Effectiveness of Supported Self-Help in Recurrent Depression: A Randomized Controlled Trial in Primary Care

Understanding mechanisms of depression prevention: study protocol of a randomized cross-over trial to investigate mechanisms of mindfulness and positive fantasizing as intervention techniques for reducing perseverative cognition in remitted depressed individuals

BACKGROUND

Major Depressive Disorder (MDD) is one of the most prevalent psychiatric disorders, and involves high relapse rates in which persistent negative thinking and rumination (i.e., perseverative cognition [PC]) play an important role. Positive fantasizing and mindfulness are common evidence-based psychological interventions that have been shown to effectively reduce PC and subsequent depressive relapse. How the interventions cause changes in PC over time, is unknown, but likely differ between the two. Whereas fantasizing may change the valence of thought content, mindfulness may operate through disengaging from automatic thought patterns. Comparing mechanisms of both interventions in a clinical sample and a non-clinical sample can give insight into the effectivity of interventions for different individuals. The current study aims to 1) test whether momentary psychological and psychophysiological indices of PC are differentially affected by positive fantasizing versus mindfulness-based interventions, 2) test whether the mechanisms of change by which fantasizing and mindfulness affect PC differ between remitted MDD versus never-depressed (ND) individuals, and 3) explore potential moderators of the main effects of the two interventions (i.e., what works for whom).

METHODS

In this cross-over trial of fantasizing versus mindfulness interventions, we will include 50 remitted MDD and 50 ND individuals. Before the start of the measurements, participants complete several individual characteristics. Daily-life diary measures of thoughts and feelings (using an experience sampling method), behavioural measures of spontaneous thoughts (using the Sustained Attention to Response Task), actigraphy, physiological measures (impedance cardiography, electrocardiography, and electroencephalogram), and measures of depressive mood (self-report questionnaires) are performed during the week before (pre-) the interventions and the week during (peri-) the interventions. After a wash-out of at least one month, pre- and peri-intervention measures for the second intervention are repeated.

DISCUSSION

This is the first study integrating self-reports, behavioural-, and physiological measures capturing dynamics at multiple time scales to examine the differential mechanisms of change in PC by psychological interventions in individuals remitted from multiple MDD episodes and ND individuals. Unravelling how therapeutic techniques affect PC in remitted individuals might generate insights that allows development of personalised targeted relapse prevention interventions.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06145984, November 16, 2023.

Economic evaluation of preventive cognitive therapy versus care as usual in cognitive behavioral therapy responders

Background

The highly recurrent nature of Major Depressive Disorder is a major contributor to disability and health care costs. Several studies indicate that recurrence may be prevented with Preventive Cognitive Therapy (PCT). This study is the first to perform an economic evaluation of PCT in comparison with care as usual for recurrently depressed patients who experienced two or more depressive episodes and remitted after receiving Cognitive Behavioural Therapy.

Methods

An economic evaluation from the societal perspective was performed alongside a randomized trial (N = 214). Health-related quality of life (QALYs), depression-free days, health care utilization, and productivity losses were measured between randomization and 15 months follow-up. The costs were indexed to the reference year 2014.

Results

QALY gains did not differ significantly between the groups (p = 0.69). Depression-free days were higher after PCT (p = 0.02). Societal costs of PCT were 10,417 euro and for care as usual 9,545 euro per person. We found a 47% likelihood that PCT led to additional QALYs at higher costs, and there was a 26% likelihood that PCT led to fewer QALYs at higher costs. When depression-free days was used as an outcome, we found PCT had a 72% likelihood of leading to more depression-free days at higher costs than care as usual and a 27% likelihood of leading to more depression-free days at lower societal costs.

Limitations

The 15-month follow-up might be too short to draw long-term conclusions about the cost-effectiveness of the PCT. The data collected for this study is part of an RCT to examine the effectiveness of adding PCT to care as usual. Therefore, the study was powered primarily to detect an effect in time to relapse/recurrences.

Conclusion

The economic evaluation is slightly in favour of the PCT condition when depression-free days is used as an outcome. PCT is not cost-effective given the high costs per additional QALYs from the societal perspective when QALYs are the effect measure.

Clinical trial registration

https://www.onderzoekmetmensen.nl/en, identifier NL2482.

