47% TAU Scale (MADRS)
• Composite International Diagnostic Interview
Mindfulness-Based Treatment for Bipolar Disorder
(CIDI)
• Depression Anxiety Stress Scale (DASS)
• State/Trait Anxiety Inventory (STAI)
• Dysfunctional Attitudes Scale 24 (DAS-24)
• Response Style Questionnaire (RSQ)
• Mindful Attention Awareness Scale (MAAS)
Perich et al. (2013b) • N = 34 • No control group • 29% dropped out of • Young Mania Rating Scale (YMRS) • 2 hour MBCT sessions • A greater number of days meditating during
• 34 completed MBCT • Compared baseline MBCT • Montgomery-Asberg Depression Rating for 8 weeks the 8 week treatment was related to lower
• 23 BD (7 male; 16 scores, post treatment • 68% did not provide Scale (MADRS) • Follow up testing at 12 depression scores at 12 month follow up.
female) completed and 12 month follow up information about • Composite International Diagnostic Interview months • MBCT was associated with improvements in
homework measures. homework (CIDI) anxiety and depression if practiced for a
• 22 (8 males; 14 females) • Structured Clinical Interview for DSM-IV-TR minimum of 3 times per week.
completed 12 moth Disorders (SCID-I)
follow up • Depression Anxiety Stress Scale DASS,
• State/Trait Anxiety Inventory (STAI)
• Mindful Attention Awareness Scale (MAAS)
• Toronto Mindfulness Scale (TMS)
Weber et al. (2010) • N = 23 • No Control group • 35% • Young Mania Rating Scale (YMRS) • 2 hour MBCT sessions • There was no significant increase in
• 23 BD (I, II and NOS) • Compared pre and post • 8 dropped out (6 • Montgomery-Asperg Depression Rating for 8 weeks plus 2 hours mindfulness skills following treatment.
participants scores of various clinical dropped out after less Scale (MADRS) booster session 3 • Mindfulness practice decreased over time.
• 15 BD attended the over scales than 4 sessions and 2 • Beck Depression Inventory (BDI-II) months after 8 week • Change in mindfulness skills was
4 MBCT sessions (11 did not start intervention) • The Kentucky Inventory of Mindfulness Skills treatment. significantly associated with change in
female, 4 male). (KIMS). depressive symptoms between pre and post
MBCT.
Ives-Deliperi et al. (2013) • N = 33 • 7 BD-waitlist • 0 drop out • Five-Facet Mindfulness Questionnaire • 8 week MBCT • Following MBCT there were significant
• 23 BD with mild to • 10-healthy controls (FFMQ) improvements in measures of mindfulness,
moderate subthreshold • 16-MBCT • Symptoms of Stress Inventory (SOSI) anxiety, emotional regulation, working
symptoms (<14 YMRS • Difficulties in Emotion Regulation Scale memory, spatial memory and verbal fluency
and HADS) (DERS) compared to the waitlist group.
• Becks Anxiety Index (BAI)
6
• Edinburgh Handedness Inventory (EHI)
Van Dijk et al. (2013) • N = 26 • 13 BD (I = 5, II = 7) on • 7.7% • Young Mania Rating Scale • 90 minute 12 weekly • Mindfulness reduced depressive symptoms,
• 13 BD (I = 5; II = 7) waitlist • 1 dropped out in MBCT • The Beck Depression Inventory (BDI-II) sessions of DBT and improved affective control and improved
group and 1 dropped out • The Mindfulness Based Self Efficacy Scale Mindfulness mindfulness self-efficacy in BD.
2017, Vol. 13(3), 1–99

of waitlist control (MSES) • Mindfulness reduced emergency room visits
Bojic & Becerra
• The Affective Control Scale (ACS) and mental health related admissions in the
doi:10.5964/ejop.v13i3.1138
6 months following treatment.

Howells et al. (2014) • N = 21 • 9 healthy controls (7 • Not reported-appears to • Young Mania Rating Scale • 8 week MBCT • Following MBCT, BD group showed
• 12 Euthymic BD I (10 females, 2 males) be 0 drop out. • Hospital Anxiety and Depression Scale attenuation of ERP N170 amplitude and
females, 2 males) • Emotional processing was measured by reduced HRV HF peak indicating that MBCT
event related potentials (ERP) and heart rate may improve emotional processing in BD.
variability (HRV)
Kenny & Williams, 2007 • N = 50 • No control group • 10% (5) • Beck Depression Inventory (BDI-II) • 2 hour MBCT sessions • MBCT improved depression scores with a
• 50 symptomatic • Compared pre and post • 1 dropped out and 4 did for 8 weeks significant proportion of patients returning to
(BDI>19) patients (BD & BDI scores. not complete post- normal/near normal level of mood.
MDD) treatment measures.
• 37 female (74%)
Note. BD = Bipolar Disorder; MBCT = Mindfulness Based Cognitive Therapy; MDD = Major Depressive Disorder; TAU = Treatment as usual; N = total number of participants.
7
Results
Findings were divided into six sections. Each section examined the impact of mindfulness on: emotional
regulation, symptoms of depression, symptoms of anxiety, symptoms of mania/hypomania, cognitive
functioning and subjective measures of MBCT. Each of the sections was subdivided to include a critical review
of research studies that have found support for MBCT and those that have found no significant effects of MBCT
on BD.
Emotional Regulation
The effects of mindfulness intervention on emotional regulation in BD patients were reported in four studies with
a total of 92 participants. Emotional regulation is defined as a process people engage in that influences the way
people experience (e.g., duration, latency, magnitude and type) and express emotions (Gross, 1998). It
consists of physiological and subjective components and thus both aspects have been investigated in the
present review. All four studies measured participants’ emotional regulation abilities prior to treatment and after
eight weeks of MBCT.
Howells, Rauch, Ives-Deliperi, Horn, and Stein (2014) focused on physiological measures of emotional
regulation, such as heart rate variability (HRV). This involved measuring event related potentials (ERP),
specifically the ERP N170, and the high frequency (HF) peak of the HRV. The ERP N170 is the most widely
used ERP marker of neural processing of faces (Eimer, 2011), whilst the HF peak of HRV serves as a marker of
ability to regulate emotions (Telles, Singh, & Balkrishna, 2011), as it is influenced by changes in mood (Hughes
& Stoney, 2000).
Howells and colleagues (2014) found that prior to treatment, patients diagnosed with BD (n = 12) were found to
differ from healthy controls (n = 9) on physiological measures of emotional regulation (the effect size was not
reported). The BD group had increased ERP N170 amplitude and increased HRV HF peak, suggesting that the
BD group had impaired emotional processing prior to treatment when compared to healthy controls (Howells et
al., 2014). When participants diagnosed with BD (n = 12) engaged in eight weeks of MBCT, there was a
decrease in their ERP N170 amplitude and decreased HRV HF peak, indicating improved emotional processing
(the effect size was not reported; Howells et al., 2014).
Similar findings were reported by Ives-Deliperi and colleagues (2013), who used the Difficulties in Emotion
Regulation Scale (DERS) to measure participants’ emotional regulation abilities. The DERS is a self-reported
instrument that measures various aspects of regulating emotions (Gratz & Roemer, 2004). Ives-Deliperi and
colleagues (2013) found that BD patients (n = 16) reported significantly more difficulties in managing emotions
(prior to treatment) when compared to healthy controls (n = 10) (the effect size was not reported). This study
reported that MBCT intervention was effective in significantly reducing emotion dysregulation scores (the effect
size was not reported) for BD patients who prior to treatment had mild or sub threshold symptoms (<14 on
Young Mania Rating Scale and Hospital Anxiety and Depression Scale; Ives-Deliperi et al., 2013).
Van-Dijk and colleagues (2013) used the Affective Control Scale (ACS), which is a 42 item self-report
questionnaire developed to measure participants’ belief in their ability to control their emotions (Williams,
Chambless, & Ahrens, 1997). BD patients were found to struggle with regulating their emotions prior to
engaging in MBCT, when emotional regulation was measured using the ACS scale (Van Dijk et al., 2013) (the

