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Cohen ZD, DeRubeis RJ, Hayes R, Watkins ER, Lewis G, Byng R, Byford S, Crane C, Kuyken W, Dalgleish T, Schweizer S. The development and internal evaluation of a predictive model to identify for whom Mindfulness-Based Cognitive Therapy (MBCT) offers superior relapse prevention for recurrent depression versus maintenance antidepressant medication. Clin Psychol Sci 2023; 11:59-76. [PMID: 36698442 PMCID: PMC7614103 DOI: 10.1177/21677026221076832] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Depression is highly recurrent, even following successful pharmacological and/or psychological intervention. We aimed to develop clinical prediction models to inform adults with recurrent depression choosing between antidepressant medication (ADM) maintenance or switching to Mindfulness-Based Cognitive Therapy (MBCT). Using data from the PREVENT trial (N=424), we constructed prognostic models using elastic net regression that combined demographic, clinical and psychological factors to predict relapse at 24 months under ADM or MBCT. Only the ADM model (discrimination performance: AUC=.68) predicted relapse better than baseline depression severity (AUC=.54; one-tailed DeLong's test: z=2.8, p=.003). Individuals with the poorest ADM prognoses who switched to MBCT had better outcomes compared to those who maintained ADM (48% vs. 70% relapse, respectively; superior survival times [z=-2.7, p=.008]). For individuals with moderate-to-good ADM prognosis, both treatments resulted in similar likelihood of relapse. If replicated, the results suggest that predictive modeling can inform clinical decision-making around relapse prevention in recurrent depression.
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Affiliation(s)
| | | | - Rachel Hayes
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula, University of Exeter
| | | | - Glyn Lewis
- Division of Psychiatry, Faulty of Brain Sciences, University College London
- Community Primary Care Research Group, University of Plymouth
| | - Richard Byng
- Community Primary Care Research Group, University of Plymouth
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care, South West Peninsula, England
| | - Sarah Byford
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London
| | - Catherine Crane
- Department of Psychiatry, Medical Sciences Division, University of Oxford
| | - Willem Kuyken
- Department of Psychiatry, Medical Sciences Division, University of Oxford
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, University of Cambridge
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, England
| | - Susanne Schweizer
- Department of Psychology, University of Cambridge
- School of Psychology, University of New South Wales
- Susanne Schweizer, Department of Psychology, University of Cambridge
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Hensen B, Phiri M, Schaap A, Sigande L, Simwinga M, Floyd S, Belemu S, Simuyaba M, Shanaube K, Fidler S, Hayes R, Ayles HM. Uptake of HIV Testing Services Through Novel Community-Based Sexual and Reproductive Health Services: An Analysis of the Pilot Implementation Phase of the Yathu Yathu Intervention for Adolescents and Young People Aged 15-24 in Lusaka, Zambia. AIDS Behav 2022; 26:172-182. [PMID: 34302282 DOI: 10.1007/s10461-021-03368-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/24/2022]
Abstract
Adolescents and young people aged 15-24 are underserved by available HIV-testing services (HTS). Delivering HTS through community-based, peer-led, hubs may prove acceptable and accessible to adolescents and young people, thus increasing HIV-testing coverage. We used data from the pilot phase of a cluster-randomised trial of community-based sexual and reproductive health services for adolescents and young people in Lusaka, Zambia, between September 2019 and January 2020, to explore factors associated with uptake of HTS through community-based hubs. 5,757 adolescents and young people attended the hubs (63% female), among whom 75% tested for HIV (76% of females, 75% of males). Community-based hubs provided HTS to 80% of adolescents and young people with no history of HIV-testing. Among females, uptake of HTS was lower among married/cohabiting females; among males, uptake was lower among unmarried males and among individuals at risk of hazardous alcohol use. The high number of adolescents and young people accessing hubs for HIV testing suggests they are acceptable. Enhanced targeting of HTS to groups who may not perceive their HIV risk needs to be implemented.
