Depression typically has a relapsing and recurrent course. Without ongoing treatment, individuals with recurrent depression have a high risk of repeated depressive relapses or recurrences throughout their life with rates of relapse or recurrence typically in the range 50–80%.
So begins this week’s Reading (which is attached). As is so often the case, the journal writing is understated.
Having been in practice for some years, many stories come to mind when considering this statistic.
Here’s one: a young woman with a challenging childhood who pulled her life together, kept an unplanned pregnancy, and then tried to do everything right for herself and her daughter. In her late 20s, she fell into a deep depression, attempted suicide, and had a long admission. And, after work on the inpatient unit and in the outpatient department, she returned to her life: free of symptoms, working full time, raising her daughter. Feeling well, she stopped her citalopram, and became sick again (and with an employer keen on her termination because – and this sounds like a 19th century novel – “she told me I look dead on the outside”).
It’s easy to say that she should have stayed on her medications. But many of our patients don’t. The reasons vary – the side effects are too strong, the concept of medications is unappealing, etc. – but the end result is so often the same.
What then are non-medication options for maintenance in patients with depression? This week’s Reading offers an interesting answer: mindfulness-based cognitive therapy.
This study has just been published by The Lancet. “Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial” by Willem Kuyken et al. is a big paper in a big journal with a big result.
Needless to say, the study has gathered significant attention from the media. The Guardian ran with the sensible headline: “Mindfulness as effective as pills for treating recurrent depression – study.” Huffington Post, Forbes, and National Post all weighed in. As a comment on how psychiatry has gone mainstream, the Daily Mail – the old British tabloid better known for reporting on models than medicine – ran a decent summary of the study (if one with an unusually large number of pictures of meditating women who seemed, well, clothing challenged). The best headline belonged to a health website that asked: “Zen or Zoloft? An Alternative to Antidepressants.”
But as a clinician, what excites me about this study isn’t the splashy headlines but the clinical possibilities.
Can mindfulness reduce the risk of relapse? As the University of Otago’s Prof. Roger Mulder notes in the accompanying Comment piece:
Mindfulness-based cognitive therapy (MBCT) was developed as an explicit intervention to reduce relapse and recurrence in depression. MBCT teaches people who have had depression that negative feelings and thoughts will recur and that, rather than worrying or ruminating about these experiences, it is possible to become aware of and disengage from them, thereby preventing a downward spiral into depression.
A 2011 meta-analysis compared this psychological intervention to the usual care with good results. Kuyken et al. push further.
Here’s what they did:
· Patients were recruited who had had 3 or more previous major depressive episodes. (!)
· Patients came from rural and urban primary care practices, and all in southern England, but also from patients who self-referred.
· Patients with co-morbid conditions were excluded (substance, persistent antisocial behaviour, brain injury, psychosis, persistent self-injuring) and so were patients with active depressive episodes. (!)
· People were assigned to one of two groups, with 424 patients randomized in total. The first group just continued the antidepressant maintenance treatment as usual. A second group was enrolled in an 8 week mindfulness-based cognitive therapy class, and offered 4 follow-ups sessions. The latter group was also offered counseling to wean off their medications. (!) So they had more than MBCT, they had MBCT-TS, to use the authors’ jargon.
· Patients were assessed at 6 time-points over 24 months.
Here’s what they found:
· Recurrence occurred similarly for patients in the medication group as it did for patients in the mindfulness group: 47% vs. 44%. (!!)
· Treatment adherence was high. 78% of people taking medications continued to take medications; 83% of people assigned to the mindfulness classes took 4 or more sessions.
· Costs were very comparable.
· The effectiveness of mindfulness was connected to childhood abuse: there was reduced risk of relapse/recurrence for participants with high severity of reported childhood abuse compared to the antidepressant group (47% vs. 59%) but slightly higher risk in the low severity of abuse (42% vs.35%).
The authors conclude:
On the primary measure – that is relapse prevention:
We noted no evidence for the superiority of MBCT-TS compared with maintenance antidepressants for patients with recurrent depression in terms of the primary outcome of time to depressive relapse or recurrence over 24 months or any of the secondary outcomes.
And with secondary measures:
Use of other health-care and social care services differed little between groups… and hence total health and social care cost per participant did not differ significantly between the MBCT-TS and the maintenance antidepressants group…
A few thoughts:
1. This is a smart and well-designed study – from the study period to the n, the authors got a big publication and it was earned. Nice.
2. This is an important study. While we emphasize treatment of the acute episode, major depressive disorder is ultimately a chronic illness (albeit one that’s episodic). Relapse prevention needs to be better understood, and this paper helps do just that.
3. This is a win for mindfulness. Mindfulness is growing in popularity. In fact, it’s become almost trendy. (British Airways has just announced a mindfulness course for its travelers.) This study suggests that there is both smoke and fire – at least for MBCT and depression relapse prevention.
4. This study raises important questions. First and foremost: what about MBCT is so useful? In his Comment piece, Prof. Mulder’s wonders if perhaps it isn’t mindfulness but a group psychotherapy approach that’s clinically useful. Needless to say, Kuyken et al. are more bullish on the mindfulness itself. Given the number of people who suffer from depression and its morbidity, this is a great debate for us to have.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.