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Bojic & Becerra 9
effect size was not reported). This study found that participants diagnosed with BD who participated in MBCT
(n = 12), reported increased self-efficacy and belief in having more control over their emotions, when compared
to participants diagnosed with BD who were on the waitlist control condition (n = 12; the effect size was not
reported).
Deckersbach and colleagues (2012) used the Emotion Reactivity Scale (ERS; 21-item) a self-report instrument
designed to measure emotional sensitivity, intensity, and persistence (Nock, Wedig, Holmberg, & Hooley,
2008). BD participants who engaged in MBCT reported that they were more aware of internal and external
stimuli, were able to respond less judgmentally to their thoughts and feelings and were less reactive to their
inner experiences (Deckersbach et al., 2012). There was a medium to large effect size for decreased
rumination (Cohen’s d = 1.02), worry (Cohen’s d = 1.33), reduced attentional difficulties (Cohen’s d = 1.50) and
increased emotional regulation measured by the ERS (Cohen’s d = 0.68) (Deckersbach et al.). It was further
noted that there was a linear improvement (from pre-treatment to follow up) in emotional regulation abilities and
positive interpersonal relationships, which may suggest that improved abilities to regulate emotions had a
positive impact on participants’ interpersonal relationships (Deckersbach et al., 2012).
The current research on MBCT in BD consistently indicates that patients with BD have difficulty regulating their
emotions prior to treatment and that engaging in MBCT resulted in improvements in their emotional regulation
abilities. These findings were supported by physiological measures (e.g., HRV; Howells et al., 2014) and a
number of subjective processes (e.g., ERS, ACS and DERS) (Deckersbach et al., 2012; Ives-Deliperi et al.,
2013; Van Dijk et al., 2013). However, it remains unclear whether these treatment gains were maintained long-
term, as this was not investigated by any of the current studies.
Depressive Symptoms
Depressive symptoms were measured using various self-report and clinician rated scales in nine out of the 13
reviewed studies, with a total of 363 participants. The literature in this area reflected mixed findings with six
studies reporting that MBCT was effective at reducing depressive symptoms in BD, whilst three studies did not
find significant differences in depression scores post-MBCT treatment.
Perich, Manicavasagar, Mitchell, Ball, and Hadzi-Pavlovic (2013a) measured symptoms of depression using the
Montgomery-Asberg Depression Rating Scale (MADRS; Montgomery & Asberg, 1979), which is a 10 item
clinician administered scale used to assess the severity of depressive symptoms with good internal consistency
(Cronbach’s alpha = 0.85; Hermens et al., 2006) and inter-rater reliability (0.76; Davidson, Turnbull, Strickland,
Miller, & Graves, 1986).
Perich and colleagues (2013a) conducted a randomized controlled trial comparing MBCT (n = 22) for BD
patients to Treatment As Usual (TAU) (n = 12), over a 12-month period. This study found that the interaction of
treatment by time for depressive scores was not significant, indicating that depressive scores did not
significantly reduce over the 12-month period. This also implied that participating in MBCT did not delay time to
reoccurrence of a depression episode when compared to the TAU group. Those who continued to practice
meditation throughout the 12- month follow-up period did not report any significant reductions in psychiatric
symptomatology compared to those that had not (Perich et al., 2013b).

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These findings were supported by Ives-Deliperi and colleagues (2013) who measured symptoms of depression
using the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983), which has acceptable
(Cronbach’s alpha = 0.67) to good (Cronbach’s alpha = 0.90) internal consistency (for the depression subscale;
Bjelland, Dahl, Haug, & Necklemann, 2002). In this study the authors compared the effects of MBCT (N = 33)
on depressive symptoms in BD treatment group (n = 16), when compared to the BD waitlist control (n = 23) and
healthy control group (n = 10) (Ives-Deliperi et al., 2013). This study found that MBCT did not significantly
reduce depression scores, as measured by the HADS scale.
Similar findings were reported in another study (Weber et al., 2010) where depression was measured using the
MADRS (this scale was used by Perich et al., 2013b and is described above in more detail) and the Beck
Depression Inventory (BDI-II), a well-established self-report questionnaire comprised of 21 items to measure
the severity of depression (Beck, Steer, Ball, & Ranieri, 1996). Weber and colleagues (2010) found no
significant change between the baseline (n = 23), post treatment (8 weeks; n = 11) and the 3-month follow up
(n = 9), on the MADRS and the BDI-II scores. In fact, this study found that four patients experienced an
increase in their BDI-II scores at the 3-month follow up. The underlying reasons behind increased depression
scores in one scale (BDI-II) measuring depressive symptoms, but not the other (MADRS), were not
investigated or reported in this study and therefore remain unclear.
Despite no evidence for reduction in the depressive symptoms in this study (Weber et al., 2010), the majority of
participants rated MBCT as helpful in the program evaluation questionnaire. The questionnaire was
administered to participants after 8 weeks of MBCT intervention and once again following a one-hour booster
session that occurred three months after the eight week MBCT intervention. It was reported that 82% of
participants in this study expressed that they benefited from the program. This was explored further, with 55%
of participants reporting that MBCT helped them manage unpleasant emotions and 45% found MBCT helped
them manage negative thoughts. At the 3-month follow up, 67% of BD patients reported that MBCT improved
their quality of life. One major difference between this study and other studies that also failed to find
improvement in depressive symptoms in BD (Ives-Deliperi et al., 2013; Perich et al., 2013a), was that Weber
and colleagues (2010) included a booster session. The effects of booster sessions in BD would need to be
investigated further, as it could potentially be the missing link in helping manage depressive symptoms in BD.
Contrary to the above findings, six studies found that MBCT was beneficial in significantly reducing depression
symptoms for patients diagnosed with BD. For example Van Dijk and colleagues (2013) conducted a
randomized controlled trial where the BD group (participants with moderate to severe depression; n = 12) was
compared to a waitlist control condition (n = 12). Depression was measured using the BDI-II self-report
questionnaire. Following treatment (12 weeks of group MBCT), the majority of participants in treatment were
classified as having minimal to mild depression and this reduction in scores was significant (the effect size was
not reported).
Similar findings were reported by Kenny and Williams (2007) where depressive symptoms were also measured
using the BDI-II scores. In this study BD participants who were currently experiencing depression symptoms
(N = 50) participated in an 8-week MBCT treatment. The study found that participants’ pre and post BDI-II
scores reduced significantly, with large effect size (Cohen’s d = 1.04). These findings were further supported by
Williams and colleagues’ study (2008) where in a randomized controlled trial a significant reduction in BDI-II
scores was reported in the treatment group (euthymic BD patients with a history of suicidal ideation or

