For some people, depression is like an unwanted guest who moves in and refuses to leave. Even with therapy and medication, the heavy fog of low mood, exhaustion and hopelessness never fully lifts for long. For around 30% of people with depression, this is a daily reality.
Authors
- Thorsten Barnhofer
Professor of Clinical Psychology, Faculty of Health and Medical Sciences, School of Psychology, University of Surrey
- Barney Dunn
Professor of Clinical Psychology, School of Psychology, University of Exeter
- Clara Strauss
Professor of Clinical Psychology, School of Psychology, University of Sussex
It's not just a personal burden. Difficult-to-treat depression affects families, workplaces and communities - and carries a huge cost for society .
In England, the NHS Talking Therapies programme is the first place many adults turn when they're struggling with depression or anxiety. In 2023-24, it supported more than 1.26 million people . Yet, for all its reach, around half of those who complete treatment still feel depressed by the end. And if the therapy hasn't worked, there are often no further options available.
Most people in this situation are sent back to their GP. A small number may be referred to more specialist mental health services, but those are typically reserved for the most severe cases. That leaves a significant number of people in limbo - still unwell, but without a clear route to further care.
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This is part of a wider problem in mental health services: the so-called "missing middle" . These are people whose needs are too complex for primary (GP) care, but not severe enough for secondary services. As a result, they fall through the cracks.
For many of these people, medication is often the only treatment on offer. But our study , with colleagues, suggests that a different approach, using mindfulness-based cognitive therapy (MBCT), could offer a way forward.
Promising results
We worked with more than 200 patients who had completed NHS Talking Therapies but were still experiencing symptoms of depression. Half were offered an eight-week MBCT course, delivered in small online groups. The others continued with their usual care.
MBCT blends traditional cognitive therapy (which aims to reduce negative thinking patterns) with intensive mindfulness training. Participants learn how to stay present, recognise harmful thought spirals early, and respond to difficult emotions with greater awareness and compassion. Most importantly, they gain skills they can use for the rest of their lives.
The results were promising. People who took part in the mindfulness programme reported bigger improvements in their depressive symptoms than those who didn't. Six months later , the benefits had not only lasted - they had consolidated and slightly strengthened.
What's more, those in the MBCT group used fewer health and social care services overall. The programme was also inexpensive to run, costing less than £100 per person. In a time when health systems are under extreme financial pressure, that's a big deal. Our research suggests MBCT is not just effective, it's cost-saving too.
When depression doesn't respond to standard treatment, it can upend lives. People may struggle to work, maintain relationships, or care for their families. Children are especially affected when a parent has long-term depression. Without the right support, things often get worse - and the costs, both personal and financial, continue to grow.
MBCT is already being used for relapse prevention - and there is a trained workforce to deliver it. Consisting of just eight group-based sessions, it is accessible and designed to equip people with practical tools. We believe it can offer hope to those who do not benefit sufficiently from existing services, and should be made available to more people.
Beyond the promise of MBCT itself, this research offers a wider message: we need to invest in psychological therapies for people in the "missing middle" . These are people who are often overlooked but stand to gain the most from targeted, practical support.
In times of tight budgets, the idea that we can improve lives and save money is more than compelling - it's necessary. This is a clear opportunity to improve outcomes, reduce strain on overstretched services, and help people move forward with their lives.
Thorsten Barnhofer is the author of a book on mindfulness-based cognitive therapy (MBCT). He regularly provides workshops on mindfulness-based interventions. He is co-investigator of a programme grant evaluating an adapted MBCT course for adolescents experiencing depression and is among the investigators for the NIHR Research for Patient Benefit-funded trial described in this article.
Barney Dunn receives funding from the National Institute of Health Research for mental health treatment trials at the University of Exeter, including the Research for Patient Benefit Funding for the RESPOND trial discussed in this article. He co-directs an NHS commissioned psychological therapies service, which delivers Mindfulness Based Cognitive Therapy.
Clara Strauss is co-lead for Sussex Mindfulness Centre (SMC), part of Sussex Partnership NHS Foundation Trust, and has received funding to conduct MBCT research from NIHR and other funders, funding to deliver MBCT courses and funding to train MBCT therapists within SMC.
