Maintenance Antidepressant Medication Research Articles

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis.

ObjectivesThe aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).MethodsA systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.ResultsThirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.ConclusionsIn patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.Systematic review registration numberPROSPERO 2018: CRD42018103142.

The development and internal evaluation of a predictive model to identify for whom Mindfulness-Based Cognitive Therapy (MBCT) offers superior relapse prevention for recurrent depression versus maintenance antidepressant medication.

Depression is highly recurrent, even following successful pharmacological and/or psychological intervention. We aimed to develop clinical prediction models to inform adults with recurrent depression choosing between antidepressant medication (ADM) maintenance or switching to Mindfulness-Based Cognitive Therapy (MBCT). Using data from the PREVENT trial (N=424), we constructed prognostic models using elastic net regression that combined demographic, clinical and psychological factors to predict relapse at 24 months under ADM or MBCT. Only the ADM model (discrimination performance: AUC=.68) predicted relapse better than baseline depression severity (AUC=.54; one-tailed DeLong's test: z=2.8, p=.003). Individuals with the poorest ADM prognoses who switched to MBCT had better outcomes compared to those who maintained ADM (48% vs. 70% relapse, respectively; superior survival times [z=-2.7, p=.008]). For individuals with moderate-to-good ADM prognosis, both treatments resulted in similar likelihood of relapse. If replicated, the results suggest that predictive modeling can inform clinical decision-making around relapse prevention in recurrent depression.

Factors associated with relapse and recurrence of major depressive disorder in patients starting mindfulness-based cognitive therapy.

BackgroundMindfulness‐based cognitive therapy (MBCT) is effective for relapse prevention in major depressive disorder (MDD). It reduces cognitive reactivity (CR) and rumination, and enhances self‐compassion and mindfulness. Although rumination and mindfulness after MBCT are associated with relapse, the association of CR, rumination, self‐compassion, and mindfulness with relapse before initiation of MBCT has never been investigated.MethodsData were drawn from two randomized controlled trials, including a total of 282 remitted MDD participants (≥3 depressive episodes) who had been using maintenance antidepressant medication (mADM) for at least 6 months before baseline. All participants were offered MBCT while either their mADM was maintained or discontinued after MBCT. CR, rumination, self‐compassion, and mindfulness were assessed at baseline by self‐rated questionnaires and were used in Cox proportional hazards regression models to investigate their association with relapse.ResultsCR and mindfulness were associated with relapse, independent of residual symptoms, previous depressive episodes, and mADM‐use. Higher CR and lower mindfulness increased the risk of relapse. Self‐compassion was not associated with relapse. For rumination, a significant interaction with mADM‐use was found. Rumination was associated with relapse in patients who discontinued their mADM, while this effect was absent if patients continued mADM.ConclusionsThese results show that CR, rumination, and mindfulness are associated with relapse in remitted MDD‐patients before initiation of MBCT, independent of residual symptoms and previous depressive episodes. This information could improve decisions in treatment planning in remitted individuals with a history of depression.

The Development and Internal Evaluation of a Predictive Model to Identify for Whom Mindfulness-Based Cognitive Therapy Offers Superior Relapse Prevention for Recurrent Depression Versus Maintenance Antidepressant Medication

Major depressive disorder is highly recurrent over the lifespan, even following successful pharmacological and/or psychological intervention. Here we investigate whether predictive modeling can be used to optimize treatment recommendations, when choosing between continuing antidepressant medication (ADM) or switching to Mindfulness-Based Cognitive Therapy (MBCT) with support for tapering ADM.

Cost-Utility Analysis of Mindfulness-Based Cognitive Therapy Versus Antidepressant Pharmacotherapy for Prevention of Depressive Relapse in a Canadian Context: Analyse coût-utilité de la thérapie cognitive basée sur la pleine conscience contre la pharmacothérapie antidépressive pour prévenir la rechute de la dépression en contexte canadien.

