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Gary Schroeder November 4th, 2005 01:39 PM

Relapse and recurrent major depression
I think that for a long time it has been "common knowledge" among mental health professionals that the more episodes of clinical depression a patient has had (I'm talking about unipolar depression here, not bipolar disorder), the more likely it is that they need to take antidepressant medications for the rest of their lives, to prevent relapse.

However, I am aware that in recent years there has been some research (e.g., Hollon, et. al.) showing a lower relapse rate for patients receiving cognitive therapy than for patients taken off medications. I don't know if any such studies have included patients with recurrent major depression, or if the subjects were being treated for their first episode.

My question is, is there a body of research showing that if a patient with RECURRENT major depression succeeds with cognitive therapy, the patient may be able to remain euthymic over time without using antidepressant medications?

The reason I am asking this is that I am a psychologist seeing a patient with recurrent major depressive disorder in individual cognitive psychotherapy, and the patient (who is also being followed on meds by a psychiatrist colleague of mine) asked us if she will need to take the antidepressant medications for the rest of her life.

Thank you very much.

James Pretzer November 10th, 2005 10:09 PM

Re: Relapse and recurrent major depression
It turns out that there are a fair number of studies of CT and related approaches for relapse prevention with recurrent unipolar depression as well as a fair amount of debate. The good news is that CT, Mindfulness-Based CT, and CT designed for relapse prevention each significantly reduce the relapse rate. In fact, it appears that they cut the relapse rate roughly in half.

The bad news is that, despite this, there still is a significant relapse rate (perhaps 35-45%) among people with recurrent depression who've had CT. This is not bad at all compared with a 70-90% relapse rate for clients treated with antidepressants alone. However, we don't have a reliable way to predict who's going to relapse and it is not yet clear whether the relapse-prevention effect of CT fades over time or not.

This presents a problem for the clinician and client. Does the patient need to stay on medication preventively once they've overcome their depression or not?

This is not an easy question to answer. We can find out if they need to stay on medication in order to maintain their improvement simply by tapering off the medication (with their psychiatrist's consent) and monitoring their mood. If their depression returns and persists despite our efforts, we have discovered that the client needs to remain on medication in order to maintain their improvement. If their depression does not return, we have discovered that they do not need medication at the moment but we do not know if remaining on medication will help prevent relapse.

Some clients prefer to "play it safe" by remaining on medication in the hopes that it will reduce the risk of relapse. Others prefer to take medication only if it is clearly necessary and want to see how they do without medication. Both approaches seem reasonable and my current approach is to discuss the pros and cons of remaining on medication with the client and have them also discuss this issue with their psychiatrist before deciding what to do. We also explicitly discuss what they need to do in order to maintain their gains, identify high-risk situations and plan how to cope with them, and identify early warning signs of impending depression.

It appears that, after successfully completing CT, a majority of clients with recurrent depression can go for several years without relapsing but that a significant minority will relapse within a few years. It is clear that clients who receive CT alone have a lower relapse rate than those who receive medication alone. It is not clear if remaining on medication significantly reduces the relapse rate for clients who have received combined treatment (most of the studies have compared CT with meds without looking at combined treatment).

One approach to preventing relapse with recurrent depression is to use maintenance CT (i.e. to continue meeting with the client periodically to monitor mood, to address any problems that arise, and to intervene promptly if depression reoccurs. The one study I found on maintenance CT (Blackburn & Moore, British Journal of Psychiatry, 1997, 328-334) found that it worked at least as well as maintenance antidepressants.

dieter (ClinPsych) December 12th, 2005 08:30 PM

Re: Relapse and recurrent major depression
I would look into Mindfulness Based Cognitive Therapy (MBCT) which seems promising for exactly this type of client/problem (recurring depression) :)

James Pretzer December 13th, 2005 10:22 AM

Re: Relapse and recurrent major depression
A number of recent studies relevant to MBCT can be found in the thread "New Developments re Mindfulness in CT." MBCT seems to have considerable potential for relapse prevention in individuals who have a history of three or more previous depressions and who currently are in remission.

Vetworker December 20th, 2005 04:47 PM

Re: Relapse and recurrent major depression
I have used maintenance CT or "booster sessions" for several years now. This has proven, at least in my experience, to be a useful intervention in the prevention of depressive relapse. I have followed patients out to 24 months post treatment and have only had some 15-25% reporting significant return of depressive symptoms. Of course I am working with a very small sample and not at all randomly selected. I am just reporting what I have seen in practice. Only 3 of those thirty individuals that I have followed have remained on antidepressants all the others discontinuted medications within three months. One individual out of the three that elected to keep taking meds had a relapse.

Neil Levitsky December 23rd, 2005 04:36 PM

Re: Relapse and recurrent major depression
Definately an important and interesting question - just thought I'd chime in my two cents worth.

