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Preventing Recurrent Depression Using Cognitive Therapy With and Without a Continuation Phase
A Randomized Clinical Trial
Robin B. Jarrett, PhD;
Dolores Kraft, PhD;
Jeanette Doyle, MA;
Barbara M. Foster, PhD;
G. Greg Eaves, PhD;
Paul C. Silver, PhD
Arch Gen Psychiatry. 2001;58:381-388.
ABSTRACT
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Background Cognitive therapy (CT) may reduce depressive relapse and recurrence
when patients learn and use the associated skills. Reported relapse and recurrence
rates after CT discontinuation vary widely. The factors that determine when
CT is preventive remain unidentified. We developed continuation-phase CT (C-CT)
to teach responders skills to prevent relapse. This is the first randomized
trial comparing CT with and without a continuation phase in responders to
CT who were vulnerable, given their history of recurrent unipolar depression.
Methods Patients aged 18 to 65 years (n = 156) with recurrent DSM-IV major depressive disorder (MDD) entered 20 sessions of acute-phase
CT (A-CT). Unmedicated responders (ie, no MDD and 17-item Hamilton Rating
Scale for Depression score  9; n = 84) were randomized to either 8 months
(10 sessions) of C-CT or control (evaluation without CT). Follow-up lasted
an additional 16 months. A clinician blind to assignment evaluated relapse
and recurrence (ie, DSM-IV MDD).
Results Over an 8-month period, C-CT significantly reduced relapse estimates
more than control (10% vs 31%). Over 24 months, including the CT-free follow-up,
age of onset and quality of remission during the late phase of A-CT each interacted
with condition assignment to influence durability of effects. In patients
with early-onset MDD, C-CT significantly reduced relapse and recurrence estimates
(16% vs 67% in control). When patients had unstable remission during late
A-CT, C-CT significantly reduced relapse and recurrence estimates to 37% (vs
62% in control).
Conclusions Findings suggest that 8 months of C-CT significantly reduces relapse
and recurrence in the highest-risk patients with recurrent MDD. Risk factors
influenced the necessity for C-CT.
INTRODUCTION
PATIENTS WHO have recovered from recurrent major depressive disorder
(MDD) face an 80% rate of recurrence in the absence of prophylactic treatment.1 To reduce risk, psychopharmacologists prescribe continuation-phase
antidepressant medication to prevent relapse (ie, the index episode continued)
and maintenance-phase medication to prevent recurrence (ie, a new episode
distinct from the index episode). In contrast, continued preventive therapy
is not routine practice after response to the acute phase of depression-specific
psychosocial interventions.
Prevention in the absence of ongoing treatment would distinguish cognitive
therapy (CT) from pharmacotherapy. Acute-phase CT (A-CT) could reduce the
likelihood of relapse and recurrence even after it is discontinued,2 perhaps because patients learn and continue to use
effective tools of symptom reduction. For example, prevention may follow discontinued
therapy if the patient has developed a constructive thinking pattern and/or
activates skills that reduce symptoms effectively.
Estimates of relapse and recurrence after A-CT lasting approximately
16 to 20 weeks have been as high as 74% and as low as 21% over 2 years.3, 4 The extent of and conditions affecting
reliable and effective prevention remain unidentified.
The durability of gains achieved with various types, rates, and phases
of psychosocial interventions for depression is not well established. Only
a few studies have evaluated the longer-term effects of discontinued A-CT,3, 4, 5, 6, 7
discontinued interpersonal psychotherapy,8
or either treatment in its continuation or maintenance phase.1, 3, 9, 10, 11
Study designs have consisted of acute-phase treatments identical to the continuation-phase
treatment3, 10, 11
or different from the continuation and maintenance phases.1, 9, 11, 12, 13, 14
We have focused on evaluating relapse and recurrence rates in patients
who respond to 3 to 4 months of CT. We reported high rates of relapse and
recurrence over a 2-year follow-up.3 After
discontinuing CT, relapse and recurrence rates were 45% over 8 months, 50%
over 1 year, and 74% over 2 years. These data motivated us to develop and
test continuation-phase CT (C-CT)15 in a second
cohort of patients who responded to A-CT. The cohort receiving C-CT had reduced
relapse rates of 20% after 8 months of A-CT, 27% after 1 year, and 36% after
2 years.3 Since the patients were not randomized,
the results were inconclusive, which prompted us to design the current trial.