Patients suffering from major depressive disorder (MDD) experience impaired functioning and reduced quality of life, including an elevated risk of episode return. MDD is associated with high societal burden due to increased healthcare utilization, productivity losses, and suicide-related costs, making the long-term management of this illness a priority. The purpose of this study is to evaluate the cost-effectiveness of mindfulness-based cognitive therapy (MBCT), a first-line preventative psychological treatment, compared to maintenance antidepressant medication (ADM), the current standard of care. A cost-utility analysis was conducted over a 24-month time horizon to model differences between MBCT and ADM in cost and quality-adjusted life years (QALY). The analysis was conducted using a decision tree analytic model. Intervention efficacy, utility, and costing data estimates were derived from published sources and expert consultation. MBCT was found to be cost-effective compared to maintenance ADM over a 24-month time horizon. Antidepressant pharmacotherapy resulted in 1.10 QALY and $17,255.37 per patient on average, whereas MBCT resulted in 1.18 QALY and $15,030.70 per patient on average. This resulted in a cost difference of $2,224.67 and a QALY difference of 0.08, in favor of MBCT. Multiple sensitivity analyses supported these findings. From both a societal and health system perspective, utilizing MBCT as a first-line relapse prevention treatment is potentially cost-effective in a Canadian setting. Future economic evaluations should consider combined treatment (e.g., ADM and psychotherapy) as a comparator and longer time horizons as the literature advances.

Recovery from recurrent depression with mindfulness-based cognitive therapy and antidepressants: a qualitative study with illustrative case studies

ObjectivesThis study aimed to describe the recovery journeys of people with a history of recurrent depression who took part in a psychosocial programme designed to teach skills to prevent depressive...

Prevention of Recurrence After Recovery From a Major Depressive Episode With Antidepressant Medication Alone or in Combination With Cognitive Behavioral Therapy

Antidepressant medication (ADM) maintenance treatment is associated with the prevention of depressive recurrence in patients with major depressive disorder (MDD), but whether cognitive behavioral therapy (CBT) treatment is associated with recurrence prevention remains unclear. To determine the effects of combining CBT with ADM on the prevention of depressive recurrence when ADMs are withdrawn or maintained after recovery in patients with MDD. A total of 292 adult outpatients with chronic or recurrent MDD who participated in the second phase of a 2-phase trial. Participants had recovered in the first phase of the trial receiving ADM, either alone or in combination with CBT. The trial was conducted in research clinics in 3 university medical centers in the United States. Patients in phase 2 were randomized to receive maintenance of or withdrawal from ADM and were followed up for 3 years. The first and last patients entered phase 2 in August 2003 and October 2009, respectively. The last patient completed phase 2 in August 2012. Data were analyzed from December 2013 to December 2018. Maintenance of or withdrawal from treatment with ADM. Recurrence of an MDD episode using longitudinal interval follow-up evaluations; sustained recovery across both phases. A total of 292 participants (171 women, 121 men; mean [SD] age 45.1 [12.9] years) were included in analyses of depressive recurrence. Maintenance ADM yielded lower rates of recurrence compared with ADM withdrawal regardless of whether patients had achieved recovery in phase 1 with ADM alone (48.5% vs 74.8%; z = -3.16; P = .002; number needed to treat [NNT], 2.8; 95% CI, 1.8-7.0) or ADM plus CBT (48.5% vs 76.7%; z = -3.49; P < .001; NNT, 2.7; 95% CI, 1.9-5.9). Sustained recovery rates differed as a function of phase 2 condition, with maintenance ADM superior to ADM withdrawal (z = 2.90; P = .004; OR, 2.54; 95% CI, 1.37-4.84; NNT, 2.3; 95% CI, 1.5-6.4). Phase 1 condition was not associated with differential rates of sustained recovery (ADM alone vs ADM plus CBT; z = 0.22; P = .83; OR, 1.08; 95% CI, 0.52-2.11; NNT, 26.0; 95% CI, number needed to harm 3.2 to NNT 2.8), nor was there a significant interaction of phase 1 condition and phase 2 condition (z = 0.30; P = .77; OR, 1.14; 95% CI, 0.49-2.88). Maintenance ADM treatment, but not previous exposure to CBT, was associated with reduced rates of depressive recurrence. In previous studies, when CBT has been provided without ADM, CBT has shown a preventive effect on depressive relapse. Whether CBT also has a preventive effect on depressive recurrence, or if adding ADM interferes with any such preventive effect, remains unclear. ClinicalTrial.gov identifier: NCT00057577.

Recommendations of the Polish Psychiatric Association for treatment of affective disorders in women of childbearing age. Part I: Treatment of depression.