Psychological interventions to prevent relapse in anxiety and depression: A systematic review and meta-analysis

Objectives

The aim of this review is to establish the effectiveness of psychological relapse prevention interventions, as stand-alone interventions and in combination with maintenance antidepressant treatment (M-ADM) or antidepressant medication (ADM) discontinuation for patients with remitted anxiety disorders or major depressive disorders (MDD).

Methods

A systematic review and a meta-analysis were conducted. A literature search was conducted in PubMed, PsycINFO and Embase for randomised controlled trials (RCTs) comparing psychological relapse prevention interventions to treatment as usual (TAU), with the proportion of relapse/recurrence and/or time to relapse/recurrence as outcome measure.

Results

Thirty-six RCTs were included. During a 24-month period, psychological interventions significantly reduced risk of relapse/recurrence for patients with remitted MDD (RR 0.76, 95% CI: 0.68–0.86, p<0.001). This effect persisted with longer follow-up periods, although these results were less robust. Also, psychological interventions combined with M-ADM significantly reduced relapse during a 24-month period (RR 0.76, 95% CI: 0.62–0.94, p = 0.010), but this effect was not significant for longer follow-up periods. No meta-analysis could be performed on relapse prevention in anxiety disorders, as only two studies focused on relapse prevention in anxiety disorders.

Conclusions

In patients with remitted MDD, psychological relapse prevention interventions substantially reduce risk of relapse/recurrence. It is recommended to offer these interventions to remitted MDD patients. Studies on anxiety disorders are needed.

Systematic review registration number

PROSPERO 2018: CRD42018103142.

Augmenting neurocognitive remediation therapy to Preventive Cognitive Therapy for partially remitted depressed patients: protocol of a pragmatic multicentre randomised controlled trial

INTRODUCTION

Major depressive disorder (MDD) affects 163 million people globally every year. Individuals who experience subsyndromal depressive symptoms during remission (ie, partial remission of MDD) are especially at risk for a return to a depressive episode within an average of 4 months. Simultaneously, partial remission of MDD is associated with work and (psycho)social impairment and a lower quality of life. Brief psychological interventions such as preventive cognitive therapy (PCT) can reduce depressive symptoms or relapse for patients in partial remission, although achieving full remission with treatment is still a clinical challenge. Treatment might be more effective if cognitive functioning of patients is targeted as well since cognitive problems are the most persisting symptom in partial remission and predict poor treatment response and worse functioning. Studies show that cognitive functioning of patients with (remitted) MDD can be improved by online neurocognitive remediation therapy (oNCRT). Augmenting oNCRT to PCT might improve treatment effects for these patients by strengthening their cognitive functioning alongside a psychological intervention.

METHODS AND ANALYSIS

This study will examine the effectiveness of augmenting oNCRT to PCT in a pragmatic national multicentre superiority randomised controlled trial. We will include 115 adults partially remitted from MDD with subsyndromal depressive symptoms defined as a Hamilton Depression Rating Scale score between 8 and 15. Participants will be randomly allocated to PCT with oNCRT, or PCT only. Primary outcome measure is the effect on depressive symptomatology over 1 year. Secondary outcomes include time to relapse, cognitive functioning, quality of life and healthcare costs. This first dual approach study of augmenting oNCRT to PCT might facilitate full remission in partially remitted individuals as well as prevent relapse over time.

ETHICS AND DISSEMINATION

Ethical approval was obtained by Academic Medical Center, Amsterdam. Outcomes will be made publicly available.

TRIAL REGISTRATION NUMBER

NL9582.

Is perceived control of depression related to therapy outcome for depression? A longitudinal study

BACKGROUND

The present study followed a group of patients over a two-year period after they had received a cognitive behavioral psychoeducational intervention targeting patients' ability to cope with depression. The main aims were to examine whether a change in both depressive symptoms and in the perceived control of depression occurred and the relationship between depressive symptoms and perceived control.

METHODS

Using a prospective longitudinal design, a sample of 183 patients was assessed at four time points during a two-year period.

RESULTS

The patients showed a large reduction in depressive symptoms over the two-year period after the course ended. During the same time period, perceived controllability of depression increased. A parallel latent growth curve model showed that increased control beliefs were related to reduced depressive symptoms. The decrease in depressive symptoms over time was not dependent on the patients' initial level of depression or initial control of depression, use of medication, duration of previous depressive episodes, alcohol use or sociodemographic variables.

