Preventing relapse after
depression: is MBCT the
answer?
Katherine Clarke, supervised by Professor Stephen Pilling
Centre for Outcomes and Research Effectiveness (CORE)
Clinical, Educational and Health Psychology
The long-term course of depression
Severely
depressed
treatment
risky
Relapse prevention
Not
depressed
Less risky
Time
You have recovered from depression.
You know you might relapse in the future, and want
to do something to reduce this risk.
What are your options? Medication, but what else?
Aim
To gather evidence about non-pharmacological
interventions to prevent relapses in those who
have recovered from depression.
1. What interventions have been tested?
2. How effective were they?
3. Are there any gaps in the evidence?
Methods
Systematic review and meta-analysis
Searched databases for trials where adults in full or
partial remission from depression were randomised
to either
• A non-pharmacological intervention,
• Any comparator condition,
• And were followed up for a minimum of 1 year
after randomisation.
Identifying trials
Sifted 20, 531 records
Reviewed 389 full
texts
Identified 29
relevant
trials
22 in
metaanalysis
What interventions had been tested?
29 relevant trials- 10 trials tested CBT, 7 MBCT, 4
IPT, 4 care programs and 4 others.
CBT= Cognitive Behavioural Therapy
• structured, time-limited, varied delivery
MBCT= Mindfulness-Based Cognitive Therapy
• structured, time-limited, consistent delivery
IPT= Interpersonal Psychotherapy
• monthly throughout follow-up
Efficacy at 1 year
CBT
CBT
•
•
•
•
•
•
•
0.65 [0.50, 0.84]
Results
=25%
reduction
in relapse risk
Mindfulness-based cognitive therapy
MBCT
Cognitive/Cognitive-behavioural therapy
Maintenance interpersonal psychotherapy
0.76 [0.65, 0.89]
Summary plot?
=24% reduction
1MBCT
line acknowledging ADM data
in relapse risk
IPT
MBCT looks no different- supposed to be a bit different
Explore absolute vs. relative risk, they may ask about this
0.69 [0.55, 0.86]
IPT
=22% reduction
in relapse risk
After 2 years
CBT
MBCT
IPT
What were the comparisons?
Antidepressant medication
Assessment only
Clinical management
Clinical management + ADM/discontinuing ADM/placebo X 4
Cognitive psychological education + TAU
Evaluation only X 2
Completely
Maintenance ADM
Manualized psychoeducation
Medication clinic (+ antidepressant medication/placebo) X 4
Minimal contact (+ amitriptyline/placebo/no drug)
None
Non-specific email support
Smoking cessation counselling
Smoking cessation treatment
Treatment as usual X 10
Usual specialty mental health care
varied!
What factors might impact efficacy?
Severely
depressed
• Clinical history
• Treatment history
• Current interventions
• Comorbidities
Not
depressed
Time
Treatment history of trial participants
Medication or CBT or psychotherapy or
anything (unspecified)
Medication (and not CBT, or not much)
Successful IPT and medication
CBT
MBCT
IPT
What hasn’t been tested?
• Guided self-help
• Unsupported work: e.g. exercise, positive
psychology, social support, self-help books,
having your own mindfulness practice ?
• Low-intensity or unsupported work may be well
suited to a ‘recovered’ population
Review conclusions
1. What interventions have been tested?
2. How effective were they?
3. Are there any gaps in the evidence?
Interesting MBCT work at the moment
• Are adjusting trial designs to reflect routine
practice
• Are examining other applications of MBCT
• Are deconstructing the therapy itself to
Pragmatic design, active control condition
• MBCT vs. depression relapse active monitoring
• Participants had 3+ previous episodes
• MBCT reduced relapse (2 year follow up)
Can MBCT help people safely stop medication?
Deconstructing MBCT
• MBCT vs. CPE (MBCT minus mindfulness)
• Participants had 3+ previous episodes
• No advantage of mindfulness (1 year follow up)
Is MBCT the answer?
Severely
depressed
Not
depressed
Time
Thank you!
Any questions or comments?
[email protected]