To our knowledge, this is the first randomized clinical trial to compare
CT with and without a continuation phase in CT responders who had presented
with recurrent MDD. The hypothesis was that C-CT provided for 8 months would
reduce relapse rates significantly more than the control (assessment only).
Secondary aims included examining effects for 2 years to evaluate the durability
of A-CT and C-CT and to identify predictors of both relapse and recurrence.
PATIENTS AND METHODS
PATIENTS
The recruitment and protocol were approved by the institutional review
board. Patients (n>3500; recruited through media, announcements, and referrals)
were triaged by telephone. If potentially eligible, patients were scheduled
for evaluation (n>1200).
Outpatients (n = 608) presented for evaluation at the Department of
Psychiatry at The University of Texas Southwestern Medical Center at Dallas
with the complaint of depression. Inclusion criteria involved the following:
(1) DSM-IV16 nonpsychotic
unipolar MDD; (2) recurrent MDD with clear interepisode recovery (ie, 2 or
more episodes of MDD separated by at least 2 months of a return to more-or-less
normal functioning); (3) 17-item Hamilton Rating Scale for Depression17 (HRSD-17) score of 16 or higher at initial diagnostic
evaluation and at a follow-up; and (4) written informed consent.
Trained evaluators, using the Structured Clinical Interview for DSM-III-R (SCID outpatient version)18
and strictly applying DSM-III-R19
and DSM-IV criteria for MDD and other disorders,
referred 361 patients (59%) for nonprotocol treatment. Exclusion criteria
were (1) did not meet criteria for MDD (n = 91); (2) MDD not recurrent (n
= 116); (3) HRSD-17 score less than 16 (n = 66); (4) contraindicated medical
condition or medication (n = 28); (5) exclusionary comorbid psychiatric disorder
(MDD with psychotic features, n = 2; current alcohol or other drug abuse,
n = 9; primary sleep, eating, or sexual disorders, n = 1 each; and borderline
personality disorder, n = 7); (5) imminent suicide risk at triage (n = 2);
or (6) inability to comply with the protocol (n = 24). Thirteen patients were
lost to follow-up after the initial clinic contact and were mailed referrals.
The remaining 247 patients completed the SCID and supplemental questions
to allow evaluation of DSM-IV diagnoses, entry criteria,
and the characteristics described in Table 1.
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Pretreatment Demographic and Clinical Characteristics of Outpatients
With Recurrent Major Depressive Disorder*
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A faculty-level diagnostician reassessed eligibility criteria at a follow-up
interview. Fifty patients were excluded because they (1) did not meet criteria
for MDD (n = 13); (2) had nonrecurrent MDD (n = 12); (3) had a concurrent
medical disorder or received treatment that might cause depressive symptoms
(n = 11); or (4) had comorbid exclusionary psychiatric disorders (MDD with
psychotic features, n = 7; delusional disorder, n = 1; current alcohol or
other drug abuse, n = 6). An additional 36 patients were excluded because
they (1) had an HRSD-17 score less than 16 at follow-up (n = 16); (2) had
primary panic disorder with agoraphobia (n = 1); (3) had primary bulimia nervosa
(n = 1); (4) had borderline personality disorder (n = 6); (5) could not complete
questionnaires or comply with the protocol (n = 10); or (6) preferred alternative
treatment (n = 2).
A total of 161 patients were eligible for the study and 5 refused consent;
thus, 156 patients consented to enter A-CT.
STUDY PROCEDURES
Pharmacotherapy was not a study procedure. From entry through follow-up,
patients agreed to postpone or report the use of psychotropic medication,
nonprotocol psychotherapy, or other psychiatric or psychosocial treatment.
Acute-Phase Cognitive Therapy
Acute-phase cognitive therapy was conducted as described by Beck et
al,2 within a 12- to 14-week protocol (twenty
50- to 60-minute individual sessions held twice weekly for the first 8 weeks
and once weekly for the last 4 weeks). The therapists completed clinician
rating scales. Strategies were focused on symptom reduction but could include
relapse prevention.
Five experienced therapists provided CT. Each had completed 1 or more
years of CT training, achieving and maintaining Cognitive Therapy Scale24 (CTS) scores of 40 or more before treating any study
patients.
An off-site consultant (see the acknowledgments at the end of the article)
used the CTS to evaluate competence and provide feedback. Therapists received
weekly group supervision.