Treatment of depressive disorders in women of childbearing age requires special attention due to the possibility of planned or unplanned pregnancy and the specificity of mood disorders associated with the perinatal period. A doctor who treats depression in a woman of childbearing age should openly discuss with the patient her sexuality and the possibility of becoming pregnant. A psychiatrist may encounter various problems, such as: a therapeutic decision regarding a woman suffering from recurrent depression who receives preventive or maintenance antidepressant medication and becomes pregnant or plans to conceive; proceedings in the case of a depressive episode in a woman who is already pregnant; proceedings in the case of postpartum depression; antidepressant treatment in the context of breastfeeding. The recommendations were prepared by the working group of the Polish Psychiatric Association based on the latest worldwide standards as well as opinions and consensus of experts. The recommendations provide general principles of therapeutic approach and include data on the safety of antidepressants.

The effect of CBT and its modifications for relapse prevention in major depressive disorder: a systematic review and meta-analysis

BackgroundThe risk of relapse in major depressive disorder (MDD) is associated with high worldwide disease burden. Cognitive behavioral therapy (CBT) and its modifications might be effective in relapse prevention. The aim of this review was to evaluate the efficacy of these treatments for reducing relapse of MDD.MethodsThe retrieval was performed in the databases of MEDLINE via Pubmed, EMBASE and PsycINFO via OVID, The Cochrane Library and four Chinese databases. Clinical trials registry platforms and references of relevant articles were retrieved as well. Hazard ratio (HR) and corresponding 95% confidence interval (CI) were used to pool evidences.ResultsA total of 16 eligible trials involving 1945 participants were included. In the first 12 months, CBT was more efficacious than control in reducing the risk of developing a new episode of depression for MDD patients in remission (HR:0.50, 95%CI:0.35–0.72, I2 = 11%). Mindfulness-based cognitive therapy (MBCT) was more efficacious than control only among patients with 3 or more previous depressive episodes (HR:0.46, 95%CI:0.31–0.70, I2 = 38%). Besides, compared with maintenance antidepressant medication (m-ADM), MBCT was a more effective intervention (HR:0.76, 95%CI:0.58–0.98, I2 = 0%). These positive effects might be only maintained at two and nearly 6 years follow up for CBT.ConclusionThe use of CBT for MDD patients in remission might reduce risk of relapse. Besides, the effect of MBCT was moderated by number of prior episodes and MBCT might only be effective for MDD patients with 3 or more previous episodes. Further exploration for the influence of previous psychological intervention is required.

Improvement of mindfulness skills during Mindfulness-Based Cognitive Therapy predicts long-term reductions of neuroticism in persons with recurrent depression in remission

BackgroundThis study examined whether changes in mindfulness skills following Mindfulness-based Cognitive Therapy (MBCT) are predictive of long-term changes in personality traits. MethodsUsing data from the MOMENT study, we included 278 participants with recurrent depression in remission allocated to Mindfulness-Based Cognitive Therapy (MBCT). Mindfulness skills were measured with the FFMQ at baseline, after treatment and at 15-month follow-up and personality traits with the NEO-PI-R at baseline and follow-up. ResultsFor 138 participants, complete repeated assessments of mindfulness and personality traits were available. Following MBCT participants manifested significant improvement of mindfulness skills. Moreover, at 15-month follow-up participants showed significantly lower levels of neuroticism and higher levels of conscientiousness. Large improvements in mindfulness skills after treatment predicted the long-term changes in neuroticism but not in conscientiousness, while controlling for use of maintenance antidepressant medication, baseline depression severity and change in depression severity during follow-up (IDS-C). In particular improvements in the facets of acting with awareness predicted lower levels of neuroticism. Sensitivity analyses with multiple data imputation yielded similar results. LimitationsUncontrolled clinical study with substantial attrition based on data of two randomized controlled trials. ConclusionsThe design of the present study precludes to establish whether there is any causal association between changes in mindfulness and subsequent changes in neuroticism. MBCT could be a viable intervention to directly target one of the most important risk factors for onset and maintenance of recurrent depression and other mental disorders, i.e. neuroticism.

Beliefs about the causes of depression and recovery and their impact on adherence, dosage, and successful tapering of antidepressants.

