Mindfulness Training Increases Momentary Positive
Emotions and Reward Experience in Adults Vulnerable
to Depression: A Randomized Controlled Trial
Citation for published version (APA):
Geschwind, N., Peeters, F., Drukker, M., van Os, J., & Wichers, M. (2011). Mindfulness Training
Increases Momentary Positive Emotions and Reward Experience in Adults Vulnerable to Depression: A
Randomized Controlled Trial. Journal of Consulting and Clinical Psychology, 79(5), 618-628.
https://doi.org/10.1037/a0024595
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Published: 01/10/2011
DOI:
10.1037/a0024595
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Mindfulness Training Increases Momentary Positive Emotions and
Reward Experience in Adults Vulnerable to Depression:
A Randomized Controlled Trial
Nicole Geschwind, Frenk Peeters, and
Marjan Drukker
Maastricht University Medical Centre
Jim van Os
Maastricht University Medical Centre and King’s College
London
Marieke Wichers
Maastricht University Medical Centre
Objective: To examine whether mindfulness-based cognitive therapy (MBCT) increases momentary
positive emotions and the ability to make use of natural rewards in daily life. Method: Adults with a
life-time history of depression and current residual depressive symptoms (mean age ⫽ 43.9 years, SD ⫽
9.6; 75% female; all Caucasian) were randomized to MBCT (n ⫽ 64) or waitlist control (CONTROL;
n ⫽ 66) in a parallel, open-label, randomized controlled trial. The Experience Sampling Method was used
to measure momentary positive emotions as well as appraisal of pleasant activities in daily life during 6
days before and after the intervention. Residual depressive symptoms were measured using the 17-item
Hamilton Depression Rating Scale (Hamilton, 1960). Results: MBCT compared to CONTROL was
associated with significant increases in appraisals of positive emotion (b
ⴱ
⫽ .39) and activity pleasantness
(b
ⴱ
⫽ .22) as well as enhanced ability to boost momentary positive emotions by engaging in pleasant
activities (b
ⴱ
⫽ .08; all ps ⬍ .005). Associations remained significant when corrected for reductions in
depressive symptoms or for reductions in negative emotion, rumination, and worry. In the MBCT
condition, increases in positive emotion variables were associated with reduction of residual depressive
symptoms (all ps ⬍ .05). Conclusions: MBCT is associated with increased experience of momentary
positive emotions as well as greater appreciation of, and enhanced responsiveness to, pleasant daily-life
activities. These changes were unlikely to be pure epiphenomena of decreased depression and, given the
role of positive emotions in resilience against depression, may contribute to the protective effects of
MBCT against depressive relapse.
Keywords: MBCT, mindfulness-based cognitive therapy, residual symptoms, positive affect, ecological
momentary assessment
Major depression is a common and highly recurrent clinical
condition—an estimated 75%–90% of patients will have multiple
episodes (e.g., Mueller et al., 1999). Even after different treatment
steps, a considerable number of depressed participants continue to
experience residual symptoms of depression (Rush et al., 2006).
Residual symptoms not only impact negatively on quality of life,
they are also associated with three times faster relapse, compared
to full recovery (Judd et al., 1998; Rush et al., 2006). Residual
symptoms commonly include sleep disturbances; loss of energy;
and decreased pleasure, motivation, and interest. Overall, this
pattern of symptoms is consistent with lower levels of positive
affect (PA; Nutt et al., 2007; Watson, Clark, & Carey, 1988)—a
core symptom of major depressive disorder. Previous studies sug-
gest that PA promotes prevention of and recovery from depression
(Geschwind et al., 2011; Morris, Bylsma, & Rottenberg, 2009;
Wichers et al., 2010). Prevention efforts focused on increases in
PA are therefore likely to (a) improve residual symptoms and
well-being and (b) prevent relapse.
PA, Well-Being, and Depression
Experiencing positive emotions and having a positive attitude
have beneficial effects on mental and physical health in general
(Seligman, Steen, & Peterson, 2005). A meta-analysis of cross-
sectional, longitudinal, and experimental studies demonstrated that
PA was associated with and preceded success, indicating that PA
This article was published Online First July 18, 2011.
