Combined Cognitive-Behavioral and Pharmacological Continuation and Maintenance Treatment of Recurrent Depression

• Applicants: Professor Dr. Martin Hautzinger; Professor Dr. Ulrich Stangier
• Subject Area: Personality Psychology, Clinical and Medical Psychology, Methodology
• Term: from 2005 to 2017
• Project identifier: Deutsche Forschungsgemeinschaft (DFG) - Project number 15048089

Final Report Abstract

While recurrent depression is an established indicator for pharmacological maintenance treatment, empirical support for the long-term benefit of additional cognitive-behavioral therapy in continuation or maintenance treatment is lacking. The major goal of the study is to compare the long-term outcome of cognitive-behavioural maintenance therapy (KET) plus pharmacological continuation/maintenance treatment (treatment as usual, TAU) versus manualized psychoeducation (MAPE) plus TAU for out-patients with recurrent depression in a multi-centre, controlled, randomised trial. Patients meeting the following criteria were included: diagnosis of recurrent depressive disorder (≥ 3 major depressive episodes, MDE), currently in remission; complete remission over 8 weeks after acute treatment of MDE; at least one index depressive episode in the 12 months prior to the intervention. Exclusion criteria were: organic disorder; psychological / behavioural disorders caused by psychotropic substances; schizophrenia; schizoaffective disorder; bipolar depression; moderate to severe mental retardation; acute suicidality; severe comorbid medical condition. Patients meeting the inclusion criteria were randomly assigned to one of the two conditions (KET plus TAU or MAPE plus TAU). 186 patients have been recruited from 12 outpatient clinics of psychiatric hospitals and psychological departments in the Rhine-Main region and Thuringia. 180 patients were included in the intent-to-treat analyses. There are no such long-term follow-ups of large and well controlled trails available. But in recurrent depression long-term relapse prevention is the most relevant outcome criteria. Results 1 (end of 1 year follow-up, 21 months after baseline): Cox regression analysis showed that time to relapse/recurrence of MDE did not differ significantly between both treatment conditions, but there was a significant interaction between treatment and the number of previous episodes (<5 vs. ≥5). Within the subsample of patients with 5 or more previous episodes, KET was significantly superior to MAPE, whereas for patients with less than 5 previous episodes, there were no significant treatment differences in time to relapse or recurrence of MDE. Results 2 (end of 3 years follow-up, 45 months after baseline): Cox regression analysis showed that time to relapse/recurrence of MDE did not differ significantly between both treatment conditions, but there was a significant interaction between treatment and the number of previous episodes (<5 vs. ≥5) during follow-up. Patients with higher number of previous episodes (> 5 MDE) benefit more from KET. KET reduced risk for a new MDE, in particular, in subjects with more previous episodes. Interventions did not differ in their effect on severity ratings (HDRS, BDI) and on functioning rating (GAF). Conclusions: Our findings indicate that Cognitive-Behavioral Therapy (KET) has significant effects on the prevention of relapse/recurrence, only in patients with a high risk of depression recurrence. For patients with a moderate risk of recurrence, non-specific effects and structured patient education with regular support (MAPE) may be equally effective. Overall, of 180 study patients with three or more previous episodes only 68 subjects had no new depressive episode during 45 months of study time, while 48 subjects had at least one and 64 subjects had even more than one new depressive episode. Our currently available treatments (medication as well as psychotherapy) are far from optimal to help patients to reduce significantly the risk for recurrence of a MDE.