I often get asked by patients how long they need to stay on meds. I generally consider a number of factors to guide me, ultimately to decide how vulnerable or at risk the individual is. I certainly look at the number and length and severity of episodes, and whether they were associated with strong suicidal ideation. If someone has made a significant suicide attempt, I think they should stay on antidepressants indefinately, given how high the risk is of eventual completed suicide among people with a history of attempting. 3 or more significant episodes of major depression, and I'll generally recommend indefinate continuation of meds. I consider other risk factors, for example whether they have a problematic marriage, an unstable or stressful job, substance abuse,poor self esteem, a personality disorder (or traits of one), etc. Also, I think about how they did with their course of CBT - did they really learn how and when to use thought records, etc, and did they make progress in shifting underlying assumptions and core beliefs?

I agree that for some people the MBCT program is a great option. I often refer patients to it, since Zindel Segal, one of the originators of it, is here in Toronto.

I like to draw a circle for patients, write inside "risk of relapse", and then write as many things as possible that might contribute, for them. That way, I'm considering each individual's risk factors, and I'm getting their input. Often the list will include getting regular exercise, proper sleep, balance of work and play, meds and self esteem. Other factors might depend on the person, for example if financial struggles often lead a given individual into depressions, their relapse prevention work might need to focus on obtaining stable employment, paying off debt and curbing impulse spending. Someone else, who for example tends to get used and taken advantage of, might need to work mostly on assertiveness and self esteem. One woman I worked with needed to focus more, when she wasn't depressed, on setting limits with her husband and kids, and organizing her day better so as to not feel frazzled and overwhelmed too often. Another patient, for whom substance abuse played a big role in his depressions, needed to have a strong set of tools in place to prevent drinking.

I think it is a complex question, without a black/white answer - like most things :)

James Pretzer October 27th, 2006 09:53 PM

CT to prevent relapse with recurrent major depression
Bockting, et al (2005) recruited 187 individuals with a history of recurrent major depression who were currently in remission then randomly assigned them to either treatment as usual (which ranged from on-going meds or counseling to no treatment) or treatment as usual plus 8 weekly sessions of group Cognitive Therapy. The presence of relapse was assessed at 3, 12, and 24 months.

The protective effect of CT was strongest in the high-risk group (5 or more previous episodes). For the high risk group, CT reduced the rate of relapse over a two-year period from 72% for the treatment as usual group to 46% for treatment as usual plus CT. CT also had a protective effect for participants with fewer than 5 previous episodes but it was smaller in magnitude.

Bockting, C. L. H., Svhene, A. H., Spinhoven, P., Koeter, M. W. J., Wouters, L. F., Huyser, J., & Kampuis, J. H. (2005). Preventing relapse/recurrence in recurrent depression with cognitive therapy: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 73,647-657.

alexandra_k October 28th, 2006 06:05 AM

Re: Relapse and recurrent major depression
What was 'treatment as usual' in the control group for the study, do you remember?

I have heard that it is 'common knowledge' that staying in anti-d's helps prevent an episode...

But I had also heard that that that had not been supported empirically (I didn't think the studies had been done)

I'd be keen to see studies where taking anti-d's actually prevented relapses (compared to people not taking anti-d's and matched for other kinds of intervention / support)


James Pretzer October 28th, 2006 09:47 PM

Re: Relapse and recurrent major depression
The "treatment as usual" control group was indeed treatment as usual which meant that some study participants were in on-going therapy and some weren't, some were on maintainence medication and some weren't, some were getting no treatment at all since they were in remission.

On your second question, I believe that there has been some research one the effectiveness of maintainence medication for preventing relapse in depression but I don't remember the details. I'll see if I can find it.

alexandra_k October 28th, 2006 10:08 PM

Re: Relapse and recurrent major depression

I guess that with the study you mentioned I'm concerned that if the experimental group and the control group weren't matched for other factors that could be relevant to prevent relapse (such as social support, therapy, time spent with a p-doc, a p-doc who had faith that the medication / placebo would make a significant difference etc) then the differences that were found could have been due to differences in those factors rather than differences in whether the person was taking medication or not.

Of course this may have been controlled for (I haven't read the study). It is just that I'm especially wary of studies that are done on medications because of the significant investment that drug companies have in sponsoring the studies (and that researchers have in finding favourable outcomes for the drug companies with respect to future funding opportunities).

Of course it is wise to think critically about experimental findings more generally... But I'm especially sceptical about ones involving pharmacuticals...

If there isn't empirical evidence that taking medication prevents relapse then there wouldn't seem to be a problem with stating this to the client. Many people find that they have nasty side effects of taking medication. Therapy would seem to have less nasty side effects and hence if the studies haven't been done on whether anti-depressants (all or some of them?) can help prevent relapse then it would seem to me that therapy would be a better option. I could be wrong... But I thought the studies had been done on cognitive behaviour therapy and it was found that people who attended a course of CBT were less likely to relapse compared to a control group who had not attended a course of CBT. Though I don't know that the groups were matched for medication and for social supports more generally...

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