










































Mindfulness-Based Cognitive Therapy for Prevention of Relapse in Depression – A Useful Approach for Patients with Cardiovascul


Graduate Student Journal of Psychology                                                                           Copyright 2009 by the Department of Counseling & Clinical Psychology  
2009, Vol. 11                                                                                                                      Teachers College, Columbia University  
 
 

Mindfulness-Based Cognitive Therapy for Prevention of Depression Relapse:  
A Useful Approach for Depressed Patients with Cardiovascular Disease? 

 
Traci R. Stein 

Columbia University Medical Center, Division of Pain Medicine 
 

Major depressive disorder (MDD) has a high prevalence rate, particularly in patients with 
cardiovascular disease (CVD). Furthermore, depression has been associated with increased risk of 
morbidity and mortality in this population. Regardless of medical status, patients who have had MDD 
manifest high relapse and recurrence rates, with as much as an 80% likelihood of experiencing another 
major depressive episode. Mindfulness-Based Cognitive Therapy (MBCT), an approach combining 
techniques and principals of both cognitive behavioral therapy and Mindfulness-Based Stress 
Reduction, has been efficacious in reducing depressive relapse and recurrence in preliminary trials. 
Though MBCT’s utility in reducing depression relapse or recurrence in patients with CVD has yet to 
be examined, the promising findings with other populations, as well as the severity of health 
consequences for depressed patients who have CVD, suggest this may also be a worthwhile 
therapeutic approach for those with heart disease. 

 
Depression is a serious and sometimes debilitating 

illness that continues to be a leading cause of disability in 
the United States (Murray & Lopez, 1996). Depressive 
syndromes and major depression are extremely common, 
with lifetime prevalence rates of major depression estimated 
to be 20% in women and approximately 10% in men 
(Kessler et al., 2005; Kessler, McGonagle, Swarz, Blazer, & 
Nelson, 1993; Steffens et al. 2000). Some researchers have 
found an almost 3-to-1 female-male ratio of depression 
(Kessler et al., 1993), as well as a family effect, with rates 2-
to-3 times higher in those with a depressed first-degree 
relative (Klerman & Weissman, 1989). In medically ill 
patients, particularly those with chronic illnesses, depression 
is more prevalent, with 8% of those who have a physical 
illness meeting criteria for major depression and 15% to 
36% meeting criteria for another depressive disorder 
(Feldman, Mayou, Hawton, Ardern, & Smith, 1987). 
Moreover, depression is particularly tenacious in both older 
adults and the medically ill, often with incomplete resolution 
in these populations despite clinical treatment (Irwin, 2002). 
This paper will describe the prevalence and impact of 
depression on patients with CVD, provide an overview of 
the research on Mindfulness-Based Cognitive Therapy 
(MBCT) with other patient populations, and examine the 
evidence for using this approach for those CVD patients 
who have recurrent major depression. 
 
Recurrent Depression in Patients with a History of Major 
Depressive Disorder 
 

Relapse and recurrence following major depressive 
disorder (MDD) is common, with the risk of 
relapse1estimated at more than 80% (Teasdale et al., 2000). 
                                                 
Correspondence: Traci Stein, Division of Pain Medicine, Columbia 
University Medical Center, 622 West 168th Street, PH-5, New York, 
NY 10032 or ts2007@columbia.edu  

This comes at tremendous personal and social costs. It has 
been theorized that repeated associations between depressed 
mood and patterns of negative, self-devaluative, hopeless 
thinking increase vulnerability to relapse (Teasdale, 1988, 
1997). Specifically, the type of thinking activated by 
dysphoria is similar to those patterns present during 
depressive episodes. Easy accessibility of depressing 
thoughts, memories, and attitudes during periods of low 
mood activates feedback loops in the body associated with 
depressive states (Segal, Williams, & Teasdale, 2001). 
Furthermore, a ruminative response style, characterized by 
the tendency to prolong sad feelings (Nolen-Hoeksema & 
Morrow, 1991), has been linked to relapse and recurrence. 
Although patients may dwell upon negative feelings in an 
effort to understand their emotions, this tendency is 
associated with a decreased, rather than increased, ability to 
restore more positive mood states (Lyubormirsky & Nolen-
Hoeksma, 1995). Finally, with repeated episodes of 
depression, less stress is required to provoke relapse (Post, 
1992). 
 