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behaviour; n = 28) when comparing the baseline and post treatment scores (the effect size was not reported).
There was also a significant reduction in depressive symptoms when comparing the BD treatment group (who
participated in eight weeks of group MBCT) and the BD waitlist control group (the effect size was not reported).
There was no significant difference between the pre to post BDI scores in the waitlist condition (n = 27),
suggesting that reduction in depressive symptoms can be attributed to treatment.
Support for MBCT in reducing depressive symptoms in BD was not exclusive to studies that measured
depressive symptoms using the BDI-II questionnaire. For example, Deckersbach and colleagues (2012) used
the clinician rated, Hamilton Depression Rating Scale (HDRS; Hamilton, 1960), which has high reliability and
validity (k = 0.73; Rush, 2000). This study found that participating in MBCT (n = 12) reduced depressive
symptoms in BD with a strong effect size (Cohen’s d = 1.02).
Moreover, Miklowitz and colleagues (2009) measured depression using both the HDRS and BDI-II (n = 14).
The study found that symptoms of depression and suicidal ideation scores improved, as mean HRSD scores
dropped by average of 0.37 SD (d = 0.37) and BDI-II scores dropped on average by 5 points (Cohen’s d =
0.49). There was also significant improvement on the Beck Scale for Suicide Ideation scores (Cohen’s d =
0.51), suggesting MBCT may be beneficial for BD patients with a history of suicidal ideation or behaviours.
Perich and colleagues (2013b) measured depressive symptoms using the MADRS (this scale was also used by
Perich et al., 2013a and Weber et al., 2010 and is described in more detail above) and found that for the BD
group, the number of days spent practicing meditation (following eight weeks of group MBCT) was significantly
inversely correlated with the MADRS scores. This means that BD participants (n = 22) that practiced
mindfulness for more days had lower MADRS scores at the 12-month follow up (the effect size was not
reported). There was some evidence to suggest that mindfulness meditation practice was associated with
improvements in depression symptoms if a certain minimum amount (three times a week or more) was
practiced weekly throughout the eight-week MBCT program. This suggested that when more time was
dedicated to practicing mindfulness it provided protection for depression symptoms over time.
Considering that the same clinical scales were used in both groups of studies, those that have not found
support from MBCT in reducing symptoms of depression in BD (Ives-Deliperi et al., 2013; Perich et al., 2013a)
and those that have found significant improvement in depressive scores following MBCT (Deckersbach et al.,
2012; Kenny & Williams, 2007; Miklowitz et al., 2009; Perich et al., 2013b; Van Dijk et al., 2013; Williams et al.,
2008), it appears that the mixed findings could be attributed to within group differences between the studies.
For example each group of authors modified MBCT in different way, as there are no evidence-based
recommendations for implementing MBCT in BD treatment.
It was also observed that studies that found support for MBCT in reducing symptoms of depression tended to
include more hours of mindfulness during treatment. For example some of these studies implemented 12
weeks of two-hour MBCT sessions (Deckersbach et al., 2012; Van Dijk et al., 2013), while those that found no
differences in depression scores, implemented only eight weeks (two-hour sessions) of MBCT (Ives-Deliperi et
al., 2013; Perich et al., 2013a; Weber et al., 2010). Weber and colleagues (2010) included a booster session,
three months after the eight-week intervention and although this study also failed to find significant differences,
participants reported they found the intervention beneficial. Therefore, it appears that when it comes to
depression symptoms in BD, MBCT seems to be more effective when treatment is held for a minimum of 12
weeks, or when booster sessions are included after 8 weeks.

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Anxiety Symptoms
Anxiety was reported in four out of 13 studies with a total of 157 participants. Unlike the findings for depressive
symptoms, the literature reflected more robust effects of MBCT in studies that measured changes in anxiety
symptoms. Studies consistently reported that MBCT was helpful in either significantly reducing or preventing
anxiety symptoms from increasing over time.
Ives-Deliperi and colleagues (2013) measured anxiety using the Beck Anxiety Inventory (BAI; Beck & Steer,
1990), which has shown good reliability (Cronbach’s alpha = 0.82; Contreras, Fernandez, Malcarne, Ingram, &
Vaccarino, 2004) and the Hospital Anxiety and Depression Scale (HADS; Zigmond & Snaith, 1983), which has
adequate to good (Cronbach’s alpha = 0.68 to 0.93) internal consistency (Bjelland et al., 2002). This study
found that prior to treatment BD participants (n = 16) reported significantly increased levels of anxiety when
compared to the healthy controls (n = 10; Ives-Deliperi et al., 2013). Eight weeks of group MBCT resulted in
significant reductions in anxiety in the BD treatment group (n = 16; the effect size was not reported), but not in
the BD waitlist group (n = 7), indicating that decrease in anxiety could be attributed to treatment. These findings
were consistent with another study, which also found modest improvements in the pre to post intervention BAI
scores of BD patients (Cohen’s d = 0.23), following eight weeks of group MBCT (Miklowitz et al., 2009).
Williams and colleagues (2008) compared pre and post BAI scores of BD patients in remission (with history of
suicidal ideation/behaviour; n = 28) and a waitlist control group (n = 27). The study found that at baseline there
were no differences between the BAI scores of BD treatment and BD waitlist group. Following eight weeks of
group MBCT, those who participated in the treatment condition had significantly lower BAI scores compared to
the waitlist group (the effect size was not reported). However, those that participated in treatment had no
significant change in BAI scores when comparing their pre and post treatment scores, whilst those on the
waitlist had significant increase in BAI scores over time (the effect size was not reported). In other words,
although MBCT did not decrease BAI scores following treatment, participating in MBCT prevented anxiety from
increasing over time. The major depression group showed no differences in BAI scores, suggesting that
protective effect of MBCT on levels on anxiety was specific to the BD group.
Perich and colleagues (2013b) measured anxiety symptoms using a self-report Depression and Anxiety Stress
Scale (DASS; Lovibond & Lovibond, 1995), which has adequate reliability for measuring symptoms of
depression (Cronbach’s alpha = 0.95; Crawford & Henry, 2003) and State/Trait Anxiety Inventory (STAI) scale
(Spielberger, 1983), with good internal consistency for the state (ranging from Cronbach’s alpha = 0.90 to 0.91)
and trait scales (ranging from Cronbach’s alpha 0.86 to 0.85, Spielberger, 1983).
Although the study (N = 34) found that anxiety scores did not improve over the 12 month follow up period
following engagement in eight week MBCT group intervention, BD participants had improvement in anxiety
symptoms (STAI trait anxiety scores; Perich et al., 2013b). The improvements were noted when mindfulness
was practiced once a day for at least three days a week during the eight-week treatment period (the effect size
was not reported). This positive effect of MBCT on levels of anxiety was consistent with studies investigating
MBCT in non-clinical populations (Schenström, Rönnberg, & Bodlund, 2006).
MBCT has shown promising positive effects on managing symptoms of anxiety in patients with BD. Three
studies have reported that engaging in eight weeks of MBCT resulted in significant decreases in anxiety scores
(Ives-Deliperi et al., 2013; Miklowitz et al., 2009; Williams et al., 2008). One study had also reported that

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engaging in MBCT was protective in the sense that it stopped anxiety scores increasing over time (Williams et
al., 2008). Most importantly MBCT was effective at reducing anxiety scores when mindfulness was practiced for
a minimum of three days per week (Perich et al., 2013b).
Mania/Hypomania Symptoms
Six out of the 13 studies measured mania/ hypomania symptoms before and after MBCT treatment (N = 209).
Other studies measured symptoms of mania prior to treatment, as an exclusion criterion for participating in the
MBCT intervention. All of the six studies measured symptoms of mania using the Young Mania Rating Scale
(YMRS), which is a clinician-administered scale with good inter-rater reliability (Young et al., 1978). Out of the
six studies that measured symptoms of mania post-MBCT treatment, five found no significant differences in the
YMRS scores after participating in MBCT (Deckersbach et al., 2012; Howells et al., 2014; Perich et al., 2013a;
Perich et al., 2013b; Weber et al., 2010). Only one study (Miklowitz et al., 2009) reported significant reduction in
the manic symptoms following participation in MBCT.
Deckersbach and colleagues (2012) (N = 12) reported that participants in their study had no to low residual
manic symptoms prior to participating in MBCT. After treatment there was no significant difference in the YMRS
scores. It was noted that there was an increase in YMRS for one participant, which appeared to be caused by
elevation in his mood. Similarly, Weber and colleagues (2010) (N = 23) only included people with BD who were
in remission and scored less than eight points on the YMRS. The study found no significant differences in the
YMRS scores after participating in MBCT, when comparing the baseline scores with the one month follow up
and three month follow up scores.
Further to this, Perich and colleagues (2013b) found that the number of days participants dedicated to
engaging in mindfulness activities was not significantly correlated with YMRS scores post-treatment (N = 34). In
addition, Perich and colleagues (2013a) found no significant differences between the pre and post YMRS
scores (N = 95), as well as no significant differences between the YMRS scores between the treatment group
and the TAU group following MBCT treatment. This study concluded that MBCT had no impact on reducing the
risk of reoccurrence of hypo/manic symptoms, total number of episodes or mood symptom severity at the 12
months follow up. It is of note that all BD participants were euthymic and complying with mood stabilising
medication for the duration of the studies.
Howells and colleagues (2014) also failed to detect significant differences in the pre and post treatment YMRS
scores (N = 21), however they reported that although participants were already euthymic at the baseline
measure, their YMRS scores reduced slightly after engaging in MBCT (Cohen’s d = 0.17). Unlike other studies,
Miklowitz and colleagues (2009) included participants with subsyndromal mania and hypomania (N = 22).
Contrary to the above studies, this study found significant reductions in the YMRS scores when they compared
the pre and post MBCT scores (Cohen’s d = 0.17).
In summary, five studies have reported that participants with BD experienced no significant differences in
symptoms of mania/hypomania following engagement in MBCT (Deckersbach et al., 2012; Howells et al., 2014;
Perich et al., 2013a; Perich et al., 2013b; Weber et al., 2010). One of these studies reported a slight reduction
in YMRS scores, although it was not significant (Howells et al., 2014). One study found that participation in
MBCT significantly reduced symptoms of mania (Miklowitz et al., 2009). It appears that when people with BD
are euthymic and complying with their mood stabilising medication, practicing mindfulness does not provide

