NIHR Signal Talking therapies may prevent relapse of depression

Published on 30 September 2015

This review looked at how effective different psychological "talking" therapies were at preventing relapse of depression. It found that cognitive behavioural therapy, mindfulness-based cognitive therapy and interpersonal psychotherapy all reduced the risk of depression relapse over a year by 20 to 25% compared with a control treatment. There was further evidence that the effect for cognitive behavioural therapy was sustained up to two years. This reinforces NICE guidance, which recommends that cognitive behavioural therapy or mindfulness-based cognitive therapy be offered to people at risk of a relapse of depression. The trial results suggested factors like participant characteristics and treatment delivery affected treatment success. These results may help therapists further tailor their treatment approaches within the NHS Improving Access to Psychological Therapies programme.

Talking therapies may prevent relapse of depression

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Why was this study needed?

Around 8-12% of people in the UK experience depression every year. Roughly half of those will recover within 18 months. However, 60% of people who have experienced one episode of depression will experience symptoms again in the future, known as relapse. The risk of relapse increases the greater the number of previous depression episodes. The World Health Organization estimates that depression is the largest single cause of disability – a physical or mental impairment that affects someone’s ability to carry out everyday tasks – worldwide.

Reviews have compared different drugs for relapse prevention, but reviews of psychological "talking" therapies have focused on one therapy at a time. This systematic review aimed to address this, by comparing the effectiveness of several psychological or non-drug treatments specifically used to prevent depression relapse.

What did this study do?

This systematic review included 29 trials that randomised people not currently depressed – but who were at risk of relapse – to receive various forms of psychological therapy or a control (comparison) therapy, such as continuing drug treatment or monitoring without an "active" treatment. The review did not provide a head to head comparison between psychological therapy and continuing medication. Relapse was defined as changing from being fully or partially recovered to being depressed, measured using accepted diagnostic criteria. The results of 22 of the studies (including 4,216 people) were pooled in a meta-analysis. Most studies looked at specific types of therapies – cognitive behavioural therapy (CBT, 10 studies), mindfulness-based cognitive therapy (MBCT, seven studies) and interpersonal psychotherapy (IPT, four studies) – see Definitions. Four studies investigated "service-led" programmes, for example involving visits or calls with a GP-based specialist.

What did it find?

  • At 12 months the differences in effectiveness between the therapies were not statistically significant. People who received CBT were 25% less likely to relapse, 21% for MBCT, and 22% for IPT, compared with controls.
  • Service-led programmes did not reduce the risk of relapse at 12 months compared with control either (RR 1.00, 95% CI 0.81 to 1.23).
  • A similar risk reduction was found for CBT at 24 months (RR 0.72, 95% confidence interval [CI] 0.57 to 0.91) and at 12 months (RR 0.75, CI 0.64 to 0.89). However, this was based on data from seven studies, and variations between the methods and findings mean that other factors may be influencing results.
  • Data from six studies did not find that the effects of IPT at 12 months (RR 0.78, 95% CI 0.65 to 0.95) were sustained at 24 months (RR 0.92, 95% CI 0.81 to 1.05). No other studies reported results at 24 months.

What does current guidance say on this issue?

The 2009 NICE depression guideline recommends individual cognitive behavioural therapy or group mindfulness-based cognitive therapy for people at high risk of relapse. This includes people who have relapsed despite continued antidepressant treatment, who are either unable or unwilling to continue antidepressant treatment, or who still have some symptoms. NICE recommends 16-20 sessions of CBT delivered over three to four months, or weekly two-hour sessions of MBCT in groups of 8-15 delivered over eight weeks, with four follow-up sessions in the 12 months after the treatment ends.

The Improving Access to Psychological Therapies (IAPT) programme is a large-scale initiative that aims to greatly increase the availability of NICE recommended psychological treatment for common mental health problems, including depression.

What are the implications?

This review identified three psychological therapies that prevented depression relapse better than control treatments. There was a lot of variation between studies, which means that we cannot be completely certain that the results were due to the treatment rather than the influence of other factors. For example, participants varied in the number of previous episodes of depression they had, and in the treatments they had previously received. There was variation in the treatment that was used as a comparison and the "intensity" of the psychological therapy – the number of sessions, and over how many weeks it was delivered. The relevance to the UK setting is not clear as the intensity of the psychological therapy used in many of the studies differed from NICE recommendations. This was a thorough review, but the evidence was generally of poor quality which limits the authority of findings.

