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 Name Interested to be at the conference. in mindfulness- Quakers? Although outraged as a child Research

The long-term course of depression Severely depressed treatment risky Relapse prevention POINT OUT, just an example line, and not the best one at that! We would want to avoid this!! For most people, depression symptoms fluctuate over time. Some people will have severe depression over a long period of time, but I think we are all hoping we will be down here, fluctuating between low or no depression symptoms. Bring up the issue of thresholds- is it helpful to have more? My feeling is no, keep it to a minimum. The period after recovery from depression is an important opportunity for intervention: people are often engaged and well, yet at increased risk of depression in the future. We asked- what can be done to intervene and reduce the risk of relapse? Not depressed Less risky Time

You have recovered from depression 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? Coming from a clinical need perspective

We conducted a systematic review and meta-analysis of randomised controlled trials of non-pharmacological interventions tested at the point of recovery. Authors- all come from different perspectives/ Steve- has done a lot of work in rolling out the IAPT program

To gather evidence about non-pharmacological Aim To gather evidence about non-pharmacological interventions to prevent relapses in those who have recovered from depression. What interventions have been tested? How effective were they? Are there any gaps in the evidence? All MBCT trials done by MBCT researchers. All CBT by CBT researchers. This translates to different ways of approaching research methodology and attitudes to relapse too.

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.

Identified 29 relevant trials Identifying trials Sifted 20, 531 records Reviewed 389 full texts Identified 29 relevant trials 22 in meta-analysis Conducted in- USA (n = 12), the UK, (n = 6), the Netherlands (n = 3), Italy (n = 2), Canada, Denmark, Germany, Sweden and Switzerland (all n = 1). 4216 participants in total

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 CBT Cognitive behavioural therapy (CBT) may also work through equipping people with specific skills to reduce their likelihood of relapse. As an acute treatment it aims to modify thoughts and behaviours in a way that alleviates key features of depression, such as identifying and challenging negative automatic thoughts and overcoming avoidance and reduced activity (Beck, 2011). There have been variations of CBT adapted to target relapse prevention, either as a continuation of prior acute treatment or as a standalone intervention. In contrast to MBCT where the delivery of the intervention follows a common format, the duration,mode of delivery (individual, group, self-help), and frequency of CBT has varied. Vittengl, Clark, Dunn, and Jarrett (2007) MBCT groups of 12 to 15 clients + 2 professionals fortnightly sessions over three months MBCT encourages people to process experience without judgement through mindfulness and meditation techniques, helping to change their relationship with troubling thoughts and feelings (Segal, Williams, & Teasdale, 2012) structured, time-limited IPT Interpersonal psychotherapy (IPT) (Klerman & Weissman, 1994) can also be used after recovery with reduced frequency of sessions. The model of delivery and objectives of IPT remain essentially the same as in the acute phase, focussing on strategies to deal with interpersonal and social role problems which are held to be casual in the development and maintenance of depression (Klerman & Weissman, 1994). IPT ‘booster sessions’ may reduce relapse by providing continued support after the period where contact with a psychologist would typically end.

Results Efficacy at 1 year =25% reduction in relapse risk CBT 0.65 [0.50, 0.84] Mindfulness-based cognitive therapy Cognitive/Cognitive-behavioural therapy Maintenance interpersonal psychotherapy Summary plot? 1 line acknowledging ADM data MBCT looks no different- supposed to be a bit different Explore absolute vs. relative risk, they may ask about this MBCT 0.76 [0.65, 0.89] MBCT =24% reduction in relapse risk IPT 0.69 [0.55, 0.86] -We conducted a systematic review and meta-analysis of randomised controlled trials of non-pharmacological interventions tested at the point of recovery. Mindfulness-based cognitive therapy (MBCT) appeared to be effective at reducing relapse rates 1 year after recovery, as did cognitive behavioural therapy (CBT) and continuation interpersonal psychotherapy (IPT). However there seemed to be systematic differences in the way participants were selected and trials were conducted between trials of the different intervention types. IPT =22% reduction in relapse risk

After 2 years CBT MBCT IPT This talk will explore the differences in approaches between 'camps' of researchers, and the difficulties this presents in comparing evidence for a specific clinical need. 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 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 Completely varied!

What factors might impact efficacy? Severely depressed Clinical history Treatment history Current interventions Comorbidities Clinical history, including whether people have fully or partially recovered from a depressive episode, severity of depression and number of previous episodes Treatment history, including prior experience of psychological therapies and duration of antidepressant medication Other interventions being concurrently undertaken (including antidepressant medication) Comorbidities And did these vary systematically between these researchers? However there seemed to be systematic differences in the way participants were selected and trials were conducted between trials of the different intervention types. Not depressed Time

Treatment history of trial participants CBT Medication or CBT or psychotherapy or anything (unspecified) MBCT Medication (and not CBT, or not much) This talk will explore the differences in approaches between 'camps' of researchers, and the difficulties this presents in comparing evidence for a specific clinical need. EXPLORE IPT Successful IPT and medication

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 What gaps in the research need to be addressed?

Review conclusions What interventions have been tested? How effective were they? 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 Review being updated currently by Iffigeneia, doesn’t look like the conclusions will chance. But interesting

Pragmatic design, active control condition MBCT vs. depression relapse active monitoring Participants had 3+ previous episodes MBCT reduced relapse (2 year follow up) Are adjusting trial designs to reflect routine practice Control condition kept people regardless of medication use, stratified for it

Can MBCT help people safely stop medication? Are examining other applications of MBCT Two trials investigating MBCT or MBCT+ ADM. MBCT + ADM looks better She has also done a trial looking at is mADM + MBCT better than just mADM? No- no difference Is it medication that’s really having the effect?

Deconstructing MBCT MBCT vs. CPE (MBCT minus mindfulness) Participants had 3+ previous episodes No advantage of mindfulness (1 year follow up) Are deconstructing the therapy itself to examine what works, why, and for whom Non-specific treatment effect? Is it the CPE that’s really having the effect?

Is MBCT the answer? Severely depressed Not depressed Time Coming back to our original question- Given the current state of evidence- what should you do after recovery from depression to try to protect your future wellbeing? POINT: I think It’s important to challenge assumptions (different researchers designing studies differently) even in trial design, and also to always relate back to the clinical need and application of the research. Not depressed Time

Thank you! Any questions or comments? k.clarke@ucl.ac.uk