Randomization to the Experimental Phase
Only responders (no MDD and HRSD-17 score of 9 or less by a blind evaluator)
who completed 20 sessions of A-CT and consented to randomization to either
C-CT or evaluation only (control) entered the 8-month experimental phase.
Responders were randomized using PROC PLAN in SAS statistical software, version
6.04 (SAS Institute Inc, Cary, NC) by strata that included the following:
(1) number of episodes (ie, 2 vs  3); (2) HRSD-17 score less than 6 and
6 to 9 based on the blind evaluator's score collected within 7 days of session
20; and (3) double depression (presence or absence of DSM-IV dysthymia before onset of the presenting episode). Research personnel
and patients concealed assignment from blind evaluators.
In both conditions, patients agreed to remain unmedicated and were scheduled
for 10 sessions that occurred biweekly for the first 2 months and monthly
for the remaining 6 months. The clinician collected self-report questionnaires,
assessed diagnostic status according to DSM-IV MDD,
recorded any medication use, and completed rating scales. Regardless of diagnostic
status, all patients proceeded with C-CT or evaluation until consent was withdrawn
or through month 8. All patients were instructed to telephone the evaluator
if they became symptomatic between visits. When patients experienced relapse
or recurrence, they were referred for additional treatment (eg, pharmacotherapy).
Continuation-Phase Cognitive Therapy
The same therapist provided A-CT and 10 sessions of C-CT as described
by Jarrett (unpublished manual available on request) and elaborated by Jarrett
and Kraft.15 Patients were taught to use emotional
distress or symptoms to trigger coping skills learned in A-CT. The purpose
of C-CT is to prevent relapse and recurrence, review strategies associated
with effective symptom reduction, maintain skills acquired during A-CT, and
develop coping strategies in preparation for identified or anticipated vulnerabilities.
Whereas A-CT emphasized reducing symptoms and acquiring skills, C-CT emphasized
preventing relapse and recurrence, reducing residual symptoms, and generalizing
skills.
Most sessions lasted 60 minutes, although 90 minutes was allowable.
Patients received no monetary incentives.
Evaluation Only (Control)
An evaluator who had not provided A-CT conducted 10 assessment visits
scheduled at the same frequency as C-CT for 8 months. Prescribed control procedures
prohibited the use of CT or other psychosocial interventions before relapse.
When patients described psychosocial problems, the evaluator did not intervene.
Self-reports and clinician ratings were collected. Sessions lasted approximately
20 to 30 minutes, and patients were paid $25 for each visit.
Longitudinal Follow-up Phase
All consenting patients attended follow-up assessments for 16 months
or until they withdrew consent. When clinic assessments were not feasible,
evaluations were conducted by telephone. An evaluator followed up the patient
monthly for the first 4 months and bimonthly for the remaining 12 months.
Procedures were identical to the control cell.
OUTCOME MEASURES
The primary dependent variables were the proportion of DSM-IV diagnoses of MDD (ie, relapse or recurrence) as specified by
an evaluator who was blind to cell assignment and used the Longitudinal Interval
Follow-up Evaluation25 (LIFE). Blind evaluations
were conducted at (1) the end of A-CT; (2) any time the patient, therapist,
or follow-up evaluators suspected relapse or recurrence; (3) early exit; (4)
months 4 and 8 of the experimental phase; and (5) months 12 and 24 of follow-up.
Assessment for months 13 to 20 was conducted by unblinded evaluators because
of the high cost of blind evaluations. If relapse or recurrence was suspected,
a blind evaluation occurred.
The following definitions were used to conceptualize and define change
points in the course of unipolar MDD.26
Response, the extent of patient response to
A-CT, was defined by the blind evaluator within 7 days after session 20 as
(1) absence of DSM-IV MDD and (2) an HRSD-17 score
of 9 or less. Remission, when the patient is no longer
fully symptomatic, was defined by a diagnostician (ie, therapist, blind evaluator,
or other clinic evaluator) specifying for 6 consecutive weeks that (1) DSM-IV criteria for MDD were not met and (2) HRSD-17 score
was 6 or less (during the acute phase) or the LIFE Psychiatric Rating Scale
(PSR) rating was 1 or 2 (during experimental and follow-up phases). Recovery, the end of an episode, was defined as any project
diagnostician declaring for 8 consecutive months that (1) DSM-IV criteria for MDD were not met and (2) HRSD-17 score was 6 or
less (during the acute phase) and/or the LIFE PSR rating was 1 or 2 (during
experimental and follow-up phases). Relapse, a continuation
of the presenting episode, was defined by the blind evaluator as symptoms
meeting DSM-IV criteria for MDD (ie, LIFE PSR score
of 5 or 6 for 2 weeks) before the criteria for recovery were met. Recurrence, the emergence of a new episode distinct from the presenting
episode, was defined by the blind evaluator as meeting DSM-IV criteria for MDD after the criteria for recovery were met.