Nicole Geschwind, Frenk Peeters, Marjan Drukker, and Marieke Wichers,
European Graduate School for Neuroscience, SEARCH, Department of Psy-
chiatry and Psychology, Maastricht University Medical Centre, Maastricht, the
Netherlands; Jim van Os, European Graduate School for Neuroscience,
SEARCH, Department of Psychiatry and Psychology, Maastricht University
Medical Centre, and Department of Psychosis Studies, Institute of Psychiatry,
King’s College London, King’s Health Partners, London, England.
Marieke Wichers was supported by the Dutch Organisation for Scientific
Research (NWO, VENI Grant Nr. 916.76.147). We thank our study partici-
pants for their time and effort. Furthermore, we thank Rufa Diederen for her
help with data collection, and Truda Driesen, Philippe Delespaul, Frieda van
Goethem, and the 4D database team for their help with data entry.
Correspondence concerning this article should be addressed to Nicole
Geschwind, Maastricht University Medical Centre, Vijverdalseweg 1, 6226
NB Maastricht, P.O. Box 616 (VIJV-SN2), 6200 MD Maastricht, the
Netherlands. E-mail: n.geschwind@maastrichtuniversity.nl
Journal of Consulting and Clinical Psychology © 2011 American Psychological Association
2011, Vol. 79, No. 5, 618–628 0022-006X/11/$12.00 DOI: 10.1037/a0024595
618
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facilitates accomplishment (Lyubomirsky, King, & Diener, 2005).
Evidence also suggests that PA is a source of resilience against
pain and negative affectivity. For example, in a study in which
women with chronic pain were interviewed weekly, higher levels
of PA predicted lower levels of pain in subsequent weeks. Higher
weekly levels of PA also resulted in lower levels of negative affect
(NA) both directly and in interaction with stress and pain (Zautra,
Johnson, & Davis, 2005). A recent study suggests that especially
in-the-moment positive emotions, rather than more general satis-
faction with life, are associated with increased resilience (Cohn,
Fredrickson, Brown, Mikels, & Conway, 2009). Momentary as-
sessment studies, in which experiences are sampled repeatedly at
random moments in daily life, support this view. For example,
high daily life reward experience (i.e., the ability to generate PA
from pleasant daily events) predicted increased resilience against
later affective symptoms in participants vulnerable to depression
(Geschwind et al., 2010; Wichers et al., 2010). Furthermore, in
participants with a lifetime history of depression, scoring one
standard deviation higher on the ability to generate PA from
pleasant daily life events was associated with a three-fold reduc-
tion in risk to experience a future episode (Wichers et al., 2010).
Studies show that depressed participants, compared to never-
depressed controls, experience less PA in the course of daily life
(Barge-Schaapveld, Nicolson, Berkhof, & deVries, 1999; Bylsma,
Taylor-Clift, & Rottenberg, 2011; Peeters, Berkhof, Delespaul,
Rottenberg, & Nicolson, 2006). Also, they generate less PA from
pleasant stimuli during experimental tasks (Bylsma, Morris, &
Rottenberg, 2008), though in daily life this phenomenon is debat-
able (Bylsma et al., 2011; Peeters, Nicolson, Berkhof, Delespaul,
& De Vries, 2003).
Taken together, the evidence suggests that (a) high levels of PA
have beneficial effects on vulnerability to, prevention of, and
recovery from depression and (b) depressed individuals generate
less PA compared to nondepressed individuals. In other words, PA
may represent a resilience phenotype against depression. Individ-
uals vulnerable to depression may therefore benefit from learning
to experience more PA. The question arises how people can
reshape emotional processes in a way that heightens their ability to
experience PA in their daily lives. One momentary assessment
study showed that response to a 6-week treatment with antidepres-
sant medication was associated with a heightened ability to boost
PA through pleasant activities, relative to baseline (Wichers et al.,
2009). However, advocating use of antidepressant medication for
prevention purposes only is problematic—and whether a behav-
ioral, nonpharmacological intervention can be used to heighten
participants’ ability to generate positive emotions in daily life has
never been tested.