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Affiliation(s)
- B Hensen
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
| | | | - A Schaap
- Zambart, Lusaka, Zambia
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - S Floyd
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - S Fidler
- Imperial College London, Imperial College National Institute of Heath Research BRC, London, UK
| | - R Hayes
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - H M Ayles
- Faculty of Infectious and Tropical Diseases, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
- Zambart, Lusaka, Zambia
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Tickell A, Byng R, Crane C, Gradinger F, Hayes R, Robson J, Cardy J, Weaver A, Morant N, Kuyken W. Recovery from recurrent depression with mindfulness-based cognitive therapy and antidepressants: a qualitative study with illustrative case studies. BMJ Open 2020; 10:e033892. [PMID: 32075835 PMCID: PMC7044862 DOI: 10.1136/bmjopen-2019-033892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study aimed to describe the recovery journeys of people with a history of recurrent depression who took part in a psychosocial programme designed to teach skills to prevent depressive relapse (mindfulness-based cognitive therapy (MBCT)), alongside maintenance antidepressant medication (ADM). DESIGN A qualitative study embedded within a multicentre, single blind, randomised controlled trial (the PREVENT trial). SETTING Primary care urban and rural settings in the UK. PARTICIPANTS 42 people who participated in the MBCT arm of the parent trial were purposively sampled to represent a range of recovery journeys. INTERVENTIONS MBCT involves eight weekly group sessions, with four refresher sessions offered in the year following the end of the programme. It was adapted to offer bespoke support around ADM tapering and discontinuation. METHODS Written feedback and structured in-depth interviews were collected in the 2 years after participants undertook MBCT. Data were analysed using thematic analysis and case studies constructed to illustrate the findings. RESULTS People with recurrent depression have unique recovery journeys that shape and are shaped by their pharmacological and psychological treatment choices. Their journeys typically include several over-arching themes: (1) beliefs about the causes of depression, both biological and psychosocial; (2) personal agency, including expectations about their role in recovery and treatment; (3) acceptance, both of depression itself and the recovery journey; (4) quality of life; (5) experiences and perspectives on ADM and ADM tapering-discontinuation; and (6) the role of general practitioners, both positive and negative. CONCLUSIONS People with recurrent depression describe unique, complex recovery journeys shaped by their experiences of depression, treatment and interactions with health professionals. Understanding how several themes coalesce for each individual can both support their recovery and treatment choices as well as health professionals in providing more accessible, collaborative, individualised and empowering care. TRIAL REGISTRATION NUMBER Clinical trial number ISRCTN26666654; post results.
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Affiliation(s)
- Alice Tickell
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Richard Byng
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Felix Gradinger
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Rachel Hayes
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - James Robson
- Department of Education, University of Oxford, Oxford, UK
| | - Jessica Cardy
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Alice Weaver
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Nicola Morant
- Department of Psychiatry, University College London, London, UK
| | - Willem Kuyken
- Department of Psychiatry, University of Oxford, Oxford, UK
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Maund E, Stuart B, Moore M, Dowrick C, Geraghty AWA, Dawson S, Kendrick T. Managing Antidepressant Discontinuation: A Systematic Review. Ann Fam Med 2019; 17:52-60. [PMID: 30670397 PMCID: PMC6342590 DOI: 10.1370/afm.2336] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/08/2018] [Accepted: 11/01/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients. METHODS We conducted a systematic review with narrative synthesis and meta-analysis of studies published to March 2017. Studies were eligible for inclusion if they were randomized controlled trials, quasi-experimental studies, or observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Our primary outcomes were antidepressant discontinuation and discontinuation symptoms. Secondary outcomes were relapse/recurrence; quality of life; antidepressant reduction; and sexual, social, and occupational function. RESULTS Of 15 included studies, 12 studies (8 randomized controlled trials, 2 single-arm trials, 2 retrospective cohort studies) were included in the synthesis. None were rated as having high risk for selection or detection bias. Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, vs 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/recurrence was lower with cognitive behavioral therapy plus taper vs clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18-0.67; 2 studies). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; 2 studies). CONCLUSIONS Cognitive behavioral therapy or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence, but are resource intensive. More scalable interventions incorporating psychological support are needed.
