Elsevier

Current Opinion in Psychology

Volume 4, August 2015, Pages 26-31
Current Opinion in Psychology

Cognitive therapy to prevent depressive relapse in adults

https://doi.org/10.1016/j.copsyc.2015.01.016Get rights and content

Highlights

  • Several cognitive therapies reduce relapse compared to no additional treatment.

  • Patients relapse less after acute phase cognitive therapy versus after medication.

  • After acute symptom reduction, cognitive therapy can be used to prevent relapse.

  • We review prevention evidence for acute, continuation, and maintenance therapies.

  • Relapse-prevention appears greater for higher-risk patient populations.

The high prevalence, frequent relapse, and recurrence of major depressive disorder (MDD) increase its personal and societal costs. Cognitive therapy (CT) aims to decrease depressive symptoms and prevent relapse/recurrence. We review prevention evidence for acute, continuation, and maintenance CTs for patients whose depression is active, remitted, and recovered, respectively. Evidence suggests that patients relapse less often after discontinuing acute phase CT versus discontinuing pharmacotherapy. Continuation CT further decreases relapse relative to inactive controls and similarly to active pharmacotherapy. Maintenance CT may decrease recurrence but needs rigorous evaluation. Post-acute CT's preventive effects appear greater for higher-risk patients (e.g., with residual depressive symptoms, unstable acute-phase treatment response, childhood trauma, more prior depressive episodes), although risks may vary by specific CTs.

Introduction

Major depressive disorder (MDD) is a common illness with a large public health cost (e.g., [58]). A curative treatment for MDD would eliminate underlying pathology, relieve all patients’ depressive symptoms rapidly, restore psychosocial functioning fully, and prevent depressive relapses and recurrences entirely. Current treatments are far from these ideals. However, cognitive and cognitive-behavioral therapy (CT) for MDD reduces depressive symptoms, improves psychosocial functioning, and lowers the probability future depression in many patients. Here we review some of the most important and most recent research on CT for adults with MDD to inform prevention of relapse and recurrence.

Section snippets

What is major depressive disorder?

The experience of at least one major depressive episode (MDE) defines MDD [1]. MDEs reflect disturbances in mood (e.g., subjectively depressed and/or loss of pleasure in life's activates) with attendant changes in behavior (e.g., increased or decreased sleep, eating, activity level) and cognition (e.g., reduced concentration, increased guilt, suicidality), last at least two weeks, and produce significant life interference (e.g., as a student, worker, parent, friend, romantic partner; [2]).

What is cognitive behavioral therapy?

Cognitive behavioral therapies for depression share efforts to change patients’ distress-related cognition as a means to improve mood and functioning. Beck et al.’s [13] individual, in-person CT is prototypical. During a limited period (e.g., 16–20 one-hour sessions over 3–4 months), Beck's CT aims to increase patients’ engagement with sources of reinforcement and adaptive functioning (‘behavioral activation’) and then to assess and restructure depressive cognition, including negative automatic

Acute phase CT

Roughly 60–70% of patients no longer meet criteria for MDD after completing acute phase CT ([24, 1]), and average symptom levels are comparable after acute phase CT versus pharmacotherapy [25]. Although CT and pharmacotherapy produce similar short-term outcomes, CT's preventive effects exceed pharmacotherapy after either acute phase treatment ends.

In an earlier meta-analysis of studies reporting follow-up data after response then discontinuation of acute phase treatment, relapse/recurrence

Conclusions and future directions

Major depressive disorder is often recurrent and treatment with CT increases patients’ periods of relative wellness, with important clinical trials ongoing (e.g., [52, 53•]). Research shows that acute, continuation, and maintenance CTs have preventive effects against relapse and/or recurrence, although none is fully efficacious. Refined treatments and treatment-application protocols may profitably focus on maximizing individual-level and population-level benefits of CT and on identifying

References and recommended reading

Papers of particular interest, published within the period of review, have been highlighted as:

  • • of special interest

  • •• of outstanding interest

Acknowledgements

This report was supported by Grants Number K24 MH001571, R01 MH58397, R01 MH69619 to Robin B. Jarrett, PhD, from the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the National Institutes of Health.

Dr. Vittengl has no financial interest or conflict of interest in the research. Dr. Jarrett's medical center collects the payments from the cognitive therapy she provides to

References (61)

  • C.H. Bockting et al.

    Long-term effects of preventive cognitive therapy in recurrent depression: a 5.5-year follow-up study

    J Clin Psychiatry

    (2009)
  • W. Kuyken et al.

    Update to the study protocol for a randomized controlled trial comparing mindfulness-based cognitive therapy with maintenance anti-depressant treatment depressive relapse/recurrence: the PREVENT trial

    Trials

    (2014)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (2013)
  • R.C. Kessler et al.

    Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers

    Am J Psychiatry

    (2006)
  • K. Wells et al.

    The functioning and well-being of depressed patients. Results from the Medical Outcomes Study

    J Am Med Assoc

    (1989)
  • R.C. Kessler et al.

    Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication

    Arch Gen Psychiatry

    (2005)
  • R.C. Kessler et al.

    Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication

    Arch Gen Psychiatry

    (2005)
  • D.S. Hasin et al.

    Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions

    Arch Gen Psychiatry

    (2005)
  • W.W. Eaton et al.

    Population-based study of first onset and chronicity in major depressive disorder

    Arch Gen Psychiatry

    (2008)
  • S. Satyanarayana et al.

    Prevalence and correlates of chronic depression in the Canadian Community Health Survey: mental health and well-being

    Can J Psychiatry

    (2009)
  • J.C. Wakefield et al.

    Predictive validation of single-episode uncomplicated depression as a benign subtype of unipolar major depression

    Acta Psychiatr Scand

    (2014)
  • D.A. Solomon et al.

    Multiple recurrences of major depressive disorder

    Am J Psychiatry

    (2000)
  • A.T. Beck et al.

    Cognitive Therapy of Depression

    (1979)
  • P.M. Lewinsohn et al.

    The coping with depression course: a psychoeducational intervention for unipolar depression

    (1984)
  • D.D. Burns

    Feeling Good: The New Mood Therapy

    (1980)
  • L. de Graaf et al.

    Predicting outcome in computerized cognitive behavioral therapy for depression in primary care: a randomized trial

    J Consult Clin Psychol

    (2010)
  • S. Dimidjian et al.

    Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression

    J Consult Clin Psychol

    (2006)
  • A. Ellis

    Rational-emotive therapy and cognitive behavior therapy: similarities and differences

    Cogn Ther Res

    (1980)
  • S.C. Hayes et al.

    Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change

    (1999)
  • Z.V. Segal et al.

    Mindfulness-based cognitive therapy for depression: a new approach to preventing relapse

    (2002)
  • Cited by (7)

    • Meta-Analysis: Relapse Prevention Strategies for Depression and Anxiety in Remitted Adolescents and Young Adults

      2023, Journal of the American Academy of Child and Adolescent Psychiatry
      Citation Excerpt :

      Relapse rates ranged from 29% over 14 months to 60% over 6 years and up to 87% over 10 years follow-up.18 Next to improved relapse rates, we found that CBT-based strategies (combined with ADMc) are associated with increased time to relapse, which is closely comparable to findings in previous meta-analyses in adults (eg, see 6,17-21). There was a small difference between CBT-based strategies and CAU control conditions on mean depressive symptoms at last follow-up, which was not found in the previous meta-analysis in youth.8

    • Mood Disorders

      2017, Clinical Psychology: A Global Perspective
    View all citing articles on Scopus
    View full text