1. 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

2. 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

3. 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

4. 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

5. 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.

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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 support
Smoking cessation counselling
Smoking cessation treatment
Treatment as usual X 10
Usual specialty mental health care
Completely varied!

12. 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

13. 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

14. 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?

15. Review conclusions What interventions have been tested?
How effective were they?
Are there any gaps in the evidence?

16. 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

17. 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

18. 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?

19. 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?

20. 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

21. Thank you! Any questions or comments?