Depression and Cardiovascular Disease 
 

Depression is prevalent among patients with 
cardiovascular disease. Estimates of major depressive 
disorder (MDD) among patients with acute coronary 
syndromes have ranged from 15-25% (Glassman et al., 
2002; Januzzi, Stern, Pasternak, & DeSanctis, 2000). 
Furthermore, patients undergoing cardiac surgery often 
experience depression as a side effect of the procedure itself, 
although the reasons for this are not well understood at 
present (Cay & O’Rourke, 1992). Postoperative anxiety and 
depression occur in about 25% of patients who undergo 
coronary artery bypass graft (CABG) surgery. Depression 
also varies along the recovery trajectory. Timberlake et al. 
(1997) found that 37% of their CABG patients were 

40 



MBCT FOR DEPRESSION IN CVD 
 

 41

depressed preoperatively. At 8 days, this figure had risen to 
50%, but by 8 weeks it had decreased to 24%, and at 12 
months was 23%. Those CABG patients who were 
depressed preoperatively had higher levels of postoperative 
mood disturbance than those who were not depressed prior 
to the procedure. Although postoperative rates of depression 
decreased over time, the 12-month rates of depression were 
higher among patients with cardiovascular disease than in 
the general population. Thus, it appears that depression in 
this population is both prevalent and enduring. 

Although a number of studies have documented the link 
between depression, anxiety, and other emotional states and 
heart disease, evidence for the relationship between 
depression and cardiovascular outcomes has been stronger 
than for other mood states in predicting additional cardiac 
events (McCrone, Lentz, Tarzian, & Perkins, 2001). The 
first research by the medical community regarding the link 
between depression and mortality was in the early 20th 
century (Malzberg, 1937, as cited in Glassman & Shapiro, 
1998, p.4). In this study, the mortality rate of depressed, 
hospitalized patients was compared to that of the general 
New York state population. Though the rate for depressed 
inpatients was elevated, as were the rates for those in the 
general population who had cardiovascular and infectious 
diseases, the study confounded the effect of depression with 
chronic institutionalization. Thus, the link between 
depression and mortality was neither taken seriously, nor 
explored further until investigators revisited this issue in the 
late 1970s (Glassman & Shapiro, 1998). At this time, using 
data from a national registry, Danish researchers identified 
individuals with either unipolar or bipolar depression. When 
they examined the causes of death, they noticed a 50% 
increase in deaths from cardiovascular disease in depressed 
individuals as compared with the Danish general population 
(Weeke, Juel, & Vaeth, 1987). A subsequent study by the 
same researchers explored the question of whether the use of 
tricyclic antidepressants, which had been in common use 
since the time of the Maltzberg study, were associated with 
the increased mortality in this group. Both the sparse 
literature available at the time and the results of this study 
revealed that treatment with tricyclic antidepressants and 
lithium was associated with reduced, rather than increased, 
mortality in this population. This further supported the link 
between depression and health outcomes (Glassman & 
Shapiro, 1998; Week et al., 1987). 