CONCLUSION

Group interventions aimed at increasing coping skills for preventing and mastering of depression may lead to a large and stable reduction in depressive symptoms. A key factor in prevention may be to strengthen patients' perceived ability to cope with the different symptoms of depression.

Blinding in randomised clinical trials of psychological interventions: a retrospective study of published trial reports

OBJECTIVES

To study the extent of blinding in randomised clinical trials of psychological interventions and the interpretative considerations if randomised clinical trials are not blinded.

DESIGN

Retrospective study of trial reports published in six high impact factor journals within the field of psychiatry in 2017 and 2018.

SETTING

Trial reports published in World Psychiatry, JAMA Psychiatry, Lancet Psychiatry, American Journal of Psychiatry, British Journal of Psychiatry, or Psychotherapy and Psychosomatics.

MAIN OUTCOME MEASURES

Blinding status of participants, treatment providers, outcome assessors, data managers, the data safety and monitoring committee, statisticians and conclusion makers, if trialists rejected the null hypothesis on the primary outcome measure, and if trialists discussed the potential bias risk from lack of blinding in the published trial report.

RESULTS

63 randomised clinical trials of psychological interventions were identified. None (0%; 95% CI 0% to 5.75%) of the trials reported blinding of all possible key persons. 37 (58.7%; 95% CI 46.42% to 70.04%) trials reported blinding of outcome assessors. Two (3.2%; 95% CI 0.87% to 10.86%) trials reported blinding of participants. Two (3.2%; 95% CI 0.87% to 10.86%) trials reported blinding of data managers. Three (4.8%; 95% CI 1.63% to 13.09%) trials reported blinding of statisticians. None of the trials reported blinding of treatment providers, the data safety and monitoring committee, and conclusion makers. 45 (71.4%; 95% CI 59.30% to 81.10%) trials rejected the null hypothesis on the primary outcome(s). 13 (20.7%; 95% CI 12.48% to 32.17%) trials discussed the potential bias risk from lack of blinding in the published trial report.

CONCLUSIONS

Blinding of key persons involved in randomised clinical trials of psychological interventions is rarely sufficiently documented. The possible interpretative limitations are only rarely considered. There is a need of randomised clinical trials of psychological interventions with documented blinding attempts of all possible key persons.

Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder: A Systematic Review and Meta-analysis

IMPORTANCE

The sequential model emerged from the awareness that the persistence of residual symptoms and the frequent occurrence of psychiatric comorbidity were both associated with poor long-term outcome of major depressive disorder (MDD).

OBJECTIVE

To conduct an updated meta-analysis to examine the association of the sequential combination of pharmacotherapy and psychotherapy with reduced risk of relapse and recurrence in MDD.

DATA SOURCES

Keyword searches were conducted in PubMed, PsycInfo, Web of Science, and the Cochrane Library from inception of each database through November 2019. Reference lists from relevant studies were examined using the following keywords: sequential treatment, drugs and psychotherapy, combined treatment, continuation or maintenance, relapse or recurrence and prevention, and depress* or major depress*, selecting adults and randomized controlled trials as additional limits. Authors of selected articles were contacted if needed.

STUDY SELECTION

Randomized clinical trials examining the effectiveness of the sequential use of psychotherapy following response to acute-phase pharmacotherapy in the treatment of adult remitted patients with MDD were selected independently by 2 reviewers.

DATA EXTRACTION AND SYNTHESIS

The methods used fulfilled the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction and methodologic quality assessment were conducted independently by the reviewers. Examination of the pooled results was performed based on the random-effects model. Heterogeneity between study results and likelihood of significant publication bias were assessed. Sensitivity analyses and meta-regressions were also run.

MAIN OUTCOMES AND MEASURES

The primary outcome measures were relapse or recurrence rates of MDD, as defined by study investigators, at the longest available follow-up.

RESULTS

Seventeen randomized clinical trials met criteria for inclusion in the meta-analysis, with 1 study yielding 2 comparisons (2283 patients overall, with 1208 patients in a sequential treatment arm and 1075 in a control arm). The pooled risk ratio for relapse/recurrence of MDD was 0.84 (95% CI, 0.74-0.94), suggesting a relative advantage in preventing relapse/recurrence for the sequential combination of treatments compared with control conditions.