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Affiliation(s)
- Emma Maund
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Michael Moore
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Adam W A Geraghty
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Sarah Dawson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tony Kendrick
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
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Ijaz S, Davies P, Williams CJ, Kessler D, Lewis G, Wiles N. Psychological therapies for treatment-resistant depression in adults. Cochrane Database Syst Rev 2018; 5:CD010558. [PMID: 29761488 PMCID: PMC6494651 DOI: 10.1002/14651858.cd010558.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antidepressants are a first-line treatment for adults with moderate to severe major depression. However, many people prescribed antidepressants for depression don't respond fully to such medication, and little evidence is available to inform the most appropriate 'next step' treatment for such patients, who may be referred to as having treatment-resistant depression (TRD). National Institute for Health and Care Excellence (NICE) guidance suggests that the 'next step' for those who do not respond to antidepressants may include a change in the dose or type of antidepressant medication, the addition of another medication, or the start of psychotherapy. Different types of psychotherapies may be used for TRD; evidence on these treatments is available but has not been collated to date.Along with the sister review of pharmacological therapies for TRD, this review summarises available evidence for the effectiveness of psychotherapies for adults (18 to 74 years) with TRD with the goal of establishing the best 'next step' for this group. OBJECTIVES To assess the effectiveness of psychotherapies for adults with TRD. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (until May 2016), along with CENTRAL, MEDLINE, Embase, and PsycINFO via OVID (until 16 May 2017). We also searched the World Health Organization (WHO) trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. There were no date or language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) with participants aged 18 to 74 years diagnosed with unipolar depression that had not responded to minimum four weeks of antidepressant treatment at a recommended dose. We excluded studies of drug intolerance. Acceptable diagnoses of unipolar depression were based onthe Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) or earlier versions, International Classification of Diseases (ICD)-10, Feighner criteria, or Research Diagnostic Criteria. We included the following comparisons.1. Any psychological therapy versus antidepressant treatment alone, or another psychological therapy.2. Any psychological therapy given in addition to antidepressant medication versus antidepressant treatment alone, or a psychological therapy alone.Primary outcomes required were change in depressive symptoms and number of dropouts from study or treatment (as a measure of acceptability). DATA COLLECTION AND ANALYSIS We extracted data, assessed risk of bias in duplicate, and resolved disagreements through discussion or consultation with a third person. We conducted random-effects meta-analyses when appropriate. We summarised continuous outcomes using mean differences (MDs) or standardised mean differences (SMDs), and dichotomous outcomes using risk ratios (RRs). MAIN RESULTS We included six trials (n = 698; most participants were women approximately 40 years of age). All studies evaluated psychotherapy plus usual care (with antidepressants) versus usual care (with antidepressants). Three studies addressed the addition of cognitive-behavioural therapy (CBT) to usual care (n = 522), and one each evaluated intensive short-term dynamic psychotherapy (ISTDP) (n = 60), interpersonal therapy (IPT) (n = 34), or group dialectical behavioural therapy (DBT) (n = 19) as the intervention. Most studies were small (except one trial of CBT was large), and all studies were at high risk of detection bias for the main outcome of self-reported depressive symptoms.A random-effects meta-analysis of five trials (n = 575) showed that psychotherapy given in addition to usual care (vs usual care alone) produced improvement in self-reported depressive symptoms (MD -4.07 points, 95% confidence interval (CI) -7.07 to -1.07 on the Beck Depression Inventory (BDI) scale) over the short term (up to six months). Effects were similar when data from all six studies were combined for self-reported depressive symptoms (SMD -0.40, 95% CI -0.65 to -0.14; n = 635). The quality of this evidence was moderate. Similar moderate-quality evidence of benefit was seen on the Patient Health Questionnaire-9 Scale (PHQ-9) from two studies (MD -4.66, 95% CI 8.72 to -0.59; n = 482) and on the Hamilton Depression Rating Scale (HAMD) from four studies (MD -3.28, 95% CI -5.71 to -0.85; n = 193).High-quality evidence shows no differential dropout (a measure of acceptability) between intervention and comparator groups over the short term (RR 0.85, 95% CI 0.58 to 1.24; six studies; n = 698).Moderate-quality evidence for remission from six studies (RR 1.92, 95% CI 1.46 to 2.52; n = 635) and low-quality evidence for response from four studies (RR 1.80, 95% CI 1.2 to 2.7; n = 556) indicate that psychotherapy was beneficial as an adjunct to usual care over the short term.With the addition of CBT, low-quality evidence suggests lower depression scores on the BDI scale over the medium term (12 months) (RR -3.40, 95% CI -7.21 to 0.40; two studies; n = 475) and over the long term (46 months) (RR -1.90, 95% CI -3.22 to -0.58; one study; n = 248). Moderate-quality evidence for adjunctive CBT suggests no difference in acceptability (dropout) over the medium term (RR 0.98, 95% CI 0.66 to 1.47; two studies; n = 549) and lower dropout over long term (RR 0.80, 95% CI 0.66 to 0.97; one study; n = 248).Two studies reported serious adverse events (one suicide, two hospitalisations, and two exacerbations of depression) in 4.2% of the total sample, which occurred only in the usual care group (no events in the intervention group).An economic analysis (conducted as part of an included study) from the UK healthcare perspective (National Health Service (NHS)) revealed that adjunctive CBT was cost-effective over nearly four years. AUTHORS' CONCLUSIONS Moderate-quality evidence shows that psychotherapy added to usual care (with antidepressants) is beneficial for depressive symptoms and for response and remission rates over the short term for patients with TRD. Medium- and long-term effects seem similarly beneficial, although most evidence was derived from a single large trial. Psychotherapy added to usual care seems as acceptable as usual care alone.Further evidence is needed on the effectiveness of different types of psychotherapies for patients with TRD. No evidence currently shows whether switching to a psychotherapy is more beneficial for this patient group than continuing an antidepressant medication regimen. Addressing this evidence gap is an important goal for researchers.
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Affiliation(s)
- Sharea Ijaz
- Population Health Sciences, Bristol Medical School, University of BristolNIHR CLAHRC West at University Hospitals Bristol NHS Foundation TrustLewins Mead, Whitefriars BuildingBristolUKBS1 2NT
| | - Philippa Davies
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
| | - Catherine J Williams
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - David Kessler
- University of BristolSchool of Social and Community Medicine39 Whatley RoadBristolUKBS8 2PS
| | - Glyn Lewis
- UCLUCL Division of Psychiatry67‐73 Riding House StLondonUKW1W 7EJ
| | - Nicola Wiles
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge HallBristolUKBS8 2PS
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Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, Lewis G, Watkins E, Morant N, Taylor RS, Byford S. The effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse/recurrence: results of a randomised controlled trial (the PREVENT study). Health Technol Assess 2016; 19:1-124. [PMID: 26379122 DOI: 10.3310/hta19730] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Individuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial. OBJECTIVES To establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCT's acceptability and mechanism of action. DESIGN Single-blind, parallel, individual randomised controlled trial. SETTING UK general practices. PARTICIPANTS Adult patients with a diagnosis of recurrent depression and who were taking m-ADM. INTERVENTIONS Participants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCT's acceptability and mechanism of action. MAIN OUTCOMES MEASURES The primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities. RESULTS In total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation. CONCLUSIONS There is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group. TRIAL REGISTRATION Current Controlled Trials ISRCTN26666654. FUNDING This project was funded by the NIHR Health Technology Assessment programme and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula and will be published in full in Health Technology Assessment; Vol. 19, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Willem Kuyken
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Rachel Hayes
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Barbara Barrett
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | - Richard Byng
- Primary Care Group, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge, UK
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | | | - Nicola Morant
- Department of Psychology, University of Cambridge, Cambridge, UK
| | - Rod S Taylor
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Sarah Byford
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