For patients with cardiovascular illnesses, the impact of 
depression on health functioning is significant, and can 
produce impairments in measures of physical functioning, 
pain, general health, and decrements in emotional health. 
Although these impairments may decrease in severity over 
time, there may be residual disability due to the chronic and 
recurrent nature of the disorder (Blazer, 2002). 
Epidemiologic data highlight the negative impact of certain 
psychiatric disorders on the development of, and prognosis 
in, coronary artery disease (CAD; von Kanel, Mills, 
Fainman, & Dimsdale, 2001). For these patients, the 
consequences of being depressed are particularly severe, as 

several studies have revealed a link between depression and 
increased morbidity and mortality from CAD and poorer 
outcomes following coronary events (Hemingway & 
Marmot, 1999; Irwin, 2002). Specifically, depressed CAD 
patients face higher readmission rates and poorer quality of 
life in the first year after a cardiac event (Pignay-Demaria, 
Lesperance, Demaria, Frasure-Smith, & Perrault, 2003). 
Furthermore, the risk of cardiac death in the six months after 
an acute myocardial infarction is approximately three-to-
four times greater in depressed than nondepressed patients 
(Connerney, Shapiro, McLaughlin, Bagiella, & Sloan, 2001; 
Frasure-Smith, Lesperance, & Talajic, 1993, 1995). These 
health risks remain even after controlling for known 
physiological risk factors, including smoking (Glassman & 
Shapiro, 1998; Pignay-Demaria et al., 2003), and the 
increased risk of cardiac mortality for depressed CAD 
patients may persist even 18 months after cardiac surgery 
(Frasure-Smith et al., 1995). 

Despite the clear association between depression and 
poorer outcomes in patients with cardiovascular disease, few 
patients who are depressed after serious cardiac events, 
including myocardial infarction, receive treatment for their 
depression (Carney & Jaffe, 2002). Because of the 
cardiotoxicity associated with older antidepressants, and 
because heart disease is still a standard exclusion criterion in 
clinical trials of antidepressants, little is known about the 
safety and efficacy of newer antidepressants in this 
population. To date, selective serotonin reuptake inhibitors 
(SSRIs), which have not been shown to have cardiotoxic 
effects in healthy depressed patients, have not been 
adequately studied in patients with cardiovascular illness 
(Roose, 2003). This has contributed to their relatively sparse 
use in this population (Carney & Jaffe, 2002). Although 
psychotherapy is considered to be a safe and efficacious 
alternative to antidepressants, it is also currently 
underutilized among cardiac and other types of medically ill 
patients. This is possibly due in part to varying availability 
and insurance coverage (Carney & Jaffe, 2002). The 
challenge for health care providers continues to be how to 
address the problem of depression and its attendant physical 
health risks in a way that is palatable to patients, minimally 
invasive, and cost-effective. 

 
Treatments for Major Depressive Disorder 

 
Pharmacotherapy and Cognitive Behavioral Therapy 
 

At present, maintenance pharmacotherapy is both the 
most widely used and most validated approach in the 
prevention of relapse, although recent studies suggest 
maintenance psychotherapy may also be effective (Teasdale 
et al., 2000). Specifically, cognitive behavioral therapy 
(CBT) administered during depressive episodes appears to 
be effective in reducing subsequent relapse and recurrence 
(Teasdale et al., 2000). Studies comparing the outcome of 
patients who recovered following treatment with 
antidepressant medications (from which they were 



STEIN 
 

 42 

subsequently withdrawn) to that of patients treated with 
CBT have found lower rates of relapse in the CBT group 
(Evans et al., 1992; Shea et al., 1992; Teasdale et al., 2000). 
This reduction in relapse/recurrence is most likely 
accomplished through the development of skills and 
fostering of changes in thinking that protect against future 
depression. Thus, CBT may be a valuable prophylactic 
treatment for major depression.   

Most recently, patients with depression have been 
successfully treated with a combination of pharmacotherapy 
during the acute phase and subsequent psychological 
interventions following recovery. Teasdale and colleagues 
(2000) sought to examine whether a strategy combining 
acute pharmacotherapy with psychological prophylaxis in 
the form of a group skills-training approach would provide 
an efficacious and cost effective relapse prevention 
alternative. The group skills-training approach they used, 
known as Mindfulness-Based Cognitive Therapy (MBCT), 
combines principles of cognitive therapy and a form of 
attentional control, otherwise known as “mindfulness” 
training, developed by Kabat-Zinn and colleagues (1990) at 
the University of Massachusetts Medical Center. 