Publications

• (2006) Neuere kognitiv-verhaltenstherapeutische Ansätze zur Rückfall-prävention bei rezidivierender Depression. Verhaltenstherapie 16, 275-281
  Risch AK, Stangier U
  
• (2009) Kognitive Verhaltenstherapie bei affektiven Störungen. Psychiatrie Up-to-Date 3, 9-20
  Hautzinger M
  
• (2010) Erfassung psychotherapeutischer Kompetenzen Validierung einer deutschsprachigen Version der Cognitive Therapy Scale. Zeitschrift für Klinische Psychologie und Psychotherapie 39, 244-250
  Weck F, Hautzinger M, Heidenreich T, Stangier U
  
• (2011) Psychoedukation bei rezidivierenden depressiven Störungen. Validierung einer Skala zur Erfassung von Behandlungskomponenten. Psychotherapie Psychosomatik Medizinische Psychologie 61, 148-153
  Weck F, Hautzinger M, Heidenreich T, Stangier U
  
• (2011) Reliability of adherence and competence assessment in cognitive behavioral therapy: influence of clinical experience. Journal of Nervous and Mental Disease 199, 276–279
  Weck F, Hilling C, Schermelleh-Engel K, Rudari V, Stangier U
  
• (2011) Reliability of adherence and competence assessment in psychoeducational treatment: influence of clinical experience. Journal of Nervous and Mental Disease 199, 983-986
  Weck F, Weigel M, Richtberg S, Stangier U
  
• (2012) Event-related brain potentials indicate increased concentration abilities after eight weeks of MBCT for depression. Psychiatry Research 199, 174-180
  Bostanov V, Keune P, Kotchoubey B, Hautzinger M
  
• (2012) Kognitive Erhaltungstherapie bei rezidivierender Depression. Heidelberg: Springer
  Risch AK, Stangier U, Heidenreich T, Hautzinger M
  
• (2012) Relapses in recurrent depression 1-year after psychoeducational treatment The role of therapist’s adherence therapist’s competence and the therapeutic alliance. Psychiatry Research 195, 51–55
  Weck F, Weigel M, Hautzinger M, Barocka A, Schlösser R, Stangier U
  
• (2013) Kognitive Verhaltenstherapie bei Depressionen (7. erweiterte Auflage). Weinheim: Beltz
  Hautzinger M
  
• (2013) Maintenance Cognitive Therapy and Manualized Psychoeducation in the Treatment of Recurrent Depression: a Randomized Controlled Trial. American Journal of Psychiatry 170, 624-632
  Stangier U, Hilling C, Heidenreich T, Risch AK, Barocka A, Schlösser R, Kronfeld K, Ruckes C, Berger H, Röschke J, Weck F, Volk S, Hembrecht M, Serfling R, Erkwoh R, Stirn A, Sobanski T, Hautzinger M
  
• (2013) Prevention of relapse in recurrent depression: Short-term and long-term outcome of a randomized controlled trial comparing cognitive maintenance therapy with manualized psychoeducation. EABCT Congress, Marakesh
  Stangier U, Heidenreich T, Hilling C, Barocka A, Risch AK, Schlösser R, Hautzinger M
  
• (2013) Relapses in recurrent depression one year after cognitive therapy: The role of therapist adherence competence and the therapeutic alliance. Psychiatry Research 210, 140-145
  Weck F, Rudari V, Hilling C, Hautzinger M, Heidenreich T, Schermelleh-Engel K, Stangier U
  
• (2014) Kognitive Erhaltungstherapie zur Rückfallprophylaxe bei unipolaren Depressionen (S. 215-232). In: Kunz O, Teismann T (Hrsg) Moderne Ansätze in der Depressionsbehandlung. Tübingen: dgvt Verlag
  Hautzinger M
  
• (2014) Kognitive Reaktivität und Stressbelastung als Prädiktoren eines Rezidivs bei remittiert depressiven Personen. Zeitschrift für Klinische Psychologie und Psychotherapie 43, 17-26
  Rojas R, Geissner E, Schirm E, Hautzinger M
  
• (2014) Rezidivierende Depressionen. Lassen sich Rückfälle verhindern und psychische Gesundheit erhalten? Psychotherapeutenjournal 13, 164-169
  Stangier U, Risch A-K, Heidenreich T, Hautzinger M