The cost-effectiveness of psychological therapy was not assessed. The authors speculate that it may be more cost-effective to deliver a psychological therapy if the effect lasts for up to two years, rather than prescribing antidepressants for that entire time to achieve a similar effect. For now, the confirmation that therapies provided as part of the NHS funded IAPT programme have proven useful adds support to efforts to make this programme more widely accessible.

This review did not provide direct comparison of psychological therapy with continued medication for people at risk of further depression. The authors noted that it was difficult to establish the different levels of medication use in the included trials. A large NIHR funded trial published recently (see also this Signal) was able to compare this directly in an NHS context and found that psychological therapies and continuing medication were equally effective. This single study will be added to future reviews to strengthen our evidence base for the future.

Bibliography

The British Psychological Society. MBCT – clinical applications for anxiety and depression. London: The British Psychological Society; 2011.

iCope. Interpersonal therapy (IPT). London: Camden and Islington Psychological Therapies Service.

NICE. Depression in adults: the treatment and management of depression in adults. CG90. London: National Institute for Health and Care Excellence; 2009.

Mental Health Foundation. Mental health statistics: the most common mental health problems. London: Mental Health Foundation.

NHS Choices. Cognitive behavioural therapy (CBT). London: NHS Choices; 2014.

Why was this study needed?

Around 8-12% of people in the UK experience depression every year. Roughly half of those will recover within 18 months. However, 60% of people who have experienced one episode of depression will experience symptoms again in the future, known as relapse. The risk of relapse increases the greater the number of previous depression episodes. The World Health Organization estimates that depression is the largest single cause of disability – a physical or mental impairment that affects someone’s ability to carry out everyday tasks – worldwide.

Reviews have compared different drugs for relapse prevention, but reviews of psychological "talking" therapies have focused on one therapy at a time. This systematic review aimed to address this, by comparing the effectiveness of several psychological or non-drug treatments specifically used to prevent depression relapse.

What did this study do?

This systematic review included 29 trials that randomised people not currently depressed – but who were at risk of relapse – to receive various forms of psychological therapy or a control (comparison) therapy, such as continuing drug treatment or monitoring without an "active" treatment. The review did not provide a head to head comparison between psychological therapy and continuing medication. Relapse was defined as changing from being fully or partially recovered to being depressed, measured using accepted diagnostic criteria. The results of 22 of the studies (including 4,216 people) were pooled in a meta-analysis. Most studies looked at specific types of therapies – cognitive behavioural therapy (CBT, 10 studies), mindfulness-based cognitive therapy (MBCT, seven studies) and interpersonal psychotherapy (IPT, four studies) – see Definitions. Four studies investigated "service-led" programmes, for example involving visits or calls with a GP-based specialist.

What did it find?

  • At 12 months the differences in effectiveness between the therapies were not statistically significant. People who received CBT were 25% less likely to relapse, 21% for MBCT, and 22% for IPT, compared with controls.
  • Service-led programmes did not reduce the risk of relapse at 12 months compared with control either (RR 1.00, 95% CI 0.81 to 1.23).
  • A similar risk reduction was found for CBT at 24 months (RR 0.72, 95% confidence interval [CI] 0.57 to 0.91) and at 12 months (RR 0.75, CI 0.64 to 0.89). However, this was based on data from seven studies, and variations between the methods and findings mean that other factors may be influencing results.
  • Data from six studies did not find that the effects of IPT at 12 months (RR 0.78, 95% CI 0.65 to 0.95) were sustained at 24 months (RR 0.92, 95% CI 0.81 to 1.05). No other studies reported results at 24 months.

What does current guidance say on this issue?

The 2009 NICE depression guideline recommends individual cognitive behavioural therapy or group mindfulness-based cognitive therapy for people at high risk of relapse. This includes people who have relapsed despite continued antidepressant treatment, who are either unable or unwilling to continue antidepressant treatment, or who still have some symptoms. NICE recommends 16-20 sessions of CBT delivered over three to four months, or weekly two-hour sessions of MBCT in groups of 8-15 delivered over eight weeks, with four follow-up sessions in the 12 months after the treatment ends.

The Improving Access to Psychological Therapies (IAPT) programme is a large-scale initiative that aims to greatly increase the availability of NICE recommended psychological treatment for common mental health problems, including depression.