 
Mindfulness-Based Cognitive Therapy 
 

Mindfulness-Based Cognitive Therapy is a manualized 
group skills-training program that integrates aspects of CBT 
for depression (Beck, Rush, Shaw, & Emery, 1979) and 
Mindfulness-Based Stress Reduction (MBSR; Kabat-
Zinn,1990; Kabat-Zinn et al., 1992). The latter approach 
teaches patients in remission to observe thoughts, feelings, 
and bodily sensations in a de-centered, non-judgmental 
manner, and view them as mental events, rather than 
identifying with them or viewing them as necessarily 
factual. The program also teaches patients to disengage from 
dysfunctional, automatic cognitive routines as a way to 
reduce future risk of depressive relapse and recurrence. 
Since the emphasis is not on changing one’s thoughts, the 
techniques can be applied with patients in the remitted state 
(when it may not be necessary to “change” cognitions). 

MBSR has been efficacious in reducing both 
psychological and physiological symptoms, including 
anxiety (Kabat-Zinn, et al., 1992), chronic pain (Kabat-Zinn, 
Lipworth, & Burney, 1985), psoriasis (Kabat-Zinn et al., 
1998), fibromyalgia (Kaplan, Goldenberg, & Galvin-
Nadeau, 1993), and more recently, reducing both state and 
trait anxiety in women with breast cancer (Tacon, Caldera, 
& Ronaghan, 2004). Only one study has examined whether 
MBSR would be beneficial for CAD patients, however. 
Tacon and colleages (2003) assessed whether MBSR would 
reduce anxiety in women with heart disease. In their trial, 18 
women with documented CAD were randomly assigned to 
either a wait-list control group or an eight-week MBSR 
program that included didactic, inductive, and experiential 
components (yoga, meditation, and the body scan) as per 
Kabat-Zinn (1990). The researchers measured state and trait 
anxiety, emotional control (as measured by the degree to 

which one suppresses negative feelings, rather than 
observing them in a detached way), and health locus of 
control (e.g., reactive, reflective, or suppressive). Significant 
between group differences were observed for state anxiety, 
emotional control, and reactive coping. Specifically, women 
in the MBSR group experienced significant decreases in 
state anxiety, decreased tendency to suppress the expression 
of negative emotions, and decreased use of impulsive, 
reactive coping as compared to controls. A key limitation of 
this study was the small, homogeneous sample (comprised 
of mostly White, middle class women), which limits the 
generalizability of its findings. 

Similar to MBSR, MBCT is delivered by an instructor 
in eight weekly, 2-hour group training sessions that involve 
homework in the form of listening to guided imagery and 
performing unguided awareness exercises designed to 
facilitate present-moment, non-judgmental awareness. 
Participants learn to observe thoughts, feelings, and bodily 
sensations in a de-centered manner. Practicing various 
exercises helps participants integrate these skills into daily 
life (Teasdale et al., 2000). In contrast to the habitual 
patterns of cognitive-affective processing employed by 
patients with recurrent depression, patients learn to develop 
a more aware, less judgmental, “mindful” mode of being. 

Like CBT, MBCT attempts to foster a greater awareness 
of thoughts and feelings, examines the role that thoughts 
have in triggering mood, and aims to cultivate understanding 
of how depressive thinking patterns and worry promote 
depression. MBCT also teaches participants to identify 
warning signs of impending declines in mood (Mason & 
Hargreaves, 2001). Unlike CBT, however, MBCT does not 
explicitly suggest changing thoughts or set out to identify 
depressive schema, as the skills taught encourage awareness 
of feelings, regardless of whether or not these are 
characterized by depression. 
 
