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Maintenance cognitive-behavioral therapy (CBT) to prevent recurrent depression is most effective in patients at highest risk for relapse, defined as those with 5 or more previous depressive episodes, new research shows.

For individuals at more moderate risk for recurrence (fewer than 5 prior episodes), structured patient psychoeducation may be equally effective, the study shows.
This pattern of results is in line with previous studies demonstrating significant treatment effects of CBT only in subsamples of patients with higher numbers of previous episodes, the investigators note.

High-risk patients in particular may benefit from specific elements of maintenance CBT by reducing cognitive vulnerability factors for recurrent depression, such as ruminating, negative attributions and memories, and dysfunctional beliefs, or by maintaining positive emotions when experiencing stress, the investigators, led by Ulrich Stangier, PhD, University of Frankfurt, in Germany, note.

The study is published in the June issue of the American Journal of Psychiatry.

Confirmatory Evidence

"This article really supports the idea that people with more severe forms of depression benefit the most from very active treatment, CBT, which is something we know, but it's nice to see this reinforced by a study with a very good design," Mason Turner, MD, chief of psychiatry at Kaiser Permanente San Francisco and associate director of Regional Mental Health Services for Kaiser Permanente's Northern California region, told Medscape Medical News. Dr. Turner was not involved in the study.

The prospective, multicenter study involved 180 patients with 3 or more previous major depressive episodes in remission. During a period of 8 months, the patients were randomly assigned to 16 sessions of either maintenance CBT or manualized psychoeducation (active control), both in addition to usual care. There were 90 patients in each group. They were followed for 1 year after treatment.

Cox regression analysis showed that time to relapse or recurrence of major depression (the primary outcome) did not differ significantly between the 2 treatments. The median time to relapse or recurrence of major depressive episode from randomization was 607 days for maintenance CBT and 531 days for psychoeducation.
The relapse rate at 1 year was 51% with maintenance CBT (46 of 90 patients) and 60% with psychoeducation (54 of 90 patients).

However, the researchers did see a significant interaction between treatment assignment and number of previous depressive episodes. Maintenance CBT was more effective than psychoeducation in preventing recurrence in patients with 5 or more prior episodes.

In this subgroup, patients who had CBT had a significantly lower relapse rate (50%, 24 of 48 patients) than those who had psychoeducation (73.2%, 30 of 41 patients). The hazard ratio associated with the comparison of CBT with psychoeducation was 0.622 (95% confidence interval, .356 - .850), indicating a 38% reduction in relapse risk for maintenance CBT.

In contrast, there was no significant difference for patients with fewer than 5 episodes in the time to relapse or recurrence of major depressive episode between treatment conditions or in the rate of recurrence at 1-year follow-up.

"This study shows that the 2 treatments, CBT and manualized psychoeducation, are about the same when you look at time to relapse and number of recurrences for patients with fewer episodes of depression. It doesn't mean that CBT is not effective in milder forms of depression, it just means that it's about the same as the psychoeducational approach," said Dr. Turner.

"The fact that the patient is receiving attention from the provider, the fact that the patient is engaging in his or her treatment and doing something proactively to try to manage the depression is oftentimes very useful for mild and more moderate forms of depression," he added.

Dr. Turner also noted that similar results have been seen for psychiatric medication, "where antidepressants work better for those with the most severe form of illness, and that makes a lot of sense. This, to my knowledge, is the first time I've seen a study of this design where its really shown a similar finding for different types of psychotherapy."
The study was supported by German Research Funding grants. Two authors have disclosed relationships with pharmaceutical companies, including AstraZeneca Pharmaceuticals LP, Bristol-Myers Squibb Company, Eli Lilly and Company, Janssen-Cilag, Pfizer Inc, and Lundbeck, Inc. Dr. Stangier and the remaining authors have disclosed no relevant financial relationships. Dr. Turner has disclosed no relevant financial relationships.

Am J Psychiatry. 2013;170:624-632. Abstract


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