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reduction of mania/hypomania symptoms or protection against future episodes. However, when people with BD
are experiencing subsyndromal mania, it appears that practicing mindfulness helps reduce the severity of
symptoms. Considering that these findings were only reported in one study, they must be interpreted with some
caution, and the effects of MBCT on symptoms of mania need to be investigated further.
Cognitive Functioning
Three studies investigated the effects of MBCT on cognitive functioning of BD patients with a total of 66
participants. All three studies reported that BD patients exhibited deficits in various aspects of their cognitive
functioning and that participating in MBCT resulted in improvements in their executive functioning (Ives-Deliperi
et al., 2013; Stange et al., 2011), attentional readiness (Howells, Ives-Deliperi, Horn, & Stein, 2012) and
memory, which were maintained at a three month follow up (Stange et al., 2011).
Ives-Deliperi and colleagues (2013) compared healthy controls (n = 10) with a waitlist BD group (n = 7) and BD
participants who took part in an eight-week MBCT condition (n = 16). The study found that prior to the
treatment BD participants scored lower on measures of executive functioning including working memory and
inhibition. Significant Blood Oxygenation Level Dependent (BOLD) signal decreases were noted in the medial
prefrontal cortex in the BD compared to the control group. This indicated that the BD group had difficulty
focusing on the tasks performed. Following MBCT, the study found that the BD treatment group improved in
neuropsychological tasks measuring working memory (digit span backward), spatial memory (Rey Complex
Figure Recall) and verbal fluency (Controlled Oral Word Association Test).
MBCT resulted in significant improvements in executive performance in the BD treatment group, but not in the
BD waitlist group (the effect size was not reported; Ives-Deliperi et al., 2013). Significant BOLD signal increases
were observed in the medial prefrontal cortex and posterior cingulate cortex in the BD treatment group,
compared to the BD waitlist group, during the mindfulness task (the effect size was not reported). These
changes in BOLD signal resulted in an activation pattern more closely resembling those of healthy controls.
Howells and colleagues (2012) found that prior to engaging in MBCT, brain activity for the BD group (n = 12)
was greater over the frontal cortex and cingulate cortex and showed activation of non-relevant information
processing, when compared to the healthy control (n = 9) group. This suggested decreased attentional
readiness prior to treatment, as theta activity was decreased, beta activity was increased and theta/beta ratios
were decreased over the frontal and cingulate cortices. This study found that BD participants had deficits in
resting brain activity, which may have reduced their ability to attend to relevant information. After participating in
eight week MBCT, the BD group showed changes in the right frontal EEG activity (beta activity was decreased
and theta and theta/beta ratios increased), which was associated with slight improvement in attention readiness
(the effect size was not reported).
Stange and colleagues (2011) compared pre and post scores on two self-reported scales for measuring
cognitive functioning (N = 12): the Frontal Systems Behavior Scale (FrSBe; Stout, Ready, Grace, Malloy, &
Paulsen, 2003) and the Behavior Rating Inventory of Executive Functioning (BRIEF; Roth, Isquith, & Gioia,
2005). Prior to MBCT treatment, cognitive functioning of BD patients (n = 8) was substantially lower than
normative comparison samples. The greatest deficits were in the BRIEF metacognition summary scores
(comprised of initiate, working memory, plan/organize, task monitor and organisation of materials). After
participating in MBCT (12, two-hour group sessions) there were improvements in executive functioning and

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memory to levels comparable with normative sample with large effects sizes (Cohen’s d = 1.13 to 1.39)
between pre treatment and post treatment scores on most subscales. Effects of the treatment in terms of
improvements in executive functioning, memory and task monitoring were maintained at a three month follow
up.
Taken together, results consistently indicate that MBCT is effective in improving cognitive functioning in BD.
Subjective Measures of MBCT

Three studies (N = 36) reported the effect of MBCT on symptoms of BD using subjective measures, such as
interviews, case studies and self-rating questionnaires about participants’ experience in taking part in a
mindfulness intervention.
Chadwick, Kaur, Swelam, Ross, and Ellett (2011) conducted semi-structured interviews (N = 12) and analysed
the data using thematic analysis. This study found that MBCT helped participants with BD increase their ability
to focus on the present moment, increase their self-awareness and acceptance and improve their ability to
manage mood states and negative thoughts. The majority of participants reported that they had to adapt their
mindfulness practice to different mood states, as mindfulness practice was more difficult when participants felt
depressed (low mood) than when their mood was high (although no one reported experiencing mania). It
appeared that having a choice of various mindfulness exercises allowed participants to be responsive to their
moods and continue completing their home practice. Participants reported that mindful movement exercise
(such as walking mindfully or engaging in gentle yoga exercises) with short mindfulness exercises was
particularly helpful while mindfulness of breath (focusing on one’s breathing while seated) was more helpful
when mood was high. This information suggests that effective MBCT interventions will need to consider the
patient’s mood and energy levels to increase compliance with homework and appropriate level of engagement
with treatment.
Weber and colleagues (2010) administered questionnaires to evaluate participants’ experience of eight weeks
of MBCT (N = 23). The study found that MBCT was well received among participants with BD, with 82%
reporting they moderately to very much benefited from MBCT. One month post-MBCT, 55% of participants with
BD reported that MBCT helped them to cope with emotions and 45% said it helped them implement more
structure in their life and cope with negative thoughts. Three months post-MBCT, 67% reported that MBCT
helped them regulate their emotions and 67% reported it improved their overall quality of life. Participants
reported that mindful breathing, body scan, sitting meditation and mindful movement exercises were the most
beneficial in managing symptoms associated with BD.
Miklowitz and colleagues (2009) included a case vignette of a 36-year-old woman, Sarah, who was diagnosed
with BD I. Sarah reported that attending MBCT group helped her “normalise” her experience of living with
symptoms of BD. She reported that MBCT helped her slow down her thoughts and take on more of an
observer’s role instead of reacting to them. Further to this Sarah reported that MBCT helped her identify her
feelings and mood changes earlier. For example, she particularly benefited from the three-minute breathing
space exercise to manage her feelings of anger and avoid angry outbursts, which she stated had a positive
impact on her intimate relationships.

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Discussion
The present paper aimed to systematically review current literature on effectiveness of MBCT on managing
symptoms associated with BD. We reported findings from 13 studies (N = 429), which were categorised into six
sections, namely, emotional regulation, depression, anxiety, mania, cognitive functioning and subjective
measures of MBCT in BD.
MBCT has shown promising positive effects on managing symptoms of anxiety in patients with BD (Ives-
Deliperi et al., 2013; Miklowitz et al., 2009; Williams et al., 2008) and preventing anxiety scores from increasing
over time (Williams et al., 2008). MBCT was also associated with improved physiological health (e.g., HRV;
Howells et al., 2014) and improvements in a number of subjective measures (e.g., ERS, ACS and DERS) of
emotional regulation in BD (Deckersbach et al., 2012; Ives-Deliperi et al., 2013; Van Dijk et al., 2013).
Furthermore participating in MBCT resulted in improvements in executive functioning (Ives-Deliperi et al., 2013;
Stange et al., 2011), attentional readiness (Howells et al., 2012) and memory, with treatment gains maintained
at a three month follow up (Stange et al., 2011).
The current literature suggests that MBCT does not provide reduction of mania/hypomania symptoms or
protection against future episodes (Deckersbach et al., 2012; Howells et al., 2014; Perich et al., 2013a; Perich
et al., 2013b; Weber et al., 2010) in euthymic BD participants. However significant reductions in mania
symptoms were reported when participants with residual manic symptoms participated in MBCT (Miklowitz et
al., 2009).
The mixed findings between studies that reported no significant differences in symptoms of depression (Ives-
Deliperi et al., 2013; Perich et al., 2013a) and those that have found significant improvement in depressive
symptoms following MBCT, (Deckersbach et al., 2012; Kenny & Williams, 2007; Miklowitz et al., 2009; Perich et
al., 2013b; Van Dijk et al., 2013; Williams et al., 2008) appear to be related to specific modifications of
mindfulness interventions across groups. It was found that MBCT was effective at managing symptoms of BD
when mindfulness was practiced for a minimum of three days per week (Perich et al., 2013b) or when booster
sessions were included (Chadwick et al., 2011; Weber et al., 2010).
Some common limitations were observed in the literature including small sample size, lack of control group,
various modifications to MBCT intervention, noncompliance or non reporting of homework completion and a
lack of adequate monitoring and reporting of any adverse effects and factors contributing to attrition rates.
Sample Size and Control Conditions