MBCT for Prevention of Depression Relapse 

 
In the first multicenter trial of MBCT, Teasdale and 

colleagues (2000) randomized 145 patients who were in 
remission or recovery from major depression as defined by 
the Diagnostic and Statistical Manual of Mental Disorders 
(3rd ed.; DSM-III-R; American Psychiatric Association, 
1987) to receive either treatment as usual (TAU) or TAU 
plus MBCT for a period of eight weeks and follow up for a 
period of one year. To meet entry criteria, patients had to 
have been treated with a recognized antidepressant 
medication, but be off medication and in recovery/remission 
at the time of baseline assessment and for at least the 
preceding 12 weeks. This is in contrast to the standard 
approach of introducing therapy during the course of 
medication withdrawal. At baseline, patients had to have a 
Hamilton Rating Scale for Depression (HRSD; Hamilton, 
1960) score of less than 10 for inclusion. Patients were 
stratified on two variables: recency of recovery from the last 
episode of MDD (up to 12 months vs. 13-24 months prior to 



MBCT FOR DEPRESSION IN CVD 
 

 43

randomization) and the number of previous episodes of 
MDD (two vs. three or more).  

Although MBCT did not reduce the risk of recurrence to 
that of what would be expected in a “normal” (not 
previously depressed) sample, the investigators found that 
patients with three or more previous episodes of MDD 
treated with at least four of the eight sessions of MBCT 
experienced relapse/recurrence rates that were reduced by 
half during the course of the follow up period. This finding 
was both statistically and clinically significant, and this 
reduction in depression was independent of medication use. 
Notably, MBCT did not significantly reduce risk of 
depression in patients with two or fewer previous depressive 
episodes. 

In a recent study by Ma and Teasdale (2004), as in the 
study by Teasdale et al. (2000), recovered, recurrently 
depressed patients were randomized to TAU or TAU plus 
MBCT. The findings from the previous study were 
replicated, with relapse rates reduced from 78% to 36% in 
patients with three or more depressive episodes. The authors 
found that MBCT was most effective in preventing relapses 
not preceded by life events. Notably, relapses were more 
often associated with significant life events in the two-
episode group than in the three-or-more episode group, 
suggesting that these groups represented two distinct 
populations. 

Although the above studies have shown MBCT to be a 
useful approach for reducing depressive relapse, and patients 
with cardiovascular illnesses have both high rates of 
depression and severe, negative health effects as a result, a 
review of the literature revealed only one study of MBCT 
with patients diagnosed with a vascular (but not cardiac) 
health problem. In this study, Moustgaard (2005) examined 
whether MBCT would reduce depression and anxiety and 
improve quality of life in 23 patients who had suffered a 
stroke. Participants were assessed at baseline, after 
completion of the nine-week program, and three months 
after the conclusion of the intervention. MBCT was 
associated with a significant improvement between baseline 
and completion on measures of depression, anxiety, and 
quality of life, and these changes were maintained at follow 
up. Among the limitations of this study were the small 
sample size and lack of a control group.  
 
Possible mechanisms of action of MBCT  
 

In a study of autobiographical memory, Williams and 
colleagues (2000) found that MBCT reduced recovered 
depressed patients’ general memory, suggesting that the 
encoding and retrieval of personal events can be altered by 
this treatment approach, and that MBCT’s effects are partly 
cognitively mediated. Teasdale (1999) has suggested that a 
theoretical cognitive framework called Interacting Cognitive 
Subsystems (ICS; Teasdale & Barnard, 1993) may explain 
MBCT’s effects. The assumption of this framework is that 
knowledge and experience are contained in qualitatively 
different forms. For individuals who are prone to depression, 

generic, richly elaborated schematic models contain global 
negative beliefs about the self and other depression-related 
thoughts and feelings. When these are triggered, a 
“depressive interlock” occurs in which sensory feedback 
from the body and cognitive feedback in the form of 
thoughts maintain depressed affect (Mason & Hargreaves, 
2000).   
 
