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  #1  
Unread November 4th, 2005, 01:39 PM
Gary Schroeder Gary Schroeder is offline
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Question 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.
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  #2  
Unread November 10th, 2005, 10:09 PM
James Pretzer James Pretzer is offline
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Default 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.
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  #3  
Unread December 20th, 2005, 04:47 PM
Vetworker Vetworker is offline
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Default 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.
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  #4  
Unread December 12th, 2005, 08:30 PM
dieter (ClinPsych) dieter (ClinPsych) is offline
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Default 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)
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  #5  
Unread December 13th, 2005, 10:22 AM
James Pretzer James Pretzer is offline
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Default 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.
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  #6  
Unread December 23rd, 2005, 04:36 PM
Neil Levitsky Neil Levitsky is offline
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Default 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
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  #7  
Unread October 27th, 2006, 09:53 PM
James Pretzer James Pretzer is offline
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Default 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.
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  #8  
Unread October 28th, 2006, 06:05 AM
alexandra_k alexandra_k is offline
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Default 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)

Thanks.
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  #9  
Unread January 7th, 2009, 11:11 PM
sk8rgrl23 sk8rgrl23 is offline
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Default Re: Relapse and recurrent major depression

Quote:
Originally Posted by Gary Schroeder View Post
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.
What about the role of eating right and exercise in combatting recurrent depression? Sometimes medicine focuses on the symptoms more than the cause. And I don't think enough recognition is given to the mind-body connection, which works both ways. If you don't feel well physically, you tend to be not in the best mood. And imagine feeling this way on a near-daily basis. How could that not lead to depression if everything feels like an insurmountable chore?

Which is not to say that people who exercise and eat well don't get depression. But if you combine mood enhancing behaviors with CT, the results may a source of natural antidepressants and possibly eliminate the need for medication. Also, if exercise can be something fun rather than a chore, this is time spent doing something construcitive instead of time left open to ruminate about depressing things.

I know this is all outside the CT box, but I truly believe that if clients want to get off meds they need to give diet and exercise a try.
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  #10  
Unread January 8th, 2009, 05:28 PM
James Pretzer James Pretzer is offline
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Default Re: Relapse and recurrent major depression

Whether or not clients want to get off of medication, diet and exercise can be important. Certainly, if an individual is not eating a reasonably balanced diet, getting regular exercise, getting enough sleep, participating in rewarding relationships, and engaging in enjoyable activities, they are at increased risk for a variety of problems. Books on CT often don't emphasize this because authors assume it should be obvious and because it applies to all approaches to therapy, not just CT or CBT. This doesn't mean that CT doesn't address these issues, we address them routinely. For example, see judy Beck's recent books on diet.

Yesterday I had a session with a client complaining of tension, anxiety, and insomnia. He also mentioned drinking 40 oz/day of caffeinated soda. This obviously is something we need to address.
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