Mindfulness Therapy may decrease need for Antidepressants

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From Medscape May 1, 2015

Mindfulness-based cognitive therapy (MBCT) may offer an effective alternative to drug treatment for recurrent depression, new research suggests.

Results of a randomized controlled trial, the first to directly compare MBCT with maintenance antidepressant treatment to prevent relapse in patients with at least three prior major depressive episodes, showed no difference in health outcomes or cost between the two therapies.

However, investigators note that “when considered in the context of the totality of randomized controlled data, we found evidence from this trial to support MBCT-TS [MBCT with support to taper or discontinue antidepressant treatment] as an alternative to maintenance antidepressants for prevention of depressive relapse or recurrence at similar costs.”

The findings were published online April 21 in the Lancet.

High Relapse Risk

Investigators led by Sarah Byford, PhD, professor of health economics, Centre for the Economics of Mental Health at the Institute of Psychiatry at King’s College London, in the United Kingdom, note that individuals with a history of recurrent depression are at high risk for relapse.

Dr Byford told Medscape Medical News that previous research has shown that maintenance with antidepressants reduces the likelihood of relapse by up to 66%. The problem is that patients tend to stop taking maintenance medications, typically because of side effects or a preference for psychotherapy.

MBCT is a manualized group therapy aimed at enabling individuals to learn skills to combat depression by becoming more aware of, and reacting more constructively to, their body sensations, thoughts, and feelings.

It combines mindfulness-based stress reduction techniques with cognitive-behavioral therapy for acute depression. The intervention consisted of MBCT with counseling on how to taper antidepressants.

MBCT has been shown to reduce risk for relapse or recurrence compared with usual care, but it had not been compared with maintenance antidepressant treatment in a definitive trial.

To determine whether MBCT-TS was superior to maintenance antidepressants for prevention of depressive relapse or recurrence, the investigators conducted a single-blind, parallel, group randomized controlled trial.

The study included 424 patients with recurrent depression in primary care practices randomly assigned to receive either MBCT (n = 212) or continued maintenance with antidepressants (n = 212). MBCT consisted of eight 2.25-hour group sessions led by a trained therapist and daily home practice with the option of participating in four refresher sessions every 3 months for 1 year. The patients were aware of their treatment, but the research assessors were blinded to the patients’ treatment assignment.

After 2 years of treatment, there was no difference in the effectiveness between groups for depression relapse, defined by meeting DSM-IV criteria for a major depressive episode. Relapse occurred in 44% of MBCT patients and in 47% of maintenance antidepressant patients (hazard ratio, 0.89; 95% confidence interval, 0.67 – 1.18).

Although the investigators postulated that MBCT would have superior effectiveness, their “finding of no difference suggests that both groups improved substantially,” said Dr Byford.

The researchers also assessed the economic costs of MBCT-TS vs maintenance antidepressants. It examined costs of heathcare and social services, as well as costs associated with lost productivity from time off work and reduced productivity at work. The study showed no significant differences between groups in all types of costs.

The trial also showed no differences in quality of life between treatment groups. Quality of life was measured by two questionnaires, the WHO Quality of Life Instrument and the health-related quality of life, EuroQuol-5D-3L.

Ten serious adverse events, including four suicides, were reported. The adverse events were evenly split among treatment groups. None of the adverse events were deemed related to the intervention.

Although the investigators found no evidence that MBCT-TS is superior to antidepressants in preventing relapse, the investigators note that it may provide a viable alternative to antidepressants, allowing “individuals to stay well and maintain a good quality of life.” However, Dr Byford noted that the problem now is that “there are too few MBCT-trained therapists to whom general practitioners can refer patients.”

Important Treatment Option

In an accompanying commentary, Roger Mulder, MB, ChB, PhD, professor, Department of Psychological Medicine, University of Otago, in New Zealand, said that despite the study’s apparent negative result, the findings have substantial clinical significance.

MBCT “might offer a similar ongoing protective effect as that of maintenance antidepressants. MBCT therefore provides an alternative effective treatment for patients who cannot tolerate or do not wish to have maintenance antidepressants,” Dr Mulder writes.

“Depression remains a disabling condition with high prevalence and a large clinical burden. Despite the increased use of drugs, the long-term outcome of mood disorders has not improved in the modern era. Having an alternative non-medication strategy to reduce relapse is an important means to help patients with depression,” he adds.

The research was funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment program and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula. Dr Byford and Dr Mulder report no relevant financial relationships.

Lancet. Published online April 21, 2015. Full text

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