CONCLUSIONS AND RELEVANCE

The results of this systematic review and meta-analysis indicate that the sequential integration of psychotherapy following response to acute-phase pharmacotherapy, alone or combined with antidepressant medication, was associated with reduced risk of relapse and recurrence in MDD. The preventive value of the sequential strategy relies on abatement of residual symptoms and/or increase in psychological well-being. The steps for implementing the sequential approach in remitted patients with recurrent MDD are provided.

Evaluation of a Blended Relapse Prevention Program for Anxiety and Depression in General Practice: Qualitative Study

BACKGROUND

Existing studies have yet to investigate the perspectives of patients and professionals concerning relapse prevention programs for patients with remitted anxiety or depressive disorders in primary care. User opinions should be considered when optimizing the use and implementation of interventions.

OBJECTIVE

This study aimed to evaluate the GET READY relapse prevention programs for patients with remitted anxiety or depressive disorders in general practice.

METHODS

Semistructured interviews (N=26) and focus group interviews (N=2) with patients and mental health professionals (MHPs) in the Netherlands were performed. Patients with remitted anxiety or depressive disorders and their MHPs who participated in the GET READY study were interviewed individually. Findings from the interviews were tested in focus group interviews with patients and MHPs. Data were analyzed using thematic analysis.

RESULTS

Participants were positive about the program because it created awareness of relapse risks. Lack of motivation, lack of recognizability, lack of support from the MHP, and symptom severity (too low or too high) appeared to be limiting factors in the use of the program. MHPs play a crucial role in motivating and supporting patients in relapse prevention. The perspectives of patients and MHPs were largely in accordance, although they had different perspectives concerning responsibilities for taking initiative.

CONCLUSIONS

The implementation of the GET READY program was challenging. Guidance from MHPs should be offered for relapse prevention programs based on eHealth. Both MHPs and patients should align their expectations concerning responsibilities in advance to ensure optimal usage. Usage of blended relapse prevention programs may be further enhanced by diagnosis-specific programs and easily accessible support from MHPs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-019-2034-6.

Supported self-help to prevent relapse or recurrence of depression: Who benefits most?

BACKGROUND

This study aimed to identify subgroups for whom supported self-help preventive cognitive therapy (S-PCT) is more (cost)effective than treatment as usual (TAU) in preventing relapse and recurrence of major depression.

METHODS

We conducted a randomized controlled trial in which 248 remitted, recurrently depressed participants were randomized to S-PCT (n = 124) or TAU (n = 124). Clinical outcome was relapse or recurrence of major depressive disorder (SCID-I). We tested the moderating effects on relapse or recurrence of age, gender, education level, residual depressive symptoms, number of previous episodes, age of onset, antidepressant medication, somatization, and self-efficacy with logistic regression analyses adjusted for baseline values of depressive symptoms. We examined moderating effects on costs using linear regression analyses adjusted for baseline costs. A stratified cost-effectiveness analysis was performed to tease out differences in cost-effectiveness between subgroups.

RESULTS

We found no moderating effect on relapse or recurrence for any of the potential moderators. For costs, the number of previous depressive episodes was identified as a moderator. At a willingness-to-pay of 16,000€, the probability that S-PCT was cost-effective compared to TAU was 95% for participants with 2-3 episodes and 11% for participants with ≥4 episodes.

LIMITATIONS

Participants and counselors were not blinded. The study was primarily designed to assess the (cost)effectiveness of S-PCT and not to conduct moderation analyses.

CONCLUSIONS

S-PCT was effective in preventing relapse or recurrence of depressive disorders in a broad range of participants, but is more likely to be cost-effective in participants with 2-3 episodes than ≥4 episodes. This indicates that S-PCT can best be offered to participants with fewer previous depressive episodes.

Cognitive behavioral therapy for primary care depression and anxiety: a secondary meta-analytic review using robust variance estimation in meta-regression