Continuation of antidepressant medication (ADM) after remission is widely used to prevent depressive relapse/recurrence. Little is known about predictors of ADM use in terms of adherence, dosage, and successful tapering. The current study aimed to explore beliefs about the causes of depression and recovery (i.e., causal beliefs) and to examine whether they predict ADM use. The data were drawn from a controlled trial and an extension of this trial with additional experience sampling. In total, 289 remitted patients with recurrent depression (ADM ≥ 6 months) were randomly assigned to Preventive Cognitive Therapy (PCT) with ADM tapering, PCT with maintenance ADM, or maintenance ADM alone. Adherence, ADM dosage, and causal beliefs regarding the first and last depressive episodes were explored via questionnaires. Most patients mentioned stressful life events as cause of depression, although more patients tended to endorse external causes for the first episode and internal causes for the last episode. ADM was most often mentioned as helpful during recovery from both episodes. Over half of all patients were adherent and under half of the patients in the tapering condition were able to complete the taper. Causal beliefs did not predict ADM use. The results suggest that causal beliefs play little role in the use of maintenance ADM. More information is needed on factors contributing to successful tapering. The results must be interpreted with caution as this is not a naturalistic study and the results might be biased toward a more favorable view regarding ADM.

Electroconvulsive therapy for medication-refractory depression in a patient with ruptured intracranial dermoid cyst, meningioma, and neurofibromatosis.

Electroconvulsive therapy (ECT) is considered relatively contraindicated in patients with intracranial space-occupying lesions. A 53-year-old male presented with a 5-year history of medication-refractory major depressive disorder. Brain imaging findings suggested the presence of a ruptured dermoid cyst in the transverse sinus and a calcified meningioma in the temporal lobe sulcal space. There was no evidence of mass effect. Neurofibromatosis was the only other clinical condition present. The patient had no clinical neurological deficits. Since the depression was severe and he was suicidal, ECT was advised. There was a substantial improvement after four bilateral and then eight right unilateral brief-pulse ECTs administered on alternate days, thrice weekly. There were no complications associated with ECT. The treatment gains were maintained with maintenance antidepressant medication at a 1-year follow-up. This is probably the first reported case of the use of ECT in a medication-refractory, severely depressed patient with a ruptured intracranial dermoid cyst and with a calcifying meningioma. The results testify to the safety of ECT even in high-risk patients.

Discontinuation of antidepressant medication after mindfulness-based cognitive therapy for recurrent depression: randomised controlled non-inferiority trial.

BackgroundMindfulness-based cognitive therapy (MBCT) and maintenance antidepressant medication (mADM) both reduce the risk of relapse in recurrent depression, but their combination has not been studied.AimsTo investigate whether MBCT with discontinuation of mADM is non-inferior to MBCT+mADM.MethodA multicentre randomised controlled non-inferiority trial (ClinicalTrials.gov: NCT00928980). Adults with recurrent depression in remission, using mADM for 6 months or longer (n = 249), were randomly allocated to either discontinue (n = 128) or continue (n = 121) mADM after MBCT. The primary outcome was depressive relapse/recurrence within 15 months. A confidence interval approach with a margin of 25% was used to test non-inferiority. Key secondary outcomes were time to relapse/recurrence and depression severity.ResultsThe difference in relapse/recurrence rates exceeded the non-inferiority margin and time to relapse/recurrence was significantly shorter after discontinuation of mADM. There were only minor differences in depression severity.ConclusionsOur findings suggest an increased risk of relapse/recurrence in patients withdrawing from mADM after MBCT.

Patients with a preference for medication do equally well in mindfulness-based cognitive therapy for recurrent depression as those preferring mindfulness

BackgroundPrevious studies have suggested that patients’ treatment preferences may influence treatment outcome. The current study investigated whether preference for either mindfulness-based cognitive therapy (MBCT) or maintenance antidepressant medication (mADM) to prevent relapse in recurrent depression was associated with patients’ characteristics, treatment adherence, or treatment outcome of MBCT. MethodsThe data originated from two parallel randomised controlled trials, the first comparing the combination of MBCT and mADM to MBCT in patients preferring MBCT (n=249), the second comparing the combination to mADM alone in patients preferring mADM (n=68). Patients’ characteristics were compared across the trials (n=317). Subsequently, adherence and clinical outcomes were compared for patients who all received the combination (n=154). ResultsPatients with a preference for mADM reported more previous depressive episodes and higher levels of mindfulness at baseline. Preference did not affect adherence to either MBCT or mADM. With regard to treatment outcome of MBCT added to mADM, preference was not associated with relapse/recurrence (χ2=0.07; p=.80), severity of (residual) depressive symptoms during the 15-month follow-up period (β=−0.08, p=.49), or quality of life. LimitationsThe group preferring mADM was relatively small. The influence of preferences on outcome may have been limited in the current study because both preference groups received both interventions. ConclusionsThe fact that patients with a preference for medication did equally well as those with a preference for mindfulness supports the applicability of MBCT for recurrent depression. Future studies of MBCT should include measures of preferences to increase knowledge in this area.