STATISTICAL ANALYSES
The hypothesized relapse rates over the 8-month experiment were 47%
for control and 19% for C-CT based on early analyses of previous samples.3 A minimum sample size of 72 was necessary to detect
a significant difference.27 Recurrence estimates
were reported as secondary measures during the 24-month follow-up.
All analyses were of an intention-to-treat strategy (N = 84; n for C-CT
= 41; n for controls = 43). The end point in all the survival analyses was
either relapse or recurrence. Patients who dropped out or survived were censored.
Survival curves and relapse and recurrence rates were estimated using Kaplan-Meier
product-limit methods.28 The survival rates
for the 2 cells were compared using the log-rank test.29
The Cox proportional hazard regression was used to evaluate the influence
of each candidate covariate (age of onset, age, sex, number of episodes, length
of current episode, comorbid lifetime diagnoses, and definite Research Diagnostic
Criteria21 endogenous diagnosis) as described
by Collett.30 Covariates were compared with
the null model to determine their influence on relapse over 8 months or on
relapse and recurrence over 24 months without regard to condition assignment.
Categorical variables were reported as percent frequency (eg, number
and percentage) and continuous variables as mean and SE. Significance was
defined as P.05; Fisher exact tests (FETs) were
2-tailed.
RESULTS
SAMPLE CHARACTERISTICS
Figure 1 enumerates the sample
composition. Eligible outpatients (n = 156) with recurrent MDD and clear interepisode
recovery entered A-CT. Eligible responders (n = 84) consented to randomization.
The demographic and clinical characteristics of responders randomized to the
2 cells, and tests of differences are reported in Table 1.
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Figure 1. Flow diagram for patients through
all study phases, including attrition. Subjects (n = 156) were registered
in the study on consenting to acute-phase cognitive therapy (A-CT). Eligible
responders were randomized to the clinical trial (N = 84). C-CT indicates
continuation-phase CT.
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PATIENT DISPOSITION
Of the 156 patients who entered A-CT, 130 (83%) completed 20 sessions
(2 patients became psychotic or homicidal and were withdrawn; 24 dropped out).
Of these 130 patients, 128 (98%) consented to the first blind evaluation.
Of these 128, 87 (68%) were judged to have responded to A-CT. Eighty-four
(97% of those eligible) consented to randomization (1 patient refused to discontinue
treatment with the A-CT therapist, 1 sought alternative treatment, and 1 had
scheduling conflicts).
Seventy-six (90%) of the 84 randomized patients completed 10 sessions
of the 8-month experiment or had a relapse or recurrence. When dropouts (n
= 8) were compared with completers (ie, had 10 sessions or had a relapse or
a recurrence; n = 76), 2 significant differences emerged. Dropouts had fewer
previous episodes of depression (|t| 15.5 = 4.03, P = .001) and more had double depression (FET, P = .04). There was no significant difference in the number of patients
who completed C-CT (95%; 39 of 41) compared with controls (86%; 37 of 43;
FET, P = .28). One patient dropped out of C-CT because
of a scheduling conflict and 1 failed to attend the first session. The 6 patients
who dropped out of the control cell reported that the study was taking too
much time.
Sixty responders survived the experiment and entered follow-up. Of these,
92% (n = 55) completed 16 months of follow-up or experienced a relapse or
recurrence. The percentage of patients completing follow-up in the 2 cells
did not differ significantly (C-CT = 86%, 30 of 35; control = 100%, 25 of
25; FET, P = .08).
PATIENT COMPLIANCE
When relapse status was disregarded, the Wilcoxon rank test showed that
neither the number of sessions (z = 1.8, P = .07) nor the number of months (z = 0.43, P = .67) differed in the 2 conditions. The 41 responders
randomized to C-CT completed an average of 9.49 ± 0.30 (mean ±
SE; mode = 10) sessions during an average of 7.26 ± 0.25 months (mode
= 7.66). The 43 responders randomized to the control cell completed an average
of 9.05 ± 0.29 sessions (mode = 10) during an average of 7.03 ±
0.26 months (mode = 7.59).