An intervention currently receiving empirical support for the
prevention of depressive relapse and recurrence, and for the treat-
ment of residual depressive symptoms, is mindfulness-based cog-
nitive therapy (MBCT; Segal, Williams, & Teasdale, 2002). Al-
though many authors assume changes in cognitive processes to be
a core element of the beneficial effects of MBCT (Segal et al.,
2002), it is unclear whether and how MBCT affects alterations in
emotional experiences. As we argue below, there is reason to
believe that MBCT may have the potential to induce changes in
resilience phenotypes associated with PA.
MBCT
During mindfulness exercises, participants attempt to maintain
attention on a particular focus, for example, their own breathing.
Whenever the attention wanders away from breathing to thoughts
or feelings, participants are encouraged to acknowledge and accept
these thoughts and feelings but then to let go of them and to direct
their attention back to breathing. Participants then use the same
approach in the course of daily life: They aim to focus on the “here
and now” (to engage with the present experience) and to redirect
their attention whenever they notice that it has switched to dis-
tracting thoughts and worries. Next to this attentional aspect,
mindfulness also works on an attitudinal dimension by promoting
the cultivation of an open, curious, and mild orientation of mind.
The essence of a mindful state is to be fully in the present moment,
to experience the present moment without judgment or evaluation
and without worrying about the future or ruminating about past
experiences (Kabat-Zinn, 1990).
MBCT is specifically designed to prevent depressive relapse
and recurrence. MBCT combines methods of meditation and mind-
fulness training (Kabat-Zinn, 1990) with features of cognitive
therapy for depression (Beck, Rush, Shaw, & Emergy, 1979;
Teasdale, Segal, & Williams, 1995). The original idea behind
MBCT was to train participants to disengage from automatic
negative thinking patterns that arise during dysphoric mood and
facilitate relapse (Teasdale et al., 2000). Several studies have
shown that MBCT is associated with reduced depressive symp-
toms and lower risk of relapse (Bondolfi et al., 2010; Kuyken et
al., 2008; Ma & Teasdale, 2004; Teasdale et al., 2000). Further-
more, recent studies found that MBCT is associated with reduced
cognitive reactivity (Kuyken et al., 2010; Raes, Dewulf, Van
Heeringen, & Williams, 2009), rumination (Williams, 2008), and
worry (Evans et al., 2008).
However, there is reason to believe that MBCT might also
increase participants’ capacity for the experience of PA (Ge-
schwind et al., 2010; see also Garland et al., 2010). Studies show
that more advanced meditators experience more positive emotions
(Easterlin & Cardena, 1998–1999) and that people report more
positive emotions when in a mindful compared to a nonmindful
state (Brown & Ryan, 2003; Killingsworth & Gilbert, 2010).
Furthermore, in a randomized controlled trial, participants of
loving-kindness meditation reported stronger increases in PA over
time compared to control participants (Fredrickson, Cohn, Coffey,
Pek, & Finkel, 2008). During loving-kindness meditation, partic-
ipants practice to experience love and compassion first toward
themselves and then toward loved ones, acquaintances, and strang-
ers (Fredrickson et al., 2008). This very explicit focus on positive
emotions may, however, create a demand bias, which is much less
pronounced in MBCT. Although awareness of pleasant events and
nourishing activities is addressed during two to three of the eight
training sessions (just as reactions to stressful situations are dealt
with), the main focus during MBCT sessions is to develop an
increased moment-to-moment awareness of experience (Baer,
2003). As pleasant events and emotions are usually less enduring,
intense, and attention-grabbing than unpleasant events and emo-
tions (Baumeister, Bratslavsky, Finkenauer, & Vohs, 2001), they
may be more easily overlooked than their unpleasant counterparts.
