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

Centre for Addiction and Mental Health, Toronto, ON, Canada.
Archives of general psychiatry (Impact Factor: 14.48). 12/2010; 67(12):1256-64. DOI: 10.1001/archgenpsychiatry.2010.168
Source: PubMed


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.

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Available from: Glenda Macqueen, Oct 12, 2015
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    • "This decentering capacity is thought to be a core protective mechanism against the increased proliferation and accessibility of negative self-related content, which is known to increase risk for recurrence and chronicity in depression. As such, MBCT has repeatedly been shown to effectively prevent depression relapse (Segal et al., 2010; Teasdale et al., 2000), as extensively reviewed in Dimidjian and Segal (2015) in this special issue. In a novel study that modeled repetitive negative thinking (memory bias recall), Van Vugt, Hitchcock, Shahar, and Britton (2012) found that when individuals with recurrent depression who were in complete or partial remission underwent MBCT, they had more positive and less negative recollection bias for memorized lists of valenced words. "
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    ABSTRACT: There has been a great increase in literature concerned with the effects of a variety of mental training regimes that generally fall within what might be called contemplative practices, and a majority of these studies have focused on mindfulness. Mindfulness meditation practices can be conceptualized as a set of attention-based, regulatory, and self-inquiry training regimes cultivated for various ends, including wellbeing and psychological health. This article examines the construct of mindfulness in psychological research and reviews recent, nonclinical work in this area. Instead of proposing a single definition of mindfulness, we interpret it as a continuum of practices involving states and processes that can be mapped into a multidimensional phenomenological matrix which itself can be expressed in a neurocognitive framework. This phenomenological matrix of mindfulness is presented as a heuristic to guide formulation of next-generation research hypotheses from both cognitive/behavioral and neuroscientific perspectives. In relation to this framework, we review selected findings on mindfulness cultivated through practices in traditional and research settings, and we conclude by identifying significant gaps in the literature and outline new directions for research. (PsycINFO Database Record
    American Psychologist 10/2015; 70(7):632-658. DOI:10.1037/a0039585 · 6.87 Impact Factor
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    • "Without a randomly assigned medication-only condition, we cannot determine whether some women with depression histories can remain off maintenance medications during pregnancy or the postpartum and substitute MBCT (with self-guided meditation practice) to maintain mood stability. A randomized trial of maintenance antidepressants, MBCT, and placebo in remitted depressed patients found that among unstable remitters (i.e., those with periods of symptom exacerbation during remission), antidepressants and MBCT were both associated with lower rates of recurrence than placebo (Segal et al. 2010). A similar study has not been conducted among perinatal women with MDD. "
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    ABSTRACT: The perinatal period is a high-risk time for mood deterioration among women vulnerable to depression. This study examined feasibility, acceptability, and improvement associated with mindfulness-based cognitive therapy (MBCT) in perinatal women with major depressive disorder (MDD) or bipolar spectrum disorder (BSD). Following a diagnostic evaluation, 39 perinatal women with a lifetime history of MDD (n = 27) or BSD (n = 12) enrolled in an 8-week program of MBCT classes (2 h each) that incorporated meditation, yoga, and mood regulation strategies. Participants were pregnant (n = 12), planning pregnancy (n = 11), or up to 1-year postpartum (n = 16). Participants were self-referred and most had subthreshold mood symptoms. Assessments of depression, (hypo)mania, and anxiety were obtained by interview and self-report at baseline, post-treatment and at 1- and 6-month post-treatment. Women with a history of MDD were more likely to complete the classes than women with BSD. Of 32 women who completed the classes, 7 (21.9 %) had a major depressive episode during the 6-month post-treatment follow-up. On average, participants with MDD reported improvements in depression from pre- to post-treatment. Mood improvement was not observed in the BSD group. In the full sample, improvements in depression symptoms across time points were associated with increasing mindful tendency scores. This study was limited by its uncontrolled design, heterogeneous sample, and questionnaire-based assessment of mindfulness skills. MBCT may be an important component of care for perinatal women with histories of major depression. Its applicability to perinatal women with BSD is unclear.
    Cognitive Therapy and Research 10/2015; 39(5). DOI:10.1007/s10608-015-9681-9 · 1.70 Impact Factor
    • "This study is the first RCT using MBCT in chronically depressed patients with an adequate sample size to detect a medium-sized effect. Moreover, although previous studies compared MBCT with pharmacological (Kuyken et al., 2008; Segal et al., 2010) or cognitive psychological education conditions (Williams et al., 2014), the present study is the first to compare MBCT with a gold standard alternative psychotherapeutic approach relying on different mechanisms of change. Whereas the primary focus of MBCT is to facilitate a mindful and compassionate relationship to inner experiences, the primary focus of CBASP is to improve patients' interpersonal functioning. "
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    ABSTRACT: Objective: Mindfulness-based cognitive therapy (MBCT) has recently been proposed as a treatment option for chronic depression. The cognitive behavioral analysis system of psychotherapy (CBASP) is the only approach specifically developed to date for the treatment of chronically depressed patients. The efficacy of MBCT plus treatment-as-usual (TAU), and CBASP (group version) plus TAU, was compared to TAU alone in a prospective, bicenter, randomized controlled trial. Method: One hundred and six patients with a current DSM-IV defined major depressive episode and persistent depressive symptoms for more than 2 years were randomized to TAU only (N = 35), or to TAU with additional 8-week group therapy of either 8 sessions of MBCT (n = 36) or CBASP (n = 35). The primary outcome measure was the Hamilton Depression Rating Scale (24-item HAM-D, Hamilton, 1967) at the end of treatment. Secondary outcome measures were the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996) and measures of social functioning and quality of life. Results: In the overall sample as well as at 1 treatment site, MBCT was no more effective than TAU in reducing depressive symptoms, although it was significantly superior to TAU at the other treatment site. CBASP was significantly more effective than TAU in reducing depressive symptoms in the overall sample and at both treatment sites. Both treatments had only small to medium effects on social functioning and quality of life. Conclusions: Further studies should inquire whether the superiority of CBASP in this trial might be explained by the more active, problem-solving, and interpersonal focus of CBASP. (PsycINFO Database Record
    Journal of Consulting and Clinical Psychology 09/2015; 83(5). DOI:10.1037/ccp0000042 · 4.85 Impact Factor
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