Most of the studies reviewed in this paper had a small sample size, (ranging from n = 8 [Stange et al., 2011] to
n = 68 [Williams et al., 2008]), consisting of predominantly female participants (72%), as many were ‘pilot’
studies in this area. Some studies did not have an active control group (Chadwick et al., 2011; Deckersbach et
al., 2012; Miklowitz et al., 2009; Stange et al., 2011; Weber et al., 2010), which only allowed comparison of pre
and post treatment scores. Others included a waitlist condition (Perich et al., 2013a; Van Dijk et al., 2013;
Williams et al., 2008), while more recent studies included a healthy control group as a comparison (Howells et
al., 2014; Ives-Deliperi et al., 2013).

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Modification of Mindfulness Interventions

One of the limitations of current literature on MBCT in BD is that mindfulness intervention was modified in some
way in almost every study, which made it difficult to attribute treatment gains exclusively to MBCT. Considering
that there are currently no published guidelines about how to implement mindfulness – based treatment for BD
patients, it is understandable that researchers implemented changes to make MBCT more applicable.
It was observed that all 13 studies included in the current review based their MBCT intervention on the program
described by Segal and colleagues (2002) and introduced various changes to make treatment more responsive
to BD patients. Some studies did not provide information about specific session outlines of their mindfulness
treatment (e.g. Howells et al., 2012; Ives-Deliperi et al., 2013; Stange et al., 2011) while others provided a
detailed account of their session plans (e.g. Perich et al., 2013a). The inconsistent reporting of the
characteristics of mindfulness interventions only allowed for a superficial comparison across studies, as
information was limited.
Most of the studies in this review delivered the mindfulness intervention during a weekly two-hour group
session for eight weeks. However, some studies (e.g., Weber et al., 2010) reported that they included a two-
hour booster session three months after treatment. Another study (Chadwick et al., 2011) delivered MBCT via
90-minute sessions for eight weeks, plus six-week booster sessions, which resulted in participants practicing in
MBCT for a minimum of 18 weeks. Other exceptions to the eight week MBCT intervention were reported in
Deckersbach and colleagues’ (2012) study where mindfulness was administered in 12 weekly, two-hour
sessions, whilst Van Dijk and colleagues (2013) conducted 12, 90-minute sessions.
Some differences were observed in duration and types of mindfulness activities that were practiced during
sessions. Williams and colleagues (2008) reported that participants engaged in two-hour meditation practice
during the last three weeks of intervention. Other studies had brief mindfulness activities (e.g. body scan,
mindfulness of sounds, mindfulness of feelings and mindful walking) of approximately 20 to 30 minutes
(Chadwick et al., 2011). Most studies reported approximately 40 minutes of mindfulness meditation practiced
during sessions (Perich et al., 2013a) and most introduced mindfulness movement exercises to address
attention difficulties (Deckersbach et al., 2012).
All of the reviewed MBCT studies introduced some level of psychoeducation about BD. For example, Weber
and colleagues (2010) reported presenting information about mania and hypomania. Similarly, Perich and
colleagues (2013a) reported introducing relapse prevention information about BD, depression, hypo/mania and
anxiety. Van Dijk and colleagues (2013) extended the psychoeducation part of their intervention to include a
session about medication and importance of self-care (e.g., sleep hygiene, eating healthy and abstaining from
drugs and alcohol). Deckersbach and colleagues (2012) incorporated daily mood monitoring, emergency plans
if mood deteriorated and problem solving focused on reducing the likelihood of dropping out of treatment. As
there are currently no specific guidelines for implementing MBCT to manage symptoms of BD, each study
included information in the psychoeducation part of their intervention as they saw fit, without providing any
empirical evidence to support introducing that particular information. Considering that there is evidence in the
literature that psychoeducation alone is effective in managing symptoms of BD (Colom et al., 2009; Stafford &
Colom, 2013), this makes attribution of change to MBCT more difficult.

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Homework Completion
It appeared that many participants struggled to complete mindfulness homework, as significant data were lost
due to participants forgetting to complete or keep a record of exercises. For example, Perich and colleagues
(2013a) reported that only 67% of participants that completed the MBCT program provided information of their
homework completion, which resulted in 33% of participants being excluded from the final analysis.
The homework expected from participants also differed in duration, content and frequency across studies. It
was observed that some studies required participants to complete a daily 10-minute mindfulness of breath
exercise (focusing on one’s breathing; Chadwick et al., 2011), while others required a minimum of 45-minute
meditation, six days a week (Williams et al., 2008). Deckersbach and colleagues (2012) indicated that
participants in their study completed 40-minute yoga exercises at home, while in another study participants’
homework involved 60 minutes of yoga exercises (Kenny & Williams, 2007). Some studies provided their
participants with a CD to help with required homework practice (Weber et al., 2010) while others omitted the
CD (Perich et al., 2013b; Weber et al., 2010). For example, Perich and colleagues (2013a) stated that purchase
of the book ‘Full Catastrophe Living’ (Kabat-Zinn, 1990) was optional, the yoga CD was omitted and the DVD
‘Healing from Within’ was unavailable for purchase at commencement of the study. Weber and colleagues
(2010) reported that instead of providing above-mentioned CDs/DVDs, they recorded their own CD, which was
given to participants to help with homework exercises.
These inconsistences in the duration, type, and frequency of mindfulness homework made it difficult to
compare across studies and attribute any treatment gains exclusively to MBCT interventions. The high rate of
noncompliance with mindfulness home practice also indicates that future research needs to investigate
effective strategies to motivate homework completion.
Attrition Rates
Reasons behind why participants decided not to engage in treatment or to stop attending MBCT before
completing the treatment were not explored in any of the studies included in the current review. The average
dropout rate in reviewed studies was 16%, which indicated that 84% of participants adhered to treatment. This
was comparable to other studies that investigated attrition rates in MBCT interventions in participants with
recurrent depression (Crane & Williams, 2010; Kuyken et al., 2008).
There was a trend for those allocated to a wait list condition to have higher dropouts and non-completion than
those who participated in MBCT (Perich et al., 2013a). Participants that dropped out from MBCT tended to be
younger than those that successfully completed treatment (Miklowitz et al., 2009) and participants that reported
a greater number of prior episodes engaged in fewer days of meditation. This appeared to reflect that this
group of participants experienced greater difficulty in engaging in mindfulness.
Crane and Williams (2010) investigated attrition rates in mindfulness treatment and found that those that
dropped out were significantly younger, less likely to be taking antidepressants, had higher levels of depressive
rumination and showed greater levels of problem solving deterioration, than those that completed treatment.
This study suggested that participants with high depressive rumination and cognitive reactivity find it particularly
difficult to engage in MBCT (Crane & Williams, 2010). Also when dropouts occurred they tended to happen
early in treatment (before treatment has started or after attending only one session). Another study (Kuyken et