Increased moment-to-moment awareness, achieved in a mindful
state, may help people to perceive fleeting pleasant events or
619
MBCT AND POSITIVE EMOTIONS
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emotions and to generate more enjoyment from pleasant activities
(Schroevers & Brandsma, 2010).
Hypotheses
PA is associated with increased resilience against depression,
but it remains unclear to which extent phenotypes related to PA
can be modified trough behavioral interventions. We propose that
MBCT is an intervention that increases the ability to make use of
natural, moment-to-moment rewards in the environment, thereby
increasing PA. Our primary hypothesis is that, after MBCT, par-
ticipants (a) experience more PA, (b) rate pleasant daily-life ac-
tivities as more pleasant, and (c) experience more reward (i.e.,
generate more PA from engaging in pleasant activities). Because
previous literature has shown that MBCT is associated with de-
creased worry, rumination (see above), and NA (Schroevers &
Brandsma, 2010), we additionally examine to which extent poten-
tial changes in PA, pleasant activities, and reward experience are
independent of decreases in worry, rumination, and NA. Because
of the protective links between PA and depression, a secondary
hypothesis is that increases in PA, pleasant activities, and reward
experience will be associated with decreases in depressive symp-
toms within the MBCT condition.
Hypotheses were tested in an open-label, parallel, randomized
controlled trial comparing participants who continued with treat-
ment as usual to participants who, additionally, received MBCT.
To measure the fleeting momentary experience of positive emo-
tions (Garland et al., 2010) in an ecologically valid and reliable
manner, the Experience Sampling Method (ESM) was used. ESM
is a momentary assessment technique in which participants are
prompted to report on their current experiences at random mo-
ments during the day. ESM is therefore ideally suited to investigate
changes in people’s emotional reactions to their daily environment
(Csikszentmihalyi & Larson, 1987). To our knowledge, this is the
first study to examine how MBCT is associated with changes in
people’s momentary affective responses in their daily life context.
Furthermore, this trial is the first to examine whether a nonphar-
macological intervention can be used to modify a resilience phe-
notype (the ability to experience and generate positive emotions in
daily life) in a sample vulnerable to depression.
Method
Participant Characteristics
For the current study (acronym: MindMaastricht; trial number:
NTR1084, Netherlands Trial Register), adults with residual symp-
tomatology after at least one episode of major depressive disorder
were recruited from outpatient mental health care facilities in
Maastricht (the Netherlands) and through posters in public spaces.
Residual symptoms are associated with higher risk of relapse (Judd
et al., 1998) and were therefore required as an indicator of vul-
nerability to depression. Residual symptoms were defined as a
score of seven or higher on the 17-item Hamilton Depression
Rating Scale (HDRS; Hamilton, 1960) at the time of screening.
Exclusion criteria included the following: fulfilling criteria for a
current depressive episode, schizophrenia, or psychotic episodes in
the past year, and recent (past 4 weeks) or upcoming changes in
ongoing psychological or pharmacological treatment. Currently
depressed individuals were excluded because, at trial preparation,
there was no evidence that currently depressed individuals were
able to participate in or benefit from MBCT. Relevant sociodemo-
graphic and clinical characteristics are displayed in Table 1.
Sampling Procedures
All study procedures were approved by the Medical Ethics
Committee of Maastricht University Medical Centre, and all par-
ticipants signed an informed consent form. An initial screening of
potential participants for this randomized controlled trial was
performed by phone to check for availability during the study
period and likelihood of meeting inclusion and exclusion criteria.
A second screening included administration of the Structured
Clinical Interview for DSM IV–Axis I (First, Spitzer, Gibbon, &
Williams, 2002) and the 17-item HDRS by trained psychologists.
