Antidepressant Monotherapy versus Sequential Pharmacotherapy and Mindfulness-Based Cognitive Therapy, or Placebo, for Relapse Prophylaxis in Recurrent Depression

Context Mindfulness Based Cognitive Therapy (MBCT) is a group-based psychosocial intervention designed to enhance self-management of prodromal symptoms associated with depressive relapse.

Objective: To compare rates of relapse in remitted depressed patients receiving MBCT against maintenance antidepressant pharmacotherapy, the current standard of care Design Patients who met remission criteria following 8 months of algorithm informed antidepressant treatment were randomized to either: Maintenance Antidepressant Medication (M-ADM), MBCT or placebo (PLA) and were followed for 18 months.

Setting: Outpatient clinics at the Centre for Addiction and Mental Health, Toronto and St. Joseph’s Healthcare, Hamilton.

Participants: One hundred sixty patients aged 18 to 65 meeting DSM-IV for major depressive disorder with a minimum of 2 past episodes. Of these, 84 achieved remission (52.5%) and were assigned to one of the 3 study conditions.

Interventions: Remitted patients either discontinued their antidepressants and attended eight weekly group sessions of MBCT, continued on their therapeutic dose of antidepressant medication or discontinued active medication onto placebo. Main Outcome Measure Relapse was defined as a return, for at least 2 weeks, of symptoms sufficient to meet the criteria for major depression on Module A of the SCID.

Results: Intention to treat analyses revealed a significant interaction between the quality of acute phase remission and subsequent prevention of relapse in randomized patients (p = .03). Among unstable remitters (defined as 1 or more HRSD >7 during remission) patients in both MBCT and M-ADM showed a 73% decrease in hazard compared to PLA (p = .03), whereas for stable remitters (all HRSD ≤ 7 during remission) there were no group differences in survival. Findings remained significant after accounting for the effects of past depressive episodes on relapse.

Conclusion: For depressed patients who are unwilling or unable to tolerate long term maintenance antidepressant treatment, MBCT offers equivalent protection from relapse.