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Preventive Cognitive Therapy Reduces Depressive Relapse or Recurrence

April 16, 2018

By Will Boggs MD

NEW YORK—Preventive cognitive therapy (PCT) is effective in reducing relapse and recurrence rates in patients with major depressive disorder, according to a new trial.

"Patients suffering from recurrent depression that use antidepressants after remission have a risk reduction of 40% over 2 years with PCT, as compared to antidepressants alone," said Dr. Claudi L. H. Bockting from Academic Medical Center, University of Amsterdam, in the Netherlands.

"It was a surprise that the relapse risk can be further reduced by adding PCT," she told Reuters Health by email.

In an earlier trial, Dr. Bockting and colleagues found that adding PCT to treatment as usual reduced the risk of recurrence over the following decade in individuals with more than three previous major depressive episodes.

In the current trial - a single-blind, multicenter study called Disrupt the Rhythm of Depression (DRD) - the team investigated whether staying on maintenance antidepressant treatment offers better protection against recurrence than does receiving PCT while tapering off antidepressants, and whether adding PCT to antidepressants enhances protection against recurrence.

Among the 289 participants with recurrent major depressive disorder who were in remission or recovery and on antidepressants, 104 were randomly assigned to PCT and antidepressants, 85 were assigned to PCT while tapering off antidepressants and 100 were assigned to antidepressants alone.

After two years of follow-up, cumulative recurrence rates were 60.0% for the antidepressants-alone group, 63.3% for the PCT with tapering of antidepressants group and 42.6% for the PCT and antidepressants group, the researchers report in The Lancet Psychiatry, online April 3.

In Cox regression analyses, the recurrence risk was 41% lower in the PCT and antidepressants group than in the antidepressants-alone group, and it was 46% lower with the combined treatment than with PCT while tapering off antidepressants. Both risk reductions were statistically significant.

Antidepressants alone were not superior to PCT with tapering of antidepressants.

Among patients with more than one recurrence of major depressive disorder, the number of recurrences was 37% lower in the PCT-and-antidepressants group than in the antidepressants-alone group. But there was no significant difference in the number or severity of recurrences between the group that received antidepressants alone and the group that received PCT while being tapered off antidepressants.

"PCT should be considered after remission of recurrent depression in patients that plan to continue antidepressants," Dr. Bockting said. "PCT should be recommended to patients that wish to taper antidepressants after remission, in combination with guidance of tapering antidepressants for 4 to 5 months by a doctor." "PCT should also be recommended to recurrently depressed patients that remitted with other types of treatment or without treatment," she said.

Dr. Giovanna A. Fava from the University of Bologna, Italy, and State University of New York at Buffalo, who wrote a linked editorial, told Reuters Health by email, "The study indicates, confirming previous findings, that the sequential model of treatment (pharmacotherapy followed by psychotherapy) is associated with benefits in terms of relapse rate compared to the standard treatment (antidepressant drug maintenance). This suggests that there is life after antidepressants."

"Currently the prescribing physician is driven by an overestimated consideration of potential benefits of long-term treatment of antidepressant drugs and neglect of potential vulnerability to the adverse effects," she said. "We need to shorten the exposure of the patients to antidepressant drugs and to integrate psychotherapy in the treatment package."

Dr. Robin B. Jarrett from The University of Texas Southwestern Medical Center, in Dallas, has researched factors contributing to the selection of antidepressants or cognitive therapy for recurrent major depressive disorder. She told Reuters Health by email, "Antidepressant medications can prevent relapse and recurrence, but only when patients take them. Often adults discontinue antidepressant medications."

"Many patients state they prefer to receive psychotherapy instead of consuming antidepressant medication," said Dr. Jarrett, who was not involved in the new work. "Cognitive behavioral therapy is another preventive option that physicians and patients can consider to maintain remission and recovery."

"Health systems will need to consider results such as these to provide comprehensive evidenced-based care which respects patient preferences and meets patient needs for continued health," she added.

Dr. Bockting will present these results at the American Psychiatric Association annual meeting in New York City in May.


Lancet Psychiatry 2018.

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