At randomization, all patients planned to defer psychiatric treatment
until they experienced a relapse or recurrence or the study ended. Only 10
patients reported seeking psychiatric "treatment" lasting 2 or more weeks
before relapse or recurrence. During the experimental phase, 2 patients reported
"treatment": 1 C-CT patient took methylphenidate hydrochloride (Ritalin) for
8 weeks and 1 control patient had 4 sessions of "peer support" for grief.
None reported depressive symptoms (ie, PSR score 4) 4 weeks before or
during the interval in which they received treatment.
During the follow-up phase and before relapse or recurrence, 8 patients
(4 in C-CT and 4 in control) reported "treatment" for 2 or more weeks. One
patient from C-CT who reported depressive symptoms also received 4 sessions
of psychotherapy. The following treatment occurred during intervals in which
the patients did not report depressive symptoms (ie, PSR score 4): 1 C-CT
patient sought marital therapy with the cognitive therapist during longitudinal
follow-up (36 sessions); 1 C-CT patient attended 2 sessions in a "women's
employment support group"; 2 patients (1 C-CT and 1 control) received 2 to
3 psychotherapy or family therapy sessions; 1 control patient had 19 sessions
of marital therapy; 1 control patient took 5 conflict resolution classes with
his partner; and 1 control patient reported taking melatonin for 3 weeks.
THERAPIST COMPETENCE
Of 210 total CTS ratings during A-CT, only 18 scores (8.6%) fell below
40. The mean A-CT CTS score was 47.10 ± 0.35 (mode = 52) with all therapists
achieving mean scores of more than 40 (when CTS ratings included more than
1 A-CT session from the same patient, a mean was calculated and used in the
analysis). Although an analysis of variance (ANOVA) showed statistically significant
differences in therapists' scores (F4 = 4.51, P = .002), the mean score for each therapist was more than 46. The
ANOVA produced nonsignificant effects across years (F3 = 1.98, P = .12). A Cox regression indicated no relation between
therapist's mean A-CT CTS score and patient's relapse status ( 21 = .09, P = .77).
Of 40 total CTS ratings during C-CT, only 6 scores (15%) were below
40. The mean C-CT CTS score was 46.3 ± 1.17 (mode = 46) with all therapists
achieving mean scores of more than 40. The ANOVAs showed no statistically
significant differences in mean CTS scores across therapists (F4
= 1.21, P = .32) or across years (F3 =
2.56, P = .07).
The primary aim of the trial was to test the hypothesis that C-CT reduced
relapse more than control (ie, assessment only) during the 8 months in which
C-CT was provided. Patients who did not relapse or drop out during the 8 months
were censored after 8 months. A log-rank test showed that during the 8 months
of C-CT, it reduced the proportion of relapse significantly more than the
control (relapse estimate: 10.3% vs 30.9%; 21 =
5.26, P = .02; Figure
2).
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Figure 2. Kaplan-Meier survival curves estimating
time until relapse (DSM-IV major depressive disorder diagnosed
by blind evaluation) during the 8-month (35-week) experiment. A log-rank test
showed that continuation-phase cognitive therapy (C-CT) reduced the proportion
of relapse significantly more than control (CT-free evaluation) (21 = 5.26, P = .02). Estimated relapse was 10%
for C-CT patients and 31% for controls (n = 41 and n = 43, respectively).
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SECONDARY ANALYSES
Both age of onset and patient age were identified as potential covariates
(P = .10) by influencing relapse over 8 months (age, 21 = 3.17, P = .09; age of onset, 21 = 9.32, P = .002) and relapse
or recurrence over 24 months (age, 21 = 6.43, P = .01; age of onset, 21 =
4.40, P = .04). The correlation between age and age
of onset for the randomized sample (n = 84) was 0.5 (P<.001).
Age of onset was used as the covariate because previous studies show that
it predicted relapse and recurrence.31, 32
A comparison of Akaike Information Criteria30
verified that age of onset by itself was as good a predictor as both age and
the 2 variables combined.
Since age of onset was identified as a covariate, the sample was divided
into 2 strata (onset 18 years vs onset >18 years) using an approximate
median split. A log-rank test for 8 months' experimental phase revealed a
significant interaction between age of onset and condition (23 = 14.22, P = .003; Figure 3). Post hoc results for 8 months' experimental phase replicated
the following pattern found throughout 24 months.