MBCT – A Potential Treatment for Depressed Patients with 
Cardiovascular Disease? 

 
There is preliminary evidence that MBCT is an effective 

treatment for patients with recurrent MDD and clear 
evidence of the need for additional treatments for depressed 
patients who have heart disease. However, a review of the 
literature revealed no studies of MBCT with depressed 
patients who had a comorbid cardiac illness, and only one 
small study with stroke patients. Depression has been 
demonstrably linked with poorer health outcomes, including 
increased mortality, in patients with cardiovascular ailments. 
Considering both the insufficient data on the safety of 
antidepressants for this patient population and the tendency 
toward relapse/recurrence in patients with MDD, it seems 
clear that more research on potentially beneficial 
psychotherapeutic approaches for those with heart disease is 
warranted. Given the evidence for MBCT’s efficacy in 
reducing depressive relapse in non-cardiac patients, future 
research should explore whether this therapeutic approach 
might be useful for recovered, depressed patients with 
cardiovascular illnesses. 
 

References 
 
American Psychiatric Association. (1987). Diagnostic and 

statistical manual of mental disorders (3rd ed., rev.).  
Washington, DC: Author.  

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). 
Cognitive therapy of depression. New York: Guilford 
Press. 

Blazer, D. (1989). Depression in the elderly. New England 
Journal of Medicine, 320, 164-166. 

Carney, R. M., & Jaffe, A. S. (2002). Treatment of 
depression following acute myocardial infarction. Journal 
of the American Medical Association, 288, 750-751. 

Cay, E., & O’Rourke, A. (1992). The emotional state of 
patients after coronary bypass surgery. In P. J. Walter 
(Ed.), Quality of life after open heart surgery (pp. 177-
185). Dordrecht, Holland: Kluwer. 

Connerney, I., Shapiro, P. A., McLaughlin, J. S., Bagiella, 
E., & Sloan, R. P. (2001). Relation between depression 
after coronary artery bypass surgery and 12-month 
outcome: a prospective study. Lancet, 358, 1766-71. 

Evans, M. D., Hollon, S. D., DeRubeis, R. J., Piasecki, J. M., 
Grove, W. M., & Garvey, M. J., et al. (1992). Differential 
relapse following cognitive therapy and pharmacotherapy 
for depression. Archives of General Psychiatry, 49, 802-
808. 



STEIN 
 

 44 

Feldman, E., Mayou, R., Hawton, K., Ardern, M., & Smith, 
E. B. (1987). Psychiatric disorder in medical in-patients. 
Quarterly Journal of Medicine, 63, 405-412. 

Frasure-Smith, N., Lesperance, F., & Talajic, M. (1993). 
Depression following myocardial infarction: Impact on 6-
month survival. Journal of the American Medical 
Association, 270, 1819–1825. 

Frasure-Smith, N., Lesperance, F., & Talajic, M. (1995). 
Depression and 18-month prognosis after myocardial 
infarction. Circulation, 91, 999-1005. 

Glassman, A. H., O’Connor, C. M., Califf, R. M., Swedberg, 
K., Schwartz, P., Bigger, J. T. Jr., et al. (2002). Sertraline 
treatment of major depression in patients with acute MI or 
unstable angina. Journal of the American Medical 
Association, 288, 701-709. 

Glassman, A. H., & Shapiro, P. A. (1998). Depression and 
the course of coronary artery disease.  American Journal 
of Psychiatry, 155, (1), 4-11. 

Hamilton, M. (1960). A rating scale for depression. Journal 
of Neurology, Neurosurgery, and Psychiatry, 23, 56-62. 

Hemingway, H., & Marmot, M. (1999). Psychosocial factors 
in the aetiology and prognosis of coronary heart disease: 
Systematic review of prospective cohort studies. British 
Medical Journal, 318, 1460-7. 