Cognitive-behavioral therapy (CBT) is well supported for treating depressive and anxiety disorders. Trials of CBT for anxiety and depression in primary care have increased over the past decade, yet only one meta-analysis, published in 2015, examined this topic and the scope of that review is relatively narrow. This study conducted a systematic review and meta-analysis of primary care based CBT for depression and anxiety. A search of seven electronic databases, six professional websites, and reference lists from articles meeting inclusion criteria was conducted for studies published between 1900 and November 2018. Fifty-seven eligible studies (including 10,701 participants; 221 effect sizes) of randomized controlled trials were eligible and included for meta-analysis using robust variance estimation in meta-regression. Outcome indicators were depression and anxiety measures. An overall significant treatment effect, d = 0.400, 95% CI (0.235, 0.566), p < 0.001, of CBT for depression and anxiety disorders in primary care was identified. Subgroup analyses indicated significant treatment effect for: (1) depressive (d = 0.425, p < 0.001) and anxiety (d = 0.393, p < 0.01) outcomes, (2) studies conducted inside primary care (d = 0.412, p < 0.001), (3) studies using individual-based CBT (d = 0.412, p < 0.001), (4) studies without primary care physician involvement (d = 0.395, p < 0.001), and (5) studies using both tele-health (d = 0.563, p < 0.001) and in-person CBT (d = 0.363, p < 0.001). The percentage of White participants, treatment composition (CBT only versus CBT + other approaches), and treatment duration were significant moderators. Implications for clinical practice are discussed based on both moderator and subgroup analysis results.

The effectiveness of four empirically supported psychotherapies for primary care depression and anxiety: A systematic review and meta-analysis

BACKGROUND

Depressive and anxiety disorders are highly prevalent and detrimental in primary care settings. However, there are gaps in the literature concerning effectiveness and generalizability of empirically supported interventions and treatment of both depression and anxiety in primary care settings. The aim of this review is to systematically assess and meta-analyze the effectiveness of brief empirically-supported psychotherapies for treating depression and/or anxiety in primary care.

METHODS

Seven electronic databases, five professional websites and manual search of reference lists were searched through April 2017 for randomized controlled trials (RCTs) of four psychotherapies treating primary care depression and anxiety: cognitive-behavior therapy (CBT), problem-solving therapy (PST), motivational interviewing (MI), and solution-focused brief therapy (SFBT).

RESULTS

From an initial pool of 1140 articles, 179 articles were eligible for full-text review and 65 articles were included for final analysis. Sixty-five articles containing 198 effect sizes reported an overall treatment effect size of d = 0.462, p < 0.001. Single-predictor meta-regression indicated that marital status, treatment modality (individual versus group), and treatment composition were significant moderators. Multiple-predictor meta-regression discovered treatment setting (inside versus outside primary care) significantly moderated treatment effect, b = -0.863, p = 0.039 after controlling for other intervention characteristics.

CONCLUSION

Treatment effects were found for CBT and PST, both for depressive and anxiety disorders. Interventions delivered outside primary care settings were more effective than those within, individual treatment had greater treatment effects compared to group treatment, and both technology-assisted and in-person treatments were found to be effective.

The GET READY relapse prevention programme for anxiety and depression: a mixed-methods study protocol

BACKGROUND

Since anxiety and depressive disorders often recur, self-management competencies are crucial for improving the long-term course of anxiety and depressive disorders. However, few relapse prevention programmes are available that focus on improving self-management. E-health combined with personal contact with a mental health professional in general practice might be a promising approach for relapse prevention. In this protocol, the GET READY (Guided E-healTh for RElapse prevention in Anxiety and Depression) study will be described in which a relapse prevention programme is developed, implemented and evaluated. The aim of the study is to determine patients' usage of the programme and the associated course of their symptoms, to examine barriers and facilitators of implementation, and to assess patients' satisfaction with the programme.

METHODS

Participants are discharged from mental healthcare services, and are in complete or partial remission. They receive access to an E-health platform, combined with regular contact with a mental health professional in general practices. Online questionnaires will be completed at baseline and after 3, 6 and 9 months. Also, semi-structured qualitative individual interviews and focus group interviews will be conducted with patients and mental health professionals.

DISCUSSION

This mixed-methods observational cohort study will provide insights into the use of a relapse prevention programme in relation to the occurrence of symptoms, as well as in its implementation and evaluation. Using the results of this study, the relapse prevention programme can be adapted in accordance with the needs of patients and mental health professionals. If this programme is shown to be acceptable, a randomized controlled trial may be conducted to test its efficacy.

TRIAL REGISTRATION

Retrospectively registered in the Netherlands Trial Register ( NTR7574 ; 25 October 2018).

Cost-effectiveness, cost-utility and the budget impact of antidepressants versus preventive cognitive therapy with or without tapering of antidepressants

BACKGROUND

As depression has a recurrent course, relapse and recurrence prevention is essential.AimsIn our randomised controlled trial (registered with the Nederlands trial register, identifier: NTR1907), we found that adding preventive cognitive therapy (PCT) to maintenance antidepressants (PCT+AD) yielded substantial protective effects versus antidepressants only in individuals with recurrent depression. Antidepressants were not superior to PCT while tapering antidepressants (PCT/-AD). To inform decision-makers on treatment allocation, we present the corresponding cost-effectiveness, cost-utility and budget impact.

