Who Best Responds to Maintenance Cognitive Therapy?

May 28, 2015

Identifying patients who are likely to relapse despite continued, maintenance cognitive therapy can help optimize management of MDD and also help ensure efficient use of healthcare resources.

RESEARCH UPDATE

Method Pinpointed to Identify Who Best Responds to Maintenance Cognitive Therapy

Specific patient characteristics following acute-phase cognitive therapy for major depressive disorder (MDD) predict effectiveness of continuation-phase cognitive therapy.1 Although major depression resolves in 50% to 70% of patients who complete acute-phase cognitive therapy, relapse/recurrence occurs in about 39%. Continuation of cognitive therapy mitigates relapse/recurrence in some but not all patients. Identifying patients who are likely to relapse despite continued, maintenance cognitive therapy can help optimize management of MDD and also help ensure efficient use of healthcare resources.

To identify patients who would benefit from alternative forms of maintenance therapy following acute-phase cognitive therapy rather than continuous-phase cognitive therapy alone, a multicenter team of researchers from 4 US teaching universities conducted a study that followed a subset of patients who had completed acute-phase therapy for treatment of a major depressive event.1 The subset consisted of 241 patients deemed to be at higher risk for relapse following acute-phase therapy, evidenced by their Hamilton Rating Scale for Depression scores.

The patients were randomly selected to receive either 8 months of continuation-phase therapy, fluoxetine, or placebo, and, upon completion, were followed for 24 months. The continuation-phase protocol consisted of ten 60-minute sessions (4 biweekly followed by 6 monthly sessions). A double-blind protocol was followed for groups receiving fluoxetine or placebo.

At randomization, patients underwent a battery of measures to assess depressive symptoms (Beck Depression Inventory,  Inventory of Depressive Symptomatology-Self-Report, and Hamilton Rating Scale of Depression), social functioning (Social Adjustment Scale-Self-Report, Inventory of Interpersonal Problem, and Perceived Criticism Scale, and Dyadic Adjustment Scale), cognition (Dysfunctional Attitudes Scale, Attributional Style Questionnaire, Self-Control Schedule, and the Beck Hopelessness Scale), and personality-disorder status (Schedule for Nonadaptive and Adaptive Personality-2nd Edition). Relapse, recurrence, remission, and recovery were measured using the Longitudinal Interval Follow-Up Evaluation and weekly psychiatric status ratings.

At study end, the authors determined that patients with lower behavioral activation (ie, lower engagement of resourceful behaviors and functioning) and lesser ratings for positive emotionality following acute-phase cognitive therapy can be expected to have a relapse or recurrence within 32 months regardless of receipt of continuous-phase cognitive therapy (P ≤. 01). In addition, those who have higher levels of residual depression following acute-phase therapy are unlikely to achieve remission (defined as 6 continuous weeks of minimal or absent symptoms; P <.01). Greater residual depression, younger age, and earlier onset of MDD also were predictive of decreased probability of recovery (defined as 35 continuous weeks of minimal or absent symptoms; P <.01) after acute-phase cognitive therapy despite continuation-phase cognitive therapy.

These results confirmed findings derived from an earlier clinical trial by the same researchers.2In that study, follow-up results showed that better long-term outcomes after acute-phase cognitive therapy were associated with older age, later onset of MDD, less depressive cognitive content, fewer residual symptoms, better social interpersonal functioning, higher positive temperament, and less social reticence/reserve.

The results provide clinical insight regarding prognosis and the appropriateness of continuation-phase cognitive therapy among patients with MDD who respond to acute-phase cognitive therapy.

References:

1. Vittengl JR, Clark LA, Thase ME, Jarrett RB. Predictors of longitudinal outcomes after unstable response to acute-phase cognitive therapy for major depressive disorder. Psychotherapy (Chic). 2015;52:268-277. http://psycnet.apa.org/journals/pst/52/2/268. Accessed May 28, 2015.

2. Vittengl J, Clark LA., Jarrett RB. Moderators of continuation phase cognitive therapy’s effects on relapse, recurrence, remission, and recovery from depression. Behav Res Ther, 2010;,48(6):449-458. http://www.sciencedirect.com/science/article/pii/S0005796710000070. Accessed May 28, 2015.