An evaluation of the 'Coping with Depression Course' for relapse prevention with unipolar depressed patients

Group cognitive–behavioural therapy for anxiety and depression

Cognitive–behavioural therapy (CBT) is a psychological treatment approach that can be delivered not only on a one-to-one basis but also to groups and in self-help formats. However, the evidence base supporting individual CBT is more extensive than the research regarding group CBT. This is likely to influence the choice of services that develop in the Improving Access to Psychological Therapies (IAPT) programme for the treatment of depression and anxiety disorders in primary care in England. This article outlines the different forms that group CBT takes, the way in which it may benefit people and the current evidence base supporting its use for anxiety and depression. It also outlines the advantages of group or individual CBT and describes those patients who appear to be best suited to a specific delivery.

A randomized controlled trial on the effectiveness of a rumination-focused group treatment for residual depression

The maintenance of residual symptoms following acute treatment is common and is associated with poor long-term prognosis. This study investigates whether a cognitive-behavioral group treatment is effective in reducing residual depression by targeting depressive rumination. Participants (N=60) were randomly assigned to either the group treatment or a wait-list control condition. Treatment significantly improved depressed mood, rumination, perceived control over rumination and dysfunctional metacognitive beliefs compared with the wait condition. Treatment gains were maintained over the follow-up period of 1 year. Attrition was low and treatment satisfaction was high. Eight individuals suffered from a depressive relapse/recurrence in the year following treatment. The results indicate that cognitive-behavioral group therapy for depressive rumination is effective and well accepted by patients suffering from residual depression.

Efficacy of the sequential integration of psychotherapy and pharmacotherapy in major depressive disorder: a preliminary meta-analysis

BACKGROUND

Prevention of relapse and recurrence represents an important task in the successful treatment of major depressive disorder (MDD). The aim of this meta-analysis was to examine the efficacy of the sequential integration of psychotherapy and pharmacotherapy in reducing the risk of relapse and recurrence in MDD.

METHOD

Keyword searches were conducted in Medline, EMBASE, PsycINFO and the Cochrane Library from inception of each database to December 2008. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with MDD were considered for inclusion in the meta-analysis.

RESULTS

Eight high-quality studies with 442 patients in a sequential treatment arm and 433 in a control treatment arm were included. The pooled risk ratio (RR) for relapse/recurrence was 0.797 [95% confidence interval (CI) 0.659-0.964] according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence for the sequential administration of treatments compared with control conditions. Performing subgroup analyses, we found a trend favoring psychotherapy during continuation of antidepressant drugs compared to antidepressants or treatment as usual (RR 0.842, 95% CI 0.674-1.051). Patients randomized to psychotherapy while antidepressants were discontinued were significantly less likely to experience relapse/recurrence compared to controls (RR 0.650, 95% CI 0.463-0.912).

CONCLUSIONS

We found evidence that the sequential integration of psychotherapy and pharmacotherapy is a viable strategy for preventing relapse and recurrence in MDD. In addition, our findings suggest that discontinuation of antidepressant drugs may be feasible when psychotherapy is provided.

Psychosocial determinants of recovery in depression

There is a growing body of literature on residual symptoms after apparently successful treatment. The strong prognostic value of subthreshold symptomatology upon remission and the relationship between residual and prodromal symptomatology (the rollback phenomenon) have been outlined. Most residual symptoms also occur in the prodromal phase of depression and may progress to become prodromes of relapse. These findings entail important implications. It is necessary to closely monitor the patient throughout the different phases of illness and to assess the quality and extent of residual symptoms. A more stringent definition of recovery, which is not limited to symptomatic assessment, but includes psychological well-being, seems to be necessary. New therapeutic strategies for improving the level of remission, such as treatment of residual symptoms that progress to become prodromes of relapse and/or increasing psychological well-being, appear to yield more lasting benefits. The sequential model may provide room for innovative treatment approaches, including the use of drugs for specifically addressing residual symptoms. As occurs in other medical disorders (such as diabetes and hypertension), the active role of the patient in achieving recovery (self-therapy homework) should be pursued.

The road to recovery from depression--don't drive today with yesterday's map

The issue of recovery is getting increasing attention in depression research, particularly after the publication of the STAR*D results. The paper analyzes some issues which may hinder effective treatment of major depressive disorders: the inadequacies of a cross-sectional DSM assessment without clinical differentiation of the extent, development and seriousness of the disturbances (staging); over-emphasis on and prolongation of drug treatment, without paying attention to problems related to tolerance; neglect of the active role of the patient in achieving recovery, with the integration of psychotherapeutic strategies in a sequential model. If we are able to remove the conceptual obstacles which obstruct our view of depression and silence the sound of propaganda, we may then become aware of a different scenario in mood disorders and be able to develop therapeutic strategies of enduring quality.

Reducing relapse and recurrence in unipolar depression: a comparative meta-analysis of cognitive-behavioral therapy's effects

Relapse and recurrence following response to acute-phase treatment for major depressive disorder (MDD) are prevalent and costly. In a meta-analysis of 28 studies including 1,880 adults, the authors reviewed the world's published literature on cognitive-behavioral therapies (CT) aimed at preventing relapse-recurrence in MDD. Results indicate that after discontinuation of acute-phase treatment, many responders to CT relapse-recur (29% within 1 year and 54% within 2 years). These rates appear comparable to those associated with other depression-specific psychotherapies but lower than those associated with pharmacotherapy. Among acute-phase treatment responders, continuation-phase CT reduced relapse-recurrence compared with assessment only at the end of continuation treatment (21% reduction) and at follow-up (29% reduction). Continuation-phase CT also reduced relapse-recurrence compared with other active continuation treatments at the end of continuation treatment (12% reduction) and at follow-up (14% reduction). The authors discuss implications for research and patient care and suggest directions, with methodological refinements, for future studies.

Differential predictors of response to preventive cognitive therapy in recurrent depression: a 2-year prospective study

BACKGROUND

Major depressive disorder is a recurrent disease. Brief cognitive therapy (CT), added to either regular care or medication, is helpful in preventing relapse/recurrence. Little is known which type of persons benefit from preventive CT, the so called 'aptitude treatment interaction' effect.

METHOD

The present cohort included exclusively patients with at least two previous episodes remitted on various types of treatments (n = 172). They were assessed within a clinical trial comparing treatment as usual (TAU) with preventive CT added to TAU. Differential demographic, illness-related, psychological and biological risk factors in postponing recurrence by preventive CT were examined.

RESULTS

Significant aptitude-treatment-interaction effects were found for the number of previous episodes, daily hassles and life events, avoidant coping, gender, and morning cortisol levels. Preventive CT seemed ineffective in patients with life events (as more frequently reported by women in our study) and in patients with high episode number characterized by higher levels of avoidant coping. Generic predictors indicate that in CT, as in TAU, patients with more residual depressive symptomatology and higher levels of dysfunctional attitudes profit less from preventive CT.

CONCLUSION

The finding that preventive CT protects against the influence of a consistently found risk factor of relapse/recurrence, i.e. the number of depressive episodes, underlines the potential of psychological preventive interventions. Preventive CT seemed to be especially effective in reducing presumably internally provoked, relapse/recurrence but may be quite ineffective in reducing externally provoked relapse/recurrence. CT possibly prevents either stress generation or disrupts kindling effects. Kindling effects probably cannot be disrupted in patients with higher levels of avoidant coping who experienced a high number of episodes, and patients who experienced life events.