Irwin, M. (2002). Presidential address: Psycho-
neuroimmunology of depression: Clinical implications. 
Brain, Behavior, and Immunity, 16, 1-16.   

Januzzi, J., Stern, T., Pasternak, R., & DeSanctis, R. W. 
(2000). The influence of anxiety and depression on 
outcomes of patients with coronary artery disease. 
Archives of Internal Medicine, 160, 1913-1921. 

Kabat-Zinn, J. (1990). Full catastrophe living:  The program 
of the Stress Reduction Clinic at the University of 
Massachusetts Medical Center. New York: Delta. 

Kabat-Zinn, J., Lipworth, I., & Burney, R. (1985). The 
clinical use of mindfulness meditation for the self-
regulation of chronic pain. Journal of Behavioral 
Medicine, 8, 163-190. 

Kabat-Zinn, J., Massio, A. O., Kristeller, J., Peterson, L., 
Fletcher, K., Pbert, L., Lenderking, W., & Santorelli, S. 
(1992). Effectiveness of a mediation-based stress 
reduction program  in the treatment of anxiety disorders. 
American Journal of Psychiatry, 149, 936-943. 

Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, 
M., Cropey, T., Hosmer, D., & Bernhard, J. (1998). 
Influence of a mindfulness meditation-based stress 
reduction intervention on rates of skin clearing in patients 
with moderate to severe psoriasis undergoing 
phototherapy (UVB) and photochemotherapy (PUVA). 
Psychosomatic Medicine, 60, 625-632. 

Kaplan, K., Goldenberg, D., & Galvin-Nadeau, M. (1993). 
The impact of a meditation-based stress reduction 
program on fibromyalgia. General Hospital Psychiatry, 
15, 284-289. 

Kessler, R. C., Berglund, P., Demler, O., Jin, R., 
Merikangas, K., & Walters, E. E. (2005). Lifetime 
prevalence and age of onset distributions of DSM-IV 

disorders in the National Comorbidity Survey Replication. 
Archives of General Psychiatry, 62, 593-602. 

Kessler, R. C., McGonagle, K. A., Swarz, M., Blazer, D. G., 
& Nelson, C. G. (1993). Sex and depression in the 
National Comorbidity Survey I: Lifetime prevalence, 
chronicity and recurrence. Journal of Affective Disorders, 
29, 85-96. 

Klerman, G. K., & Weissman, M. M. (1989). Increasing 
rates of depression. Journal of the American Medical 
Association, 261, 2229-2235. 

Lyubomirsky, S., & Nolen-Hoeksma, S. (1995). Effects of 
self-focused rumination on negative thinking and 
interpersonal problem solving. Journal of Personality and 
Social Psychology, 69, 176-190. 

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. 

Malzberg, B. (1937). Mortality among patients with 
involution melancholia. American Journal of Psychiatry, 
93, 1231–1238. 

Mason, O., & Hargreaves, I. (2001). A qualitative study of 
mindfulness-based cognitive therapy for depression. 
British Journal of Medical Psychology, 74, 197-212. 

McCrone, S., Lentz, E., Tarzian, A., & Perkins, S. (2001). 
Anxiety and depression: Incidence and patterns in patients 
undergoing coronary artery bypass graft surgery. Applied 
Nursing Research, 14, 155-164. 

Moustgaard, A. M. (2005). Mindfulness-Based Cognitive 
Therapy (MBCT) for stroke survivors: An application of a 
novel intervention. Dissertation Abstracts International: 
Section B: The Sciences and Engineering, 65(11-B). 

Murray, C. J. L., & Lopez, A. D. (Eds.). (1996). Summary: 
The global burden of disease: A comprehensive 
assessment of mortality and disability from diseases, 
injuries, and risk factors in 1990 and projected to 2020. 
Cambridge, MA: Harvard University Press. 