METHOD

Data were analysed (n = 289) using a societal perspective with 24-months of follow-up, with depression-free days and quality-adjusted life years (QALYs) as health outcomes. Incremental cost-effectiveness ratios were calculated and cost-effectiveness planes and cost-effectiveness acceptability curves were derived to provide information about cost-effectiveness. The budget impact was examined with a health economic simulation model.

RESULTS

Mean total costs over 24 months were €6814, €10 264 and €13 282 for AD+PCT, antidepressants only and PCT/-AD, respectively. Compared with antidepressants only, PCT+AD resulted in significant improvements in depression-free days but not QALYs. Health gains did not significantly favour antidepressants only versus PCT/-AD. High probabilities were found that PCT+AD versus antidepressants only and antidepressants only versus PCT/-AD were dominant with low willingness-to-pay thresholds. The budget impact analysis showed decreased societal costs for PCT+AD versus antidepressants only and for antidepressants only versus PCT/-AD.

CONCLUSIONS

Adding PCT to antidepressants is cost-effective over 24 months and PCT with guided tapering of antidepressants in long-term users might result in extra costs. Future studies examining costs and effects of antidepressants versus psychological interventions over a longer period may identify a break-even point where PCT/-AD will become cost-effective.Declaration of interestC.L.H.B. is co-editor of PLOS One and receives no honorarium for this role. She is also co-developer of the Dutch multidisciplinary clinical guideline for anxiety and depression, for which she receives no remuneration. She is a member of the scientific advisory board of the National Insure Institute, for which she receives an honorarium, although this role has no direct relation to this study. C.L.H.B. has presented keynote addresses at conferences, such as the European Psychiatry Association and the European Conference Association, for which she sometimes receives an honorarium. She has presented clinical training workshops, some including a fee. She receives royalties from her books and co-edited books and she developed preventive cognitive therapy on the basis of the cognitive model of A. T. Beck. W.A.N. has received grants from the Netherlands Organisation for Health Research and Development and the European Union and honoraria and speakers' fees from Lundbeck and Aristo Pharma, and has served as a consultant for Daleco Pharma.

A supported self-help for recurrent depression in primary care; An economic evaluation alongside a multi-center randomised controlled trial

BACKGROUND

Major depression is a prevalent mental disorder with a high risk of relapse or recurrence. Only few studies have focused on the cost-effectiveness of interventions aimed at the prevention of relapse or recurrence of depression in primary care.

AIM

To evaluate the cost-effectiveness of a supported Self-help Preventive Cognitive Therapy (S-PCT) added to treatment-as-usual (TAU) compared with TAU alone for patients with a history of depression, currently in remission.

METHODS

An economic evaluation alongside a multi-center randomised controlled trial was performed (n = 248) over a 12-month follow-up. Outcomes included relapse or recurrence of depression and quality-adjusted-life-years (QALYs) based on the EuroQol-5D. Analyses were performed from both a societal and healthcare perspective. Missing data were imputed using multiple imputations. Uncertainty was estimated using bootstrapping and presented using the cost-effectiveness plane and the Cost-Effectiveness Acceptability Curve (CEAC). Cost estimates were adjusted for baseline costs.

RESULTS

S-PCT statistically significantly decreased relapse or recurrence by 15% (95%CI 3;28) compared to TAU. Mean total societal costs were €2,114 higher (95%CI -112;4261). From a societal perspective, the ICER for relapse or recurrence was 13,515. At a Willingness To Pay (WTP) of 22,000 €/recurrence prevented, the probability that S-PCT is cost-effective, in comparison with TAU, is 80%. The ICER for QALYs was 63,051. The CEA curve indicated that at a WTP of 30,000 €/QALY gained, the probability that S-PCT is cost-effective compared to TAU is 21%.

CONCLUSIONS

Though ultimately depending on the WTP of decision makers, we expect that for both relapse or recurrence and QALYs, S-PCT cannot be considered cost-effective compared to TAU.