Eligible participants were invited for a detailed one-on-one expla-
nation of the experience sampling procedure, and then they took
part in the baseline assessment. The baseline assessment consisted
of 6 days of experience sampling in their own environment (see the
ESM section) and subsequent administration of a battery of ques-
tionnaires (see the Measures section) as well as the HDRS inter-
view (in the laboratory). After the baseline assessment, partici-
pants were randomized to either MBCT or waitlist control
(CONTROL; allocation ratio 1:1) if they were likely to have at
least 20 valid ESM assessments (Delespaul, 1995; see the ESM
section). After either 8 weeks of MBCT (see the Intervention
section) or equivalent waiting time (in the CONTROL condition),
participants again took part in 6 days of experience sampling,
followed by the administration of the HDRS and the question-
naires. All participants were compensated with gift vouchers worth
50 Euros. Participants in the CONTROL condition had the oppor-
tunity to take part in MBCT after the postintervention assessment.
Randomization to treatment condition was stratified according
to number of depressive episodes (two or less vs. three or more),
as previous studies suggest a greater benefit for those with three or
more previous episodes (Ma & Teasdale, 2004; Teasdale et al.,
2000). An independent researcher not involved in the project
generated the randomization sequence in blocks of five (using the
Table 1
Baseline Demographic and Clinical Characteristics per Group
Variable
MBCT
(n ⫽ 63)
CONTROL
(n ⫽ 66)
Age (M, SD) 44.6 (9.7) 43.2 (9.5)
Female gender (%) 79 73
Full-/part-time work (%) 62 68
Illness/unemployment benefits (%) 19 23
Living with partner/own family (%) 64 64
ⱕ2 previous episodes of MDD (%) 56 55
ⱖ3 previous episodes of MDD (%) 44 45
Comorbid anxiety disorder (present) (%) 35 49
Comorbid anxiety disorder (past) (%) 51 64
Current psycho-counseling/-therapy (%) 13 12
Current use of antidepressants (%) 32 38
(Occasional) use of benzodiazepines (%) 8 8
Note. There were no significant differences between groups (at p ⬍ .05).
MBCT ⫽ mindfulness-based cognitive therapy; CONTROL ⫽ waitlist
control condition; MDD ⫽ major depressive disorder.
620
GESCHWIND, PEETERS, DRUKKER, VAN OS, AND WICHERS
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sequence generator on www.random.org) and wrote the random-
ization code into sealed numbered envelopes. After completion of
all baseline assessments, the researcher allocated participants to
their treatment condition based on the randomization code in the
sealed envelope (opened in order of sequence). No masking of
treatment condition took place.
Sample Size and Power
Sample size (n ⱖ 120) was determined on the basis of sufficient
power for gene–environment interactions (not analyzed here). Post
hoc power calculations for the current analyses (using Stata 11s
SAMPSI command; StataCorp, 2009) indicated a power of ⬎.90
to detect small effects (d ⫽ 0.2) in the parameter of interest: the
Group ⫻ Time interaction.
Intervention (MBCT)
Content of MBCT training sessions followed the protocol of
Segal et al. (2002). Trainings consisted of eight weekly meetings
lasting 2.5 hr and were run in groups of 10–15 participants (thus
occasionally larger than the usual 10–12 participants per group).
Assessment periods for control participants were matched to those
of MBCT participants. Sessions included guided meditation, ex-
periential exercises, and discussions. In addition to the weekly
group sessions, participants received CDs with guided exercises
and were assigned daily homework exercises (30–60 min daily).
Trainings were given by experienced trainers in a center special-
ized in mindfulness trainings. All trainers were supervised by an
experienced health care professional who had trained with Teas-
dale and Williams, the co-developers of MBCT (Teasdale et al.,
1995).
ESM
ESM is a momentary assessment method to assess participants
in their daily living environment, thus providing repeated in-the-
moment assessments of affect in a prospective and ecologically
valid manner (Csikszentmihalyi & Larson, 1987; Peeters et al.,
2003). Compared to retrospective questionnaires and interviews,
ESM offers several advantages: (a) enhanced ecological validity,
because participants are assessed in their normal daily environ-
ments; (b) minimized retrospective bias, because participants’
experiences are assessed in the moment; and (c) enhanced reliabil-
ity, because participants’ experiences are assessed repeatedly
(Csikszentmihalyi & Larson, 1987).
