A potentially valuable approach, especially for patients with unstable remissions who wish to discontinue their medication after successful acute treatment.
Discontinuation of antidepressants after successful treatment of recurrent depression causes relapse in many patients. In a randomized, controlled trial, researchers evaluated the 18-month effectiveness of three maintenance approaches — mindfulness-based cognitive therapy (MBCT), continued antidepressant monotherapy, and pill placebo plus clinical management. Of 160 patients with recurrent depression who received open-label, two-step antidepressant monotherapy, 84 achieved remission in at least 7 months and entered the maintenance phase. Remission before randomization was labeled as stable (n=41 patients) or unstable (i.e., patients had frequent symptom flurries before finally remitting; n=43).
Mindfulness skills, taught in eight weekly 2-hour group meetings and a daylong retreat after session six, helped patients substitute nonjudgmental awareness and acceptance for automatic modes of thinking that promote rumination and avoidance. Treatment effects of MBCT were significant only in unstable remitters; relapse rates in this subgroup were significantly lower with continuation pharmacotherapy (27%) and MBCT (28%) than with placebo (71%), in contrast to the relapse rates in patients who had achieved stable remission before randomization (59%, 62%, and 50%, respectively).
Comment: This study shows that medication and MBCT had prophylactic effects only in patients with an unstable pattern of remission. The small effect of prophylactic pharmacotherapy in stable remitters is puzzling; the authors speculate that these patients might have been responding to nonspecific supportive aspects of the intervention. Nonetheless, the equivalent effect of mindfulness and continuation medication in unstable remitted patients is noteworthy and suggests the value of this approach for patients wishing to discontinue their medication after successful acute treatment.