Nolen-Hoeksman, S., & Morrow, J. (1991). A prospective 
study of depression and posttraumatic stress symptoms 
after a natural disaster: The 1989 Loma Prieta earthquake. 
Journal of Personality and Social Psychology, 61, 115-
121. 

Pignay-Demaria, V., Lesperance, F., Demaria , R. G., 
Frasure-Smith, N., & Perrault, L. P. (2003). Depression 
and anxiety and outcomes of coronary artery bypass 
surgery. Annals of Thoracic Surgery, 75, 314-21.

Post, R. M. (1992). Transduction of psychosocial stress into 
the neurobiology of recurrent affective disorder. American 
Journal of Psychiatry, 149, 999-1010. 

Roose, S. P. (2003).  Treatment of depression in patients 
with heart disease. Biological Psychiatry. 54, 262-268. 

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). 
Mindfulness-Based Cognitive Therapy for depression: A 
new approach to preventing relapse. New York: Guilford 
Press. 

Shea, M. T., Elkin, I., Imber, S. D., Sotsky, F. M., Watkins, 
J. T., & Collings, J. F., et al. (1992).  Course of depressive 



MBCT FOR DEPRESSION IN CVD 
 

 45

symptoms over follow-up: Findings from the NIMH 
Treatment of Depression Collaborative Research Program. 
Archives of General Psychiatry, 49, 782-787. 

Steffens, D. C., Skoog, I., Norton, M. C., Hart, A. D., 
Tschanz, J. T., & Plassman, B. L., et al. (2000). 
Prevalence of depression and its treatment in an elderly 
population: The Cache County study. Archives of General 
Psychiatry, 57, 601-607.   

Tacon, A. M., Caldera, Y. M., & Ronaghan, C. (2004). 
Mindfulness-based stress reduction in women with breast 
cancer. Families, Systems, & Health, 22, 193-203. 

Tacon, A. M., McComb, J., Caldera, Y., & Randolph, P. 
(2003). Mindfulness meditation, anxiety reduction, and 
heart disease: A pilot study. Family & Community Health, 
26, 25-33.

Teasdale, J. D. (1999). Metacognition, mindfulness and the 
modification of mood disorders. Clinical Psychology and 
Psychotherapy, 6, 146-155. 

Teasdale, J. D. (1997). The relationship between cognition 
and emotion: The mind-in-place in mood disorders. In 
D.M. Clark & C.G. Fairburn (Eds.), Science and practice 
of cognitive  behaviour therapy (pp. 67-93). Oxford, 
England: Oxford University Press.  

Teasdale, J. D. (1988). Cognitive vulnerability to persistent 
depression. Cognition and Emotion, 2, 247-274. 

Teasdale, J. D., & Barnard, P. J. (1993). Affect, cognition  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

and change: Re-modeling depressive thought. Hove:  
Lawrence Erlbaum Associates, Ltd. 

Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgway, 
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. 

Timberlake, N., Klinger, L., Smith, P., Venn, G., Treasure, 
T., Harrison, M., & Newman, S. P. (1997). Incidence and 
patterns of depression following coronary artery bypass 
graft surgery. Journal of Psychosomatic Research, 43, 
197-207. 

von Kanel, R., Mills, J. P., Fainman, C., & Dimsdale, J. E. 
(2001). Effects of psychological stress and psychiatric 
disorders on blood coagulation and fibrinolysis: A 
biobehavioral pathway to coronary artery disease?  
Psychosomatic Medicine, 63, 531-544.  

Weeke, A., Juel, K., & Vaeth, M. (1987). Cardiovascular 
death and manic-depressive psychosis. Journal of 
Affective Disorders, 13, 287–292. 

Williams, J. M. G., Teasdale, J. D., Segal, Z., & Soulsby, J. 
(2000). Mindfulness-based cognitive therapy reduces 
overgeneral autobiographical memory in formerly 
depressed patients. Journal of Abnormal Psychology, 97, 
89-96. 

 