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al., 2008) found that some of the common reasons for dropout included disliking the group format and the time
commitment involved in mindfulness based treatment. Attrition rates in studies examining effects of MBCT on
symptoms associated with BD need to be investigated in future studies.
Adverse Effects
Potential adverse effects were not adequately investigated or reported in studies that examined effects of
MBCT in BD. One study (Deckersbach et al., 2012) reported that there was a small increase in mood elevation
at follow up, which was driven by one participant who experienced hypomania. In another study (Miklowitz et
al., 2009), one patient had worsening of mania symptoms, however it was noted that overall improvement with
depression did not coincide with worsening of mania. Kenny and Williams (2007) reported that four participants
had increased BDI (depression) scores. Adverse effects appeared to be rare in MBCT for BD, however it is
possible that the numbers of patients that suffered from adverse effects were higher than reported and could
include some of the participants that dropped out of treatment.
It was noted that adverse effects were not monitored or recorded routinely in mindfulness interventions in
general (Dobkin, Irving, & Amar, 2012). There are documented cases of participants experiencing mania
following participating in meditation (Yorston, 2001) and more extreme cases of participants experiencing
psychosis following intensive meditation training (Chan-Ob & Boonyanaruthee, 1999; VanderKooi, 1997). For
some patients with a history of psychosis it can be beneficial to engage in mindfulness during remission (Bach
& Hayes, 2002; Gaudiano & Herbert, 2006), while for others it could aggravate their symptoms (Dobkin et al.,
2012). Thus the potential adverse effects of MBCT in BD require further research.
Conclusion and Recommendations

Mindfulness research in BD is in the early stages and definite conclusions about effectiveness cannot yet be
drawn. However, the current review of the literature indicated that MBCT was associated with improvements in
emotional regulation (Howells et al., 2014) and reductions in symptom of anxiety (Ives-Deliperi et al., 2013) and
depression in BD (Kenny & Williams, 2007). Furthermore, MBCT intervention was associated with
improvements comparable to normative samples in several aspects of cognitive functioning (Howells et al.,
2014; Stange et al., 2011). These gains were maintained at a three-month follow up (Stange et al., 2011) and
some were also maintained at a 12-month follow up (Perich et al., 2013b), however a booster session
appeared to be necessary (Deckersbach et al., 2012). Practicing mindfulness for a minimum of three days a
week was associated with improvement of depression and anxiety symptoms, and this was recommended as
the minimal effective dose of MBCT for BD (Perich et al., 2013b).
MBCT in euthymic BD patients resulted in no significant difference between pre and post mania scores
(Deckersbach et al., 2012; Howells et al., 2014), however when participants reported residual mania or
hypomania symptoms (prior to MBCT intervention), significant reduction in their mania symptoms was
documented, indicating that MBCT may be effective for those patients (Miklowitz et al., 2009). Further studies
are needed as symptoms of mania were not adequately examined in the available literature and were in fact
considered an exclusion criterium for some studies.
Some of the current studies have not adequately reported and investigated attrition rates or the adverse effects
of MBCT. Other limitations of reviewed studies included using various clinical scales to measure mindfulness

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
and modifying mindfulness interventions to varying degrees, which made comparisons across studies difficult
and raising serious doubts about treatment integrity. It is recommended for future studies in this area, to focus
on implementing a control group, larger sample size, and developing a standard MBCT intervention specifically
for BD patients. In addition, future studies should explore potential detrimental effects of MBCT for some people
with BD. Overall it can be concluded that MBCT is a promising treatment for BD in conjunction with
pharmacotherapy, however further studies are required to investigate long-term effects.
Funding
The authors have no funding to report.
Competing Interests
The authors have declared that no competing interests exist.
Acknowledgments
The authors gratefully acknowledge Dr Ken Robinson, Dr David Ryder and Jennifer Hoare for their constructive comments
and suggestions.
References
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of
psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129-1139.
doi:10.1037/0022-006X.70.5.1129
Becerra, R., D’Andrade, C., & Harms, C. (2016). Can specific attentional skills be modified with mindfulness training for
novice practitioners? Current Psychology. Advance online publication. doi:10.1007/s12144-016-9454-y
Beck, A. T., & Steer, R. A. (1990). Manual for the Beck Anxiety Inventory. San Antonio, TX, USA: Psychological
Corporation.
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric
outpatients. Journal of Personality Assessment, 67, 588-597. doi:10.1207/s15327752jpa6703_13
Bjelland, I., Dahl, A. A., Haug, T. T., & Necklemann, D. (2002). The validity of the Hospital Anxiety and Depression Scale:
An updated literature review. Journal of Psychosomatic Research, 52, 69-77. doi:10.1016/S0022-3999(01)00296-3
Brand, S., Holsboer-Trachsler, E., Naranjo, J. R., & Schmidt, S. (2012). Influence of mindfulness practice on cortisol and
sleep in long-term and short-term meditators. Neuropsychobiology, 65, 109-118. doi:10.1159/000330362
Carlson, L. E., & Garland, S. N. (2005). Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and
fatigue symptoms in cancer outpatients. International Journal of Behavioral Medicine, 12, 278-285.
doi:10.1207/s15327558ijbm1204_9

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Bojic & Becerra 21
Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (2003). Mindfulness-based stress reduction in relation to quality of life,
mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic
Medicine, 65, 571-581. doi:10.1097/01.PSY.0000074003.35911.41
Chadwick, P., Kaur, H., Swelam, M., Ross, S., & Ellett, L. (2011). Experience of mindfulness in people with bipolar disorder:
A qualitative study. Psychotherapy Research, 21, 277-285. doi:10.1080/10503307.2011.565487
Chan-Ob, T., & Boonyanaruthee, V. (1999). Meditation in association with psychosis. Journal of the Medical Association of
Thailand, 82, 925-930.
Chiesa, A., Brambilla, P., & Serretti, A. (2010). Functional neural correlates of mindfulness meditations in comparison to
psychotherapy, pharmacotherapy and placebo effect: Is there a link? Acta Neuropsychiatrica, 22, 104-117.
doi:10.1111/j.1601-5215.2010.00460.x
Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive abilities? A systematic review of
neuro-psychological findings. Clinical Psychology Review, 31, 449-464. doi:10.1016/j.cpr.2010.11.003
Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: A review
and meta-analysis. Journal of Alternative and Complementary Medicine, 15, 593-600. doi:10.1089/acm.2008.0495
Craigie, M. A., Rees, C. S., Marsh, A., & Nathan, P. (2008). Mindfulness-based cognitive therapy for generalized anxiety
disorder: A preliminary evaluation. Behavioural and Cognitive Psychotherapy, 36, 553-568.
doi:10.1017/S135246580800458X
Crane, C., & Williams, J. M. G. (2010). Factors associated with attrition from Mindfulness-Based Cognitive Therapy in
patients with a history of suicidal depression. Mindfulness, 1, 10-20. doi:10.1007/s12671-010-0003-8
Crawford, J. R., & Henry, J. D. (2003). The Depression Anxiety Stress Scales (DASS): Normative data and latent structure
in a large non-clinical sample. British Journal of Clinical Psychology, 42, 111-131. doi:10.1348/014466503321903544
Colom, F., Vieta, E., Sanchez-Moreno, J., Palomino-Otiniamo, R., Reinares, M., Goikolea, M., . . . Martinez-Aran, A. (2009).
Group psychoeducation for stabilised bipolar disorders: A 5-year outcome of a randomised clinical trial. The British
Journal of Psychiatry, 194, 260-265. doi:10.1192/bjp.bp.107.040485
Contreras, S., Fernandez, S., Malcarne, V. L., Ingram, R. E., & Vaccarino, V. R. (2004). Reliability and validity of the Beck
depression and anxiety inventories in Caucasian Americans and Latinos. Hispanic Journal of Behavioral Sciences, 26,
446-462. doi:10.1177/0739986304269164
Davidson, J., Turnbull, C. D., Strickland, R., Miller, R., & Graves, K. (1986). The Montgomery-Åsberg Depression Scale:
Reliability and validity. Acta Psychiatrica Scandinavica, 73, 544-548. doi:10.1111/j.1600-0447.1986.tb02723.x
Deckersbach, T., Holzel, B. K., Eisner, L. R., Stange, J. P., Peckham, A. D., Dougherty, D. D., . . . Nierenberg, A. A. (2012).
Mindfulness-based cognitive therapy for nonremitted patients with bipolar disorder. CNS Neuroscience & Therapeutics,
18, 133-141. doi:10.1111/j.1755-5949.2011.00236.x
Dobkin, P. L., Irving, J. A., & Amar, S. (2012). For whom may participation in a mindfulness-based stress reduction program
be contraindicated? Mindfulness, 3, 44-50. doi:10.1007/s12671-011-0079-9