Development and validation of a clinical prediction tool to estimate the individual risk of depressive relapse or recurrence in individuals with recurrent depression

OBJECTIVES

Many studies examined predictors of depressive relapse/recurrence but no simple tool based on well-established risk factors is available that estimates the risk within an individual. We developed and validated such a prediction tool in remitted recurrently depressed individuals.

METHODS

The tool was developed using data (n = 235) from a pragmatic randomised controlled trial in remitted recurrently depressed participants and externally validated using data (n = 209) from a similar randomised controlled trial of remitted recurrently depressed participants using maintenance antidepressants. Cox regression was used with time to relapse/recurrence within 2 years as outcome and well-established risk factors as predictors. Performance measures and absolute risk scores were calculated, a practically applicable risk score was created, and the tool was externally validated.

RESULTS

The 2-year cumulative proportion relapse/recurrence was 46.2% in the validation dataset. The tool included number of previous depressive episodes, residual depressive symptoms, severity of the last depressive episode, and treatment. The C-statistic and calibration slope were 0.56 and 0.81 respectively. The tool stratified participants into relapse/recurrence risk classes of 37%, 55%, and 72%. The C-statistic and calibration slope in the external validation were 0.59 and 0.56 respectively, and Kaplan Meier curves showed that the tool could differentiate between risk classes.

CONCLUSIONS

This is the first study that developed a simple prediction tool based on well-established risk factors of depressive relapse/recurrence, estimating the individual risk. Since the overall performance of the model was poor, more studies are needed to enhance the performance before recommending implementation into clinical practice.

Effectiveness of preventive cognitive therapy while tapering antidepressants versus maintenance antidepressant treatment versus their combination in prevention of depressive relapse or recurrence (DRD study): a three-group, multicentre, randomised controlled trial

BACKGROUND

Keeping individuals on antidepressants after remission or recovery of major depressive disorder is a common strategy to prevent relapse or recurrence. Preventive cognitive therapy (PCT) has been proposed as an alternative to maintenance antidepressant treatment, but whether its addition would allow tapering of antidepressants or enhance the efficacy of maintenance antidepressant treatment is unclear. We aimed to compare the effectiveness of antidepressants alone, with PCT while tapering off antidepressants, or PCT added to antidepressants in the prevention of relapse and recurrence.

METHODS

In this single-blind, multicentre, parallel, three-group, randomised controlled trial, individuals recruited by general practitioners, pharmacists, secondary mental health care, or media were randomly assigned (10:10:8) to PCT and antidepressants, antidepressants alone, or PCT with tapering of antidepressants, using computer-generated randomised allocation stratified for number of previous depressive episodes and type of care. Eligible participants had previously experienced at least two depressive episodes and were in remission or recovery on antidepressants, which they had been receiving for at least the past 6 months. Exclusion criteria were current mania or hypomania, a history of bipolar disorder, any history of psychosis, current alcohol or drug abuse, an anxiety disorder that requires treatment, psychological treatment more than twice a month, and a diagnosis of organic brain damage. The primary outcome was time-related proportion of individuals with depressive relapse or recurrence in the intention-to-treat population, assessed four times in 24 months. Assessors were masked to treatment allocation, whereas physicians and participants could not be masked. This trial is registered with the Netherlands Trial Register, number NTR1907.

FINDINGS

Between July 14, 2009, and April 30, 2015, 2486 participants were assessed for eligibility and 289 were randomly assigned to PCT and antidepressant (n=104), antidepressant alone (n=100), or PCT with tapering of antidepressant (n=85). The overall log-rank test was significant (p=0·014). Antidepressants alone were not superior to PCT while tapering off antidepressants in terms of the risk of relapse or recurrence (hazard ratio [HR] 0·86, 95% CI 0·56-1·32; p=0·502). Adding PCT to antidepressant treatment resulted in a 41% relative risk reduction compared with antidepressants alone (0·59, 0·38-0·94; p=0·026). There were two suicide attempts (one in the antidepressants alone group and one in the PCT with tapering of antidepressants group) and one death (in the PCT and antidepressants group) not related to the interventions during the 24 months' follow-up.

INTERPRETATION

Maintenance antidepressant treatment is not superior to PCT after recovery, whereas adding PCT to antidepressant treatment after recovery is superior to antidepressants alone. PCT should be offered to recurrently depressed individuals on antidepressants and to individuals who wish to stop antidepressants after recovery.

FUNDING

The Netherlands Organisation for Health Research and Development.