Mindfulness-based cognitive therapy as an alternative to maintenance antidepressant medication to prevent relapse and recurrence in depression

ABSTRACT FROM: Kuyken W, Hayes R, Barrett B, et al . Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or...

Adding mindfulness-based cognitive therapy to maintenance antidepressant medication for prevention of relapse/recurrence in major depressive disorder: Randomised controlled trial

BackgroundMindfulness-based cognitive therapy (MBCT) and maintenance antidepressant medication (mADM) both reduce the risk of relapse in recurrent depression, but their combination has not been studied. Our aim was to investigate whether the addition of MBCT to mADM is a more effective prevention strategy than mADM alone. MethodsThis study is one of two multicenter randomised trials comparing the combination of MBCT and mADM to either intervention on its own. In the current trial, recurrently depressed patients in remission who had been using mADM for 6 months or longer (n=68), were randomly allocated to either MBCT+mADM (n=33) or mADM alone (n=35). Primary outcome was depressive relapse/recurrence within 15 months. Key secondary outcomes were time to relapse/recurrence and depression severity. Analyses were based on intention-to-treat. ResultsThere were no significant differences between the groups on any of the outcome measures. LimitationsThe current study included patients who had recovered from depression with mADM and who preferred the certainty of continuing medication to the possibility of participating in MBCT. Lower expectations of mindfulness in the current trial, compared with the parallel trial, may have caused selection bias. In addition, recruitment was hampered by the increasing availability of MBCT in the Netherlands, and even about a quarter of participants included in the trial who were allocated to the control group chose to get MBCT elsewhere. ConclusionsFor this selection of recurrently depressed patients in remission and using mADM for 6 months or longer, MBCT did not further reduce their risk for relapse/recurrence or their (residual) depressive symptoms.

Improvement in Quality of Life With Left Prefrontal Transcranial Magnetic Stimulation in Patients With Pharmacoresistant Major Depression: Acute and Six Month Outcomes

BackgroundTranscranial magnetic stimulation (TMS) is a safe and effective treatment for major depression. We describe quality of life (QOL) outcomes from acute treatment with TMS, and describe the durability of benefit across 24-weeks. MethodsThree hundred and one medication-free patients with pharmacoresistant major depression were randomized to active or sham TMS in a 6-week controlled trial. Nonresponders to the 6-week blinded phase of the study were enrolled in a 6-week open-label study without unblinding the prior treatment assignment. Responders and partial responders to both the blinded (active or sham treatment) or open acute treatment phases were tapered off TMS over three weeks, while initiating maintenance antidepressant medication monotherapy. These subjects entered the 24-week study to examine the durability of response to TMS. The Medical Outcomes Study-36 Item Short Form (SF-36) and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) were used to measure overall function and QOL. During the 24-week durability of effect study, QOL assessments were done at study entry and at the end of 24-weeks. ResultsStatistically significant improvement in both functional status and QOL outcomes was observed in patients treated with active TMS compared with sham TMS during the acute phase of the randomized, sham-controlled trial. Similar benefits were observed in patients who entered the open-label extension study. These improvements were sustained across the 24-week follow up study. ConclusionsAcute treatment with TMS improved functional status and QOL outcomes in patients with major depression. This clinical effect was durable in long-term follow up.

2993 – Is mindfullness an evidence-based treatment?

Derived from ancient Buddhist and Yoga practices, mindfulness is a mental state characterized by nonjudgmental awareness of the present moment experience while encouraging openness, curiosity, and acceptance. This skill can be learned through practice, and has be integrated in different clinical approaches. Mindfulness-Based Stress Reduction (MBSR) is a structured group programme conceived to alleviate suffering associated with physical, psychosomatic and psychiatric disorders. A systematic review of RCTs on MBSR supports that this approach improves mental health in non-clinical and clinical populations. In clinical populations with psychiatric disorders, MBSR has some benefit as it reduces symptoms of distress, anxiety and depression or teaches patients coping skills to handle these symptoms. Mindfulness-Based Cognitive Therapy (MBCT), which is an adaptation of the MBSR programme, incorporates elements of cognitive therapy to prevent depressive relapse. Meta-analysis indicate that MBCT is an effective intervention for relapse prevention in patients with recurrent major depressive disorder in remission, at least in case of three or more previous episodes. Moreover, in two studies, MBCT was at least as effective as maintenance antidepressant medication. While MBCT is a relapse prevention programme for patients in full remission, recent data suggest that it may be indicated also for people in partial remission, including those with quite significant residual depressive symptoms.