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Eimer, M. (2011). The face-sensitive N170 component of the event-related brain potential. In A. J. Calder, G. Rhodes, M.
Johnson, & J. Haxby (Ed.), The Oxford handbook of face perception (pp. 329-344). Oxford, United Kingdom: University
Press.
Gaudiano, B. A., & Herbert, J. D. (2006). Acute treatment of inpatients with psychotic symptoms using Acceptance and
Commitment Therapy: Pilot results. Behaviour Research and Therapy, 44, 415-437. doi:10.1016/j.brat.2005.02.007
Gitlin, M. J., Swendsen, J., Heller, T. L., & Hammen, C. (1995). Relapse and impairment in Bipolar Disorder. The American
Journal of Psychiatry, 152, 1635-1640. doi:10.1176/ajp.152.11.1635
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development,
factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and
Behavioral Assessment, 26, 41-54. doi:10.1023/B:JOBA.0000007455.08539.94
Green, M. J., Cahill, C. M., & Malhi, G. S. (2007). The cognitive and neurophysiological basis of emotion dysregulation in
bipolar disorder. Journal of Affective Disorders, 103, 29-42. doi:10.1016/j.jad.2007.01.024
Gross, J. J. (1998). The emerging field of emotion regulation: An integrative review. Review of General Psychology, 2,
271-299. doi:10.1037/1089-2680.2.3.271
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A
meta-analysis. Journal of Psychosomatic Research, 57, 35-43. doi:10.1016/S0022-3999(03)00573-7
Gruber, J., Eidelman, P., & Harvey, A. G. (2008). Transdiagnostic emotion regulation processing in bipolar disorder and
insomnia. Behaviour Research and Therapy, 46(9), 1096-1100. doi:10.1016/j.brat.2008.05.004
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56-62.
doi:10.1136/jnnp.23.1.56
Hermens, M. L. M., Adèr, H., van Hout, H. P. J., Terluin, B., van Dyck, R., & de Haan, M. (2006). Administering the MADRS
by telephone or face-to-face: A validity study. Annals of General Psychiatry, 5, Article 3. doi:10.1186/1744-859X-5-3
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and
depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169-183. doi:10.1037/a0018555
Howells, F. M., Ives-Deliperi, V. L., Horn, N., & Stein, D. (2012). Mindfulness based cognitive therapy improves frontal
control in bipolar disorder: A pilot EEG study. BMC Psychiatry, 12, 15-23. doi:10.1186/1471-244X-12-15
Howells, F. M., Rauch, H. G. L., Ives-Deliperi, V. L., Horn, N. R., & Stein, D. J. (2014). Mindfulness based cognitive therapy
may improve emotional processing in bipolar disorder: A pilot ERP and HRV study. Metabolic Brain Disease, 29,
367-375. doi:10.1007/s11011-013-9462-7
Hughes, J. W., & Stoney, C. M. (2000). Depressed mood is related to high frequency heart rate variability during stressors.
Psychosomatic Medicine, 62, 796-803. doi:10.1097/00006842-200011000-00009
Ives-Deliperi, V. L., Howells, F., Stein, D. J., Meintjes, E. M., & Horn, N. (2013). The effects of mindfulness-based cognitive
therapy in patients with bipolar disorder: A controlled functional MRI investigation. Journal of Affective Disorders, 150,
1152-1157. doi:10.1016/j.jad.2013.05.074

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Bojic & Becerra 23
Jain, S., Shapiro, S. L., Swanick, S., Roesch, S. C., Mills, P. J., Bell, I., & Schwartz, G. E. R. (2007). A randomized
controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind,
rumination, and distraction. Annals of Behavioral Medicine, 33, 11-21. doi:10.1207/s15324796abm3301_2
Jermann, F., Van der Linden, M., Gex-Fabry, M., Guarin, A., Kosel, M., Bertschy, G., . . . Bondolfi, G. (2013). Cognitive
functioning in patients remitted from recurrent depression: Comparison with acutely depressed patients and controls and
follow-up of a mindfulness-based cognitive therapy trial. Cognitive Therapy and Research, 37, 1004-1014.
doi:10.1007/s10608-013-9544-1
Johnson, S. L. (2005). Life events in bipolar disorder: Towards more specific models. Clinical Psychology Review, 25,
1008-1027. doi:10.1016/j.cpr.2005.06.004
Judd, L. L., Schettler, P. J., Akiskal, H. S., Coryell, W., Leon, A. C., Master, J. D., & Solomon, D. A. (2008). Residual
symptom recovery from major affective episodes in bipolar disorder and rapid episode relapse/recurrence. Archives of
General Psychiatry, 65, 386-394. doi:10.1001/archpsyc.65.4.386
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New
York, NY, USA: Delta Books.
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY, USA:
Hyperion.
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., . . . Santorelli, S. F. (1992).
Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. The American
Journal of Psychiatry, 149, 936-943. doi:10.1176/ajp.149.7.936
Keng, S. L., Smoski, M. J., & Robins, C. J. (2011). Effects of mindfulness on psychological health: A review of empirical
studies. Clinical Psychology Review, 31(6), 1041-1056. doi:10.1016/j.cpr.2011.04.006
Kenny, M. A., & Williams, J. M. G. (2007). Treatment-resistant depressed patients show a good response to mindfulness-
based cognitive therapy. Behaviour Research and Therapy, 45, 617-625. doi:10.1016/j.brat.2006.04.008
Khoury, B., Lecomte, T., Fortin, G., & Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis.
Clinical Psychology Review, 33, 763-771. doi:10.1016/j.cpr.2013.05.005
Kumar, S., Feldman, G., & Hayes, A. (2008). Changes in mindfulness and emotion regulation in an exposure-based
cognitive therapy for depression. Cognitive Therapy and Research, 32, 734-744. doi:10.1007/s10608-008-9190-1
Kuyken, W., Byford, S., Taylor, R. S., Watkins, E., Holden, E., White, K., . . . Teasdale, J. D. (2008). Mindfulness-based
cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology, 76,
966-978. doi:10.1037/a0013786
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety stress scale (2nd ed.). Sydney, Australia:
Psychology Foundation.
Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of
differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72, 31-40.
doi:10.1037/0022-006X.72.1.31

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Miklowitz, D., Alatiq, Y., Goodwin, G. M., Geddes, J. R., Fennell, M. J. V., Dimidjian, S., . . . Williams, J. M. G. (2009). A pilot
study of mindfulness-based cognitive therapy for bipolar disorder. International Journal of Cognitive Therapy, 2,
373-382. doi:10.1521/ijct.2009.2.4.373
Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-
based stress reduction intervention in the treatment of anxiety disorder. General Hospital Psychiatry, 17, 192-200.
doi:10.1016/0163-8343(95)00025-M
Montgomery, S. A., & Asberg, M. A. (1979). A new depression scale, designed to be sensitive to change. The British
Journal of Psychiatry, 134, 382-389. doi:10.1192/bjp.134.4.382
NICE. (2016, April). Depression: The treatment and management of depression in adults. Retrieved from
http://www.nice.org.uk/guidance/cg90
Nock, M. K., Wedig, M. M., Holmberg, E. B., & Hooley, J. M. (2008). The emotion reactivity scale: Development, evaluation
and relation to self-injurious thoughts and behaviours. Behavior Therapy, 39, 107-116. doi:10.1016/j.beth.2007.05.005
Perich, T., Manicavasagar, V., Mitchell, P. B., & Ball, J. R. (2013b). The association between meditation practice and
treatment outcome in mindfulness-based cognitive therapy for bipolar disorder. Behaviour Research and Therapy, 51,
338-343. doi:10.1016/j.brat.2013.03.006
Perich, T., Manicavasagar, V., Mitchell, P. B., Ball, J. R., & Hadzi-Pavlovic, D. (2013a). A randomized controlled trial of
mindfulness-based cognitive therapy for bipolar disorder. Acta Psychiatrica Scandinavica, 127, 333-343.
doi:10.1111/acps.12033
Perry, A. (1999). Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms
of relapse and obtain treatment. British Medical Journal, 318, 149-153. doi:10.1136/bmj.318.7177.149
Ramel, W., Goldin, P. R., Carmona, P. E., & McQuaid, J. R. (2004). The effects of mindfulness meditation on cognitive
processes and affect in patients with past depression. Cognitive Therapy and Research, 28, 433-455.
doi:10.1023/B:COTR.0000045557.15923.96
Roth, R. M., Isquith, P. K., & Gioia, G. A. (2005). Behavior Rating Inventory of Executive Function – Adult Version. Lutz, FL,
USA: Psychological Assessment Resources.
Rush, A. J. (2000). Handbook of psychiatric measures. Washington, DC, USA: American Psychiatric Publishing.
Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., . . . Fava, M. (2006). Acute and
long term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. The American
Journal of Psychiatry, 163, 1905-1917. doi:10.1176/ajp.2006.163.11.1905
Sachse, S., Keville, S., & Feigenbaum, J. (2011). A feasibility of mindfulness-based cognitive therapy for individuals with
borderline personality disorder. Psychology and Psychotherapy: Theory, Research and Practice, 84, 184-200.
doi:10.1348/147608310X516387
Schenström, A., Rönnberg, S., & Bodlund, O. (2006). Mindfulness-based cognitive attitude training for primary care staff: A
pilot study. Complementary Health Practice Review, 11, 144-152. doi:10.1177/1533210106297033