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Demarzo MMP, Montero-Marin J, Cuijpers P, Zabaleta-del-Olmo E, Mahtani KR, Vellinga A, Vicens C, López-del-Hoyo Y, García-Campayo J. The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review. Ann Fam Med 2015; 13:573-82. [PMID: 26553897 PMCID: PMC4639383 DOI: 10.1370/afm.1863] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Positive effects have been reported after mindfulness-based interventions (MBIs) in diverse clinical and nonclinical populations. Primary care is a key health care setting for addressing common chronic conditions, and an effective MBI designed for this setting could benefit countless people worldwide. Meta-analyses of MBIs have become popular, but little is known about their efficacy in primary care. Our aim was to investigate the application and efficacy of MBIs that address primary care patients. METHODS We performed a meta-analytic review of randomized controlled trials addressing the effect of MBIs in adult patients recruited from primary care settings. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane guidelines were followed. Effect sizes were calculated with the Hedges g in random effects models. RESULTS The meta-analyses were based on 6 trials having a total of 553 patients. The overall effect size of MBI compared with a control condition for improving general health was moderate (g = 0.48; P = .002), with moderate heterogeneity (I(2) = 59; P <.05). We found no indication of publication bias in the overall estimates. MBIs were efficacious for improving mental health (g = 0.56; P = .007), with a high heterogeneity (I(2) = 78; P <.01), and for improving quality of life (g = 0.29; P = .002), with a low heterogeneity (I(2) = 0; P >.05). CONCLUSIONS Although the number of randomized controlled trials applying MBIs in primary care is still limited, our results suggest that these interventions are promising for the mental health and quality of life of primary care patients. We discuss innovative approaches for implementing MBIs, such as complex intervention and stepped care.
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Affiliation(s)
- Marcelo M P Demarzo
- Federal University of Sao Paulo (UNIFESP), "Mente Aberta" - Brazilian Center for Mindfulness and Health Promotion, Department of Preventive Medicine, Sao Paulo, Brazil
| | - Jesús Montero-Marin
- Faculty of Health Sciences and Sports, University of Zaragoza, Huesca, Spain
| | - Pim Cuijpers
- VU University Amsterdam, Department of Psychology, Amsterdam, Netherlands
| | | | - Kamal R Mahtani
- Oxford University, Department of Primary Care, Oxford, United Kingdom
| | - Akke Vellinga
- National University of Ireland, Galway, Department of Primary Care, Galway, Ireland
| | - Caterina Vicens
- Red de Investigación en Actividades Preventivas y Promoción de la Salud (redIAPP), Primary Care, Palma de Mallorca, Spain
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Abstract
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.
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Affiliation(s)
- Jeffrey R. Vittengl
- Department of Psychology, Truman State University, 100 East Normal Street, Kirksville, MO 63501-4221, USA. Telephone: 660-785-6041
| | - Robin B. Jarrett
- Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9149, USA. Telephone: 214-648-5345
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Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, Lewis G, Watkins E, Brejcha C, Cardy J, Causley A, Cowderoy S, Evans A, Gradinger F, Kaur S, Lanham P, Morant N, Richards J, Shah P, Sutton H, Vicary R, Weaver A, Wilks J, Williams M, Taylor RS, Byford S. 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. Lancet 2015; 386:63-73. [PMID: 25907157 DOI: 10.1016/s0140-6736(14)62222-4] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months. METHODS In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654. FINDINGS Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67-1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial. INTERPRETATION We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life. FUNDING National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.
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Affiliation(s)
- Willem Kuyken
- Department of Psychiatry, University of Oxford, Oxford, UK; Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK.
| | - Rachel Hayes
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Barbara Barrett
- Centre for the Economics of Mental and Physical Health, King's College London, London, UK
| | - Richard Byng
- Primary Care Group, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Tim Dalgleish
- Medical Research Council Cognition and Brain Sciences Unit, Cambridge, UK
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | - Edward Watkins
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Claire Brejcha
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Jessica Cardy
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Aaron Causley
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Suzanne Cowderoy
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Alison Evans
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Felix Gradinger
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Surinder Kaur
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Nicola Morant
- Department of Psychology, University of Cambridge, Cambridge, UK
| | | | - Pooja Shah
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Harry Sutton
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Rachael Vicary
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Alice Weaver
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Jenny Wilks
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Matthew Williams
- Mood Disorders Centre, Psychology, University of Exeter, Exeter, UK
| | - Rod S Taylor
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Sarah Byford
- Centre for the Economics of Mental and Physical Health, King's College London, London, UK
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