One-year postcollaborative depression care trial outcomes among predominantly Hispanic diabetes safety net patients

Objective The aim of this study was to determine sustained effectiveness in reducing depression symptoms and improving depression care 1 year following intervention completion. Method Of 387 low-income, predominantly Hispanic diabetes patients with major depression symptoms randomized to 12-month socioculturally adapted collaborative care (psychotherapy and/or antidepressants, telephone symptom monitoring/relapse prevention) or enhanced usual care, 264 patients completed 2-year follow-up. Depression symptoms (Symptom Checklist-20 [SCL-20], Patient Health Questionnaire-9 [PHQ-9]), treatment receipt, diabetes symptoms and quality of life were assessed 24 months postenrollment using intent-to-treat analyses. Results At 24 months, more intervention patients received ongoing antidepressant treatment (38% vs. 25%, χ 2=5.11, df=1, P=.02); sustained depression symptom improvement [SCL-20 <0.5 (adjusted odds ratio=2.06, 95% confidence interval=1.09–3.90, P=.03), SCL-20 score (adjusted mean difference −0.22, P=.001) and PHQ-9 ≥50% reduction (adjusted odds ratio=1.87, 95% confidence interval =1.05–3.32, P=.03)]. Over 2 years, improved effects were found in significant study group by time interaction for Short Form-12 mental health, Sheehan Disability Scale (SDS) functional impairment, diabetes symptoms, anxiety and socioeconomic stressors ( P=.02 for SDS; P<.0001 for all others); however, group differences narrowed over time and were no longer significant at 24 months. Conclusions Socioculturally tailored collaborative care that included maintenance antidepressant medication, ongoing symptom monitoring and behavioral activation relapse prevention was associated with depression improvement over 24 months for predominantly Hispanic patients in primary safety net care.

Antidepressant Monotherapy vs Sequential Pharmacotherapy and Mindfulness-Based Cognitive Therapy, or Placebo, for Relapse Prophylaxis in Recurrent Depression

Mindfulness-based cognitive therapy (MBCT) is a group-based psychosocial intervention designed to enhance self-management of prodromal symptoms associated with depressive relapse. To compare rates of relapse in depressed patients in remission receiving MBCT against maintenance antidepressant pharmacotherapy, the current standard of care. Patients who met remission criteria after 8 months of algorithm-informed antidepressant treatment were randomized to receive maintenance antidepressant medication, MBCT, or placebo and were followed up for 18 months. Outpatient clinics at the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and St Joseph's Healthcare, Hamilton, Ontario. One hundred sixty patients aged 18 to 65 years meeting DSM-IV criteria for major depressive disorder with a minimum of 2 past episodes. Of these, 84 achieved remission (52.5%) and were assigned to 1 of the 3 study conditions. Patients in remission discontinued their antidepressants and attended 8 weekly group sessions of MBCT, continued taking their therapeutic dose of antidepressant medication, or discontinued active medication and were switched to placebo. Relapse was defined as a return, for at least 2 weeks, of symptoms sufficient to meet the criteria for major depression on module A of the Structured Clinical Interview for DSM-IV. Intention-to-treat analyses showed a significant interaction between the quality of acute-phase remission and subsequent prevention of relapse in randomized patients (P = .03). Among unstable remitters (1 or more Hamilton Rating Scale for Depression score >7 during remission), patients in both MBCT and maintenance treatment showed a 73% decrease in hazard compared with placebo (P = .03), whereas for stable remitters (all Hamilton Rating Scale for Depression scores ≤7 during remission) there were no group differences in survival. For depressed patients achieving stable or unstable clinical remission, MBCT offers protection against relapse/recurrence on a par with that of maintenance antidepressant pharmacotherapy. Our data also highlight the importance of maintaining at least 1 long-term active treatment in unstable remitters.