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Bojic & Becerra 25
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new
approach to preventing relapse. New York, NY, USA: The Guilford Press.
Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care
professionals: Results from a randomized trial. International Journal of Stress Management, 12, 164-176.
doi:10.1037/1072-5245.12.2.164
Shapiro, S. L., Bootzin, R. R., Figueredo, A. J., Lopez, A. M., & Schwartz, G. E. (2003). The efficacy of mindfulness-based
stress reduction in the treatment of sleep disturbance in women with breast cancer: An exploratory study. Journal of
Psychosomatic Research, 54, 85-91. doi:10.1016/S0022-3999(02)00546-9
Simon, N. M., Otto, M. W., Fischmann, D., Racette, S., Nierenberg, A. A., Pollack, M. H., & Smoller, J. W. (2005). Panic
disorder and bipolar disorder: Anxiety sensitivity as a potential mediator of panic during manic states. Journal of
Affective Disorders, 87, 101-105. doi:10.1016/j.jad.2005.02.004
Spielberger, C. D. (1983). State-trait anxiety inventory for adults. Redwood City, CA, USA: Mind Garden.
Stafford, N., & Colom, F. (2013). Purpose and effectiveness of psychoeducation in patients with bipolar disorder in a bipolar
clinic setting. Acta Psychiatrica Scandinavica, 127, 11-18. doi:10.1111/acps.12118
Stange, J. P., Eisner, L. R., Holzel, B. K., Peckham, A. D., Dougherty, D. D., Rauch, S. L., . . . Deckersbach, T. (2011).
Mindfulness-based cognitive therapy for bipolar disorder: Effects on cognitive functioning. Journal of Psychiatric
Practice, 17, 410-419. doi:10.1097/01.pra.0000407964.34604.03
Stout, J. C., Ready, R. E., Grace, J., Malloy, P. F., & Paulsen, J. S. (2003). Factor analysis of the Frontal Systems Behavior
Scale (FrSBe). Assessment, 10, 79-85. doi:10.1177/1073191102250339
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/
recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology,
68, 615-623. doi:10.1037/0022-006X.68.4.615
Telles, S., Singh, N., & Balkrishna, A. (2011). Heart rate variability changes during high frequency yoga breathing and
breath awareness. BioPsychoSocial Medicine, 5, 4-10. doi:10.1186/1751-0759-5-4
Trede, K., Salvatore, P., Baethge, C., Gerhard, A., Maggini, C., & Baldessarini, R. J. (2005). Manic-depressive illness:
Evolution in Kraepelin’s textbook, 1883–1926. Harvard Review of Psychiatry, 13, 155-178.
doi:10.1080/10673220500174833
van Aalderen, J. R., Donders, A. R. T., Giommi, F., Spinhoven, P., Barendregt, H. P., & Speckens, A. E. M. (2012). The
efficacy of mindfulness-based cognitive therapy in recurrent depressed patients with and without a current depressive
episode: A randomized controlled trial. Psychological Medicine, 42, 989-1001. doi:10.1017/S0033291711002054
VanderKooi, L. (1997). Buddhist teachers’ experience with extreme mental-states in western meditators. Journal of
Transpersonal Psychology, 29, 31-46.
Van Dijk, S., Jeffrey, J., & Katz, M. R. (2013). A randomized controlled pilot study of dialectical behavior therapy skills in
psychoeducational group from individuals with bipolar disorder. Journal of Affective Disorders, 145, 386-393.
doi:10.1016/j.jad.2012.05.054

2017, Vol. 13(3), 1–99
doi:10.5964/ejop.v13i3.1138
Vettese, L., Toneatto, T., Stea, J. N., Nguyen, L., & Wang, J. J. (2009). Do mindfulness meditation participants do their
homework? And does it make a difference? A review of the empirical evidence. Journal of Cognitive Psychotherapy, 23,
198-225. doi:10.1891/0889-8391.23.3.198
Weber, B., Jermann, F., Gex-Fabry, M., Nallet, A., Bondolfi, G., & Aubry, J.-M. (2010). Mindfulness-based cognitive therapy
for bipolar disorder: A feasibility trial. European Psychiatry, 25, 334-337. doi:10.1016/j.eurpsy.2010.03.007
Williams, J. M. G., Alatiq, Y., Crane, C., Barnhofer, T., Fennell, M. J. V., Duggan, D. S., . . . Goodwin, G. M. (2008).
Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: Perliminary evaluation of immediate effects on
between episode functioning. Journal of Affective Disorders, 107, 275-279. doi:10.1016/j.jad.2007.08.022
Williams, K. E., Chambless, D. L., & Ahrens, A. (1997). Are emotions frightening? An extension of the fear of fear construct.
Behaviour Research and Therapy, 35, 239-248. doi:10.1016/S0005-7967(96)00098-8
Williams, J. M. G., Teasdale, J. D., Segal, Z. V., & Soulsby, J. (2000). Mindfulness based cognitive therapy reduces
overgeneral autobiographical memory in formally depressed patients. Journal of Abnormal Psychology, 109, 150-155.
doi:10.1037/0021-843X.109.1.150
Yorston, G. A. (2001). Mania precipitated by meditation: A case report and literature review. Mental Health, Religion &
Culture, 4, 209-213. doi:10.1080/713685624
Young, R. C., Biggs, J. T., Ziegler, V. E., & Meyer, D. A. (1978). A rating scale for mania: reliability, validity and sensitivity.
The British Journal of Psychiatry, 133, 429-435. doi:10.1192/bjp.133.5.429
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67,
361-370. doi:10.1111/j.1600-0447.1983.tb09716.x
About the Authors
Sanja Bojic completed her Masters Degree in Clinical Psychology at Edith Cowan University in 2015. She has over 5 years
experience facilitating rehabilitation programs in the areas of emotional regulation, distress tolerance, cognitive skills, addic-
tions and offending behaviour.
Dr Rodrigo Becerra is a senior Lecturer at Edith Cowan University and a Clinical Psychologist in private practice. He is the
Director of the Psychopathology Research group at Edith Cowan University and specializes in emotions and psychopathol-
ogy.
Europe's Journal of Psychology PsychOpen is a publishing service by Leibniz Institute

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Mindfulness-Based Treatment for Bipolar Disorder: A Systematic Review

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Europe's Journal of Psychology, 2017, Vol. 13(3), 1–99, doi:10.5964/ejop.v13i3.1138

Psychological interventions implementing mindfulness, such as mindfulness-based cognitive therapy (MBCT;

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Figure 1. Flow chart of study inclusion/exclusion process.

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Deckersbach et al. (2012)

Europe's Journal of Psychology

(decreased beta band power) in the BD

2017, Vol. 13(3), 1–99

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• Edinburgh Handedness Inventory (EHI)

2017, Vol. 13(3), 1–99

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Subjective Measures of MBCT

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Sample Size and Control Conditions

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Modification of Mindfulness Interventions

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Conclusion and Recommendations

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About the Authors

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