Mindfulness-based cognitive therapy appears to be similar to maintenance antidepressant medication for preventing relapse or recurrence among patients successfully treated for depression, according to a report in the December issue of Archives of General Psychiatry, one of the JAMA/Archives journals.
"Relapse and recurrence after recovery from major depressive disorder are common and debilitating outcomes that carry enormous personal, familial and societal costs," the authors write as background information in the article. The current standard for preventing relapse is maintenance therapy with a single antidepressant. This regimen is generally effective if patients take their medications, but as many as 40 percent of them do not. "Alternatives to long-term antidepressant monotherapy, especially those that address mood outcomes in a broader context of well-being, may appeal to patients wary of continued intervention."
Zindel V. Segal, Ph.D., of the Centre for Addiction and Mental Health, Toronto, Ontario, Canada, and colleagues studied 160 patients age 18 to 65 who met criteria for major depressive disorder and had experienced at least two episodes of depression. After eight months of treatment, 84 (52.5 percent) achieved remission. Patients in remission were then randomly assigned to one of three treatment groups: 28 continued taking their medication; 30 had their medication slowly replaced by placebo; and 26 tapered their medication and then received mindfulness-based cognitive behavioral therapy.
In this therapy, patients learn to monitor and observe their thinking patterns when they feel sad, changing automatic reactions associated with depression (such as rumination and avoidance) into opportunities for useful reflection. "This is accomplished through daily homework exercises featuring (1) guided (taped) awareness exercises directed at increasing moment-by-moment nonjudgmental awareness of bodily sensations, thoughts, and feelings; (2) accepting difficulties with a stance of self-compassion; and (3) developing an 'action plan' composed of strategies for responding to early warning signs of relapse/recurrence," the authors write.
During the 18-month follow-up period, relapse occurred among 38 percent of those in the cognitive behavioral therapy group, 46 percent of those in the maintenance medication group and 60 percent of those in the placebo group, making both medication and behavioral therapy effective at preventing relapse.
About half (51 percent) of patients were classified as unstable remitters, defined as individuals who had symptom "flurries" or intermittently higher scores on depression rating scales despite having a low enough average score to qualify for remission. The other half (49 percent) were stable remitters with consistently low scores. Among unstable remitters, those taking maintenance medication or undergoing cognitive behavioral therapy were about 73 percent less likely to relapse than those taking placebo. Among stable remitters, there were no differences between the three groups.
"Our data highlight the importance of maintaining at least one active long-term treatment in recurrently depressed patients whose remission is unstable," the authors write. "For those unwilling or unable to tolerate maintenance antidepressant treatment, mindfulness-based cognitive therapy offers equal protection from relapse during an 18-month period." It is unclear exactly how mindfulness-based therapy works, but it may change neural pathways to support patterns that lead to recovery instead of to deeper depression, they note.
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