What are the implications?

This review identified three psychological therapies that prevented depression relapse better than control treatments. There was a lot of variation between studies, which means that we cannot be completely certain that the results were due to the treatment rather than the influence of other factors. For example, participants varied in the number of previous episodes of depression they had, and in the treatments they had previously received. There was variation in the treatment that was used as a comparison and the "intensity" of the psychological therapy – the number of sessions, and over how many weeks it was delivered. The relevance to the UK setting is not clear as the intensity of the psychological therapy used in many of the studies differed from NICE recommendations. This was a thorough review, but the evidence was generally of poor quality which limits the authority of findings.

The cost-effectiveness of psychological therapy was not assessed. The authors speculate that it may be more cost-effective to deliver a psychological therapy if the effect lasts for up to two years, rather than prescribing antidepressants for that entire time to achieve a similar effect. For now, the confirmation that therapies provided as part of the NHS funded IAPT programme have proven useful adds support to efforts to make this programme more widely accessible.

This review did not provide direct comparison of psychological therapy with continued medication for people at risk of further depression. The authors noted that it was difficult to establish the different levels of medication use in the included trials. A large NIHR funded trial published recently (see also this Signal) was able to compare this directly in an NHS context and found that psychological therapies and continuing medication were equally effective. This single study will be added to future reviews to strengthen our evidence base for the future.

Bibliography

The British Psychological Society. MBCT – clinical applications for anxiety and depression. London: The British Psychological Society; 2011.

iCope. Interpersonal therapy (IPT). London: Camden and Islington Psychological Therapies Service.

NICE. Depression in adults: the treatment and management of depression in adults. CG90. London: National Institute for Health and Care Excellence; 2009.

Mental Health Foundation. Mental health statistics: the most common mental health problems. London: Mental Health Foundation.

NHS Choices. Cognitive behavioural therapy (CBT). London: NHS Choices; 2014.

Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials

Published on 6 May 2015

Clarke, K.,Mayo-Wilson, E.,Kenny, J.,Pilling, S.

Clin Psychol Rev Volume 39 , 2015

OBJECTIVE: To identify studies of non-pharmacological interventions provided following recovery from depression, and to evaluate their efficacy in preventing further episodes. METHOD: We identified relevant randomised controlled trials from searching MEDLINE, Embase, PsycINFO, CENTRAL, and ProQuest, searching reference and citation lists, and contacting study authors. We conducted a meta-analysis of relapse outcomes. RESULTS: There were 29 eligible trials. 27 two-way comparisons including 2742 participants were included in the primary analysis. At 12months cognitive-behavioural therapy (CBT), mindfulness-based cognitive therapy (MBCT), and interpersonal psychotherapy (IPT) were associated with a 22% reduction in relapse compared with controls (95% CI 15% to 29%). The effect was maintained at 24months for CBT, but not for IPT despite ongoing sessions. There were no 24-month MBCT data. A key area of heterogeneity differentiating these groups was prior acute treatment. Other psychological therapies and service-level programmes varied in efficacy. CONCLUSION AND IMPLICATIONS: Psychological interventions may prolong the recovery a person has achieved through use of medication or acute psychological therapy. Although there was evidence that MBCT is effective, it was largely tested following medication, so its efficacy following psychological interventions is less clear. IPT was only tested following acute IPT. Further exploration of sequencing of interventions is needed. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO 2011:CRD42011001646.

The key interventions examined in this review are: cognitive behavioural therapy (CBT), a “talking therapy” that helps people to break negative thought spirals and provide them with coping strategies; mindfulness based cognitive therapy (MBCT), which uses meditative practices to help people to experience the moment and deal with negative situations as they happen; and interpersonal therapy (IPT) which focuses on relationships, particularly those causing conflict, and how the individual feels about themselves.

Expert commentary

This thought-provoking review addresses a deceptively simple question and the answer appears to be a cautious ‘yes’. Beyond suggesting that offering (or extending) psychological therapies for a time after recovery from depression is generally a good idea, there’s little else this study can tell us other than “more research is needed”.

Although this is a good review, there are too many uncertainties, and too much heterogeneity between studies, to support major changes in clinical practice. Patients with residual symptoms will continue to be offered extended treatment, and those at high risk of relapse will be followed up more closely than those at low risk.

Professor Scott Weich, Professor in Psychiatry, Warwick Medical School