For 24 months after randomization, a log-rank test revealed a significant
interaction between age of onset and condition (23
= 10.09, P = .02; Figure 3). Control patients with an earlier age of onset were significantly
more likely to experience a relapse than were those with later onset (67%
vs 36%; 21 = 4.34, P =
.04). Patients with an earlier onset were significantly less likely to experience
a relapse or recurrence if they received C-CT than if they did not (16% vs
67%; 21 = 6.78, P = .009).
There was no difference in the relapse and recurrence estimates for patients
with early and late onset who were treated with C-CT (16% vs 50%; 21 = 2.71, P = .10). Similarly,
there was no significant difference in the relapse and recurrence estimates
for patients with later-onset MDD who did and did not receive C-CT (50% vs
36%; 21 = 0.549, P = .47).
Since previous studies4, 7, 13, 14, 33, 34, 35
showed that quality of acute-phase remission predicted relapse or recurrence,
we hypothesized that C-CT might reduce relapse or recurrence when remission
was unstable in late-phase A-CT. Based on the work of Thase and associates,7 we formed 2 strata to determine whether the pattern
of remission interacted with condition to influence the cumulative survival
rates. Fifty-two (62%) of 84 patients showed "unstable" remission (1 or more
HRSD-17 scores were 7 during the 6 final A-CT sessions and first blind
evaluation spread over an average of 6.70 ± 0.13 weeks). Thirty-two
(38%) of 84 patients showed "stable" remission (all 7 HRSD-17 scores were
<7 over an average of 6.34 ± 0.15 weeks).
An overall log-rank test comparing the survival curves throughout 8
months for condition and stability of remission showed that the interaction
between condition and stability was significant (23
= 14.96, P = .002; Figure 4). Pairwise comparisons using log-rank tests replicated
the following pattern found throughout 24 months.
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Figure 4. Kaplan-Meier survival curves estimating
time until relapse or recurrence (DSM-IV major depressive disorder
diagnosed by blind evaluation) during 24 months (102 weeks). A log-rank test
produced significant interaction between condition (continuation-phase cognitive
therapy [C-CT] or control [CT-free evaluation]) and stability of acute-phase
CT remission (stable and unstable) (23 = 8.67, P = .03).
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Over 24 months, the log-rank test comparing survival curves for condition
and stability of remission also showed a significant interaction (23 = 8.67, P = .03; Figure 4). Pairwise comparisons using log-rank tests showed that
patients with an unstable remission were significantly more likely to experience
a relapse or recurrence without C-CT (62%) than with C-CT (37%; 21 = 5.36, P = .02). Of the patients
without C-CT, those who had an unstable pattern of remission were more likely
to experience a relapse or recurrence than were those with a stable pattern
of remission (62% vs 30%; 21 = 4.70, P = .03). All other comparisons were nonsignificant.
COMMENT
To our knowledge, this is the first randomized clinical trial that compares
CT with and without a continuation phase in CT responders who remain at high
risk for relapse and recurrence because of a history of recurrent depression.
Eight months of C-CT focusing on residual symptoms, relapse prevention, and
consolidation of skills reduced estimated relapse rates significantly more
than the control. The 24-month analyses revealed that in patients at higher
risk for relapse and recurrence (ie, those with early onset of their first
depression or unstable remission late in the acute phase), C-CT reduced rates
even after therapy was discontinued. This finding suggests that in vulnerable
patients, the effects of C-CT may endure after discontinuation, distinguishing
the effects of CT from those of pharmacotherapy. Furthermore, the estimates
of relapse and recurrence during 2 years in the higher-risk patients treated
with C-CT are comparable to rates observed during continuation and maintenance
pharmacotherapy.36 When the higher-risk patients
received C-CT, their estimated relapse or recurrence did not differ from those
at lower risk who had only A-CT. Specifying these interactions between C-CT
and unstable remission or age of onset in robust prediction of relapse or
recurrence adds to similar, emerging literature.4, 7, 13, 14, 23, 31, 32, 33, 34, 37
The major limitation of this study is that the sample size decreases
over time. The findings require replication. Changing any combination of the
parameters defining the sample or treatment may affect generalizability. This
study design differs from studies with (1) CT in all 3 phases, (2) pharmacotherapy
in all 3 phases, (3) acute-phase pharmacotherapy followed by continuation-
and maintenance-phase CT (combination therapy), or (4) CT focused exclusively
on residual symptoms.