In the current study, participants received a digital wristwatch
and a set of ESM self-assessment forms collated in a booklet for
each day. The wristwatch was programmed to emit a signal
(“beep”) at an unpredictable moment in each of ten 90-min time
blocks between 7:30 a.m. and 10:30 p.m., on 6 consecutive days,
resulting in a maximum of 60 beeps per study period. After each
beep, participants were asked to fill out the ESM self-assessment
forms previously handed to them, collecting reports of current
mood and context. All self-assessments were rated on 7-point
Likert scales. Trained research assistants explained the ESM pro-
cedure to the participants during an initial briefing session, and a
practice form was completed to confirm that participants under-
stood the 7-point Likert scale. Participants were instructed to
complete their reports immediately after the beep, thus minimizing
memory distortion, and to record the time at which they completed
the form. All reports not filled in within 15 min after the actual
beep were excluded from the analysis, because previous work
(Delespaul, 1995) has shown that reports completed after this
interval are less reliable and consequently less valid. For the same
reason, participants with less than 20 valid reports at baseline were
excluded from the analysis (Delespaul, 1995).
Measures
Pleasantness of daily life activities. To define pleasantness
of daily life activities in an ecologically valid manner, ESM
self-rated appraisals of ongoing activities were used, consistent
with several previous studies of emotional reactivity to appraised
daily activities and contexts (Myin-Germeys & van Os, 2007;
Myin-Germeys, van Os, Schwartz, Stone, & Delespaul, 2001;
Wichers et al., 2009). Participants rated their current activity on a
7-point Likert scale (1 ⫽ not at all, and 7 ⫽ very). Factor analysis
supported inclusion of four items for activity appraisal (with factor
loadings ⬎ .6), namely, “I enjoy this activity,” “This activity
requires effort,” “I would prefer to do something else,” and “I am
skilled at doing this activity.” Two items (“I feel I’m being active,”
and “This is a challenge”) had low factor loadings (.05 and .12,
respectively) and were consequently not included in the activity
pleasantness score. On the basis of the included ratings, a variable
reflecting “pleasantness of current activity” was generated. Before
creating the activity pleasantness variable, the items “This activity
requires effort,” and “I would prefer to do something else” were
first recoded so that high scores reflected lower appraised effort
and higher preference for the current activity. Consistent with
Wichers et al. (2009), low scores (ⱕ4) on all four items were set
to zero (so that negative activity appraisals did not contribute to the
overall score), and higher scores were recoded (5 ⫽ 1, 6 ⫽ 2, 7 ⫽
3) before calculating a sum score for activity pleasantness. High
pleasantness thus reflected high skill, low effort, low preference
for doing something else, and high enjoyment of the activity.
PA and NA. At each beep, several ESM mood adjectives
were assessed on 7-point Likert scales ranging from 1 (not at all)
to7(very). Consistent with previous work (Myin-Germeys et al.,
2001; Wichers et al., 2010), principal component factor analysis
with oblique rotation was used to generate a factor representing PA
and a factor representing NA. The mood adjectives “happy,”
“satisfied,” “strong,” “enthusiastic,” “curious,” “animated,” and
“inspired” loaded on the PA factor (␣⫽.89), whereas “down,”
“anxious,” “lonely,” “suspicious,” “disappointed,” “insecure,”
and “guilty” loaded on the NA factor (␣⫽.86). One mood item (“I
feel relaxed”) was not included in the PA factor due to low factor
loadings (⬍ .6). Mean levels of PA and NA were then computed
per participant and beep moment.
Reward experience. Reward experience was conceptualized
as the effect (the standardized coefficient b
ⴱ
) of pleasant activities
on momentary PA. This coefficient captures the increase in PA
when engaging in pleasant activities, relative to baseline. Reward
experience thus was not a precalculated variable but was hidden in
the outcome of the analyses (consistent with Wichers et al., 2009),
so there was no way in which participants could consciously fake
the outcome on this variable.
621
MBCT AND POSITIVE EMOTIONS
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