When combined with the literature, results suggest that CT used as a
continuation- and maintenance-phase treatment deserves more evaluation and
appears to offer patients safe, tolerable, and effective prevention for an
extended period. To date, after response to the acute phase has been documented,
C-CT and its variants have protected responders to A-CT,3, 10, 11
acute-phase pharmacotherapy,11, 12, 13, 14
and acute-phase pharmacotherapy plus CT.10
The appropriate number of CT sessions, as well as the months needed
to prevent relapse and recurrence, likely depends on age of onset and the
extent of remission that a patient achieves during A-CT.4, 7, 13, 14, 33, 34, 35
Current results suggest that A-CT alone (a total of 20 sessions) can reduce
depressive relapse when stable remission has been achieved or in patients
with a later age of onset. On the other hand, A-CT plus C-CT (30 sessions
total, including a focus on prevention) can reduce relapse and recurrence
in patients with an earlier age of onset or unstable remission. Clinicians
and third-party payers can easily use extent of acute-phase remission to identify
patients who no longer meet DSM-IV criteria for MDD,
yet continue to require additional CT because the risk of relapse or recurrence
is high.
The finding that people who develop depression early in life are vulnerable
to depressive relapse and recurrence after successful treatment highlights
the importance of evaluating early intervention and preventive strategies
for children and adolescents. Psychosocial treatments offer promise for this
population.37, 38
To reduce residual symptoms and relapse and recurrence, C-CT should
be standard practice, not only in psychopharmacology, but also in cognitive
therapy when acute-phase remission is unstable. Additional controlled studies
are necessary to evaluate the relative efficacy and effectiveness of 8 months
of C-CT vs continuation-phase pharmacotherapy in patients at highest risk
for depressive relapse and recurrence. Future treatments that reduce residual
symptoms, relapse, and recurrence further will increase the relevance of the
findings for affected patients.
AUTHOR INFORMATION
Accepted for publication October 16, 2000.
This research was supported in part by grants MH-38238 and MH-01571
from the National Institute of Mental Health, Bethesda, Md (Dr Jarrett).
Presented in part at the 33rd Annual Convention of the Association for
Advancement of Behavior Therapy, Toronto, Ontario, November 13, 1999.
Gratitude is expressed to our colleagues for contributing to this research.
Marjorie Woodruff, PhD, Bethany Hampton, PhD, Catherine Judd, PA-C, MS, Douglas
Lisle, PhD, Regina Kinney, PhD, Maria Marwill-Magee, PhD, Andrew Clifford,
PhD, Martin Schaffer, MD, and Rodger Kobes, MD, provided clinical support.
Research support was provided by Michelle White, BS, Edna Christian, MA, Joseph
Begue, BA, Julie Lowe, BA, Daisha Cipher, PhD, Patricia Green, MS, Demetria
Clinton, BA, Paula Reese, and Benjamin McPhee, BS. Brian F. Shaw, PhD, rated
the cognitive therapy. Janet Smith, BA, and Richard C. Risser, MS, provided
programming support. Thanks are expressed to Lee Anna Clark, PhD, and Donald
McIntire, PhD, who commented on an early draft of the manuscript. We appreciate
the administrative support of Kenneth Z. Altshuler, MD (Stanton Sharp Professor
and previous chairman), and Eric J. Nestler, MD, PhD (The Lou and Ellen McGinley
Distinguished Chair in Psychiatric Research and current chairman).
From The University of Texas Southwestern Medical Center at Dallas.
Corresponding author and reprints: Robin B. Jarrett, PhD, The University
of Texas Southwestern Medical Center, Department of Psychiatry, 5323 Harry
Hines Blvd, Dallas, TX 75390-9149.
REFERENCES
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1. Frank E, Kupfer DJ, Perel JM, Cornes C, Jarrett RB, Mallinger AG, Thase ME, McEachran AB, Grochocinski VJ. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry. 1990;47:1093-1099.
ABSTRACT
2. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive Therapy of Depression. New York, NY: Guilford Press; 1979.
3. Jarrett RB, Basco MR, Risser RC, Ramanan J, Marwill M, Kraft D, Rush AJ. Is there a role for continuation phase cognitive therapy for depressed
outpatients? J Consult Clin Psychol. 1998;66:1036-1040.
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