December 05, 2019
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Antidepressant maintenance, not CBT, associated with reduced depressive recurrence risk

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Robert J. DeRubeis

Patients with chronic or recurrent major depressive disorder who recovered using antidepressants alone or combined with cognitive behavioral therapy experienced substantially lower recurrence rates if they were maintained on medication compared with those who withdrew, according to results of a phase 2 randomized clinical trial published in JAMA Psychiatry.

Researchers noted that CBT was associated with a preventive effect on depressive relapse when used alone but not when combined with maintenance monotherapy.

“The recurrence prevention effects of maintaining the medications that bring about recovery are substantial,” Robert J. DeRubeis, PhD, of the department of psychology at the University of Pennsylvania, told Healio Psychiatry. “We do not know why CBT, provided alongside the medications, failed to prevent the return of depression in this study, as it has done when provided without medications in previous research. Patients who take medications while participating in therapy for depression would do well to engage the therapy as fully as possible, and to check in with their therapist periodically once therapy is concluded, especially if their symptoms begin to return.”

DeRubeis and colleagues conducted the phase 2 trial across three United States research clinics. They included 292 adult outpatients from the phase 1 trial with recurrent or chronic MDD who had recovered from a major depressive episode with medication treatment alone or combined with CBT. Patients were randomly assigned to maintenance or withdrawal of treatment with antidepressant medications.

The researchers found that patients who withdrew from antidepressants had higher rates of recurrence compared with those who maintained medication treatment regardless of whether patients achieved recovery with or without acute CBT. Those receiving monotherapy with medication maintained had a 48.5% recurrence rate vs. 74.8% for those with medication withdrawn (P = .002), and recurrence rates were 48.5% for maintained and 76.7% for withdrawn among those receiving combination therapy treatment. Maintenance was associated with sustained recovery rates, and phase 1 and 2 treatment condition interactions did not significantly impact sustained recovery.

“It is vital for future research to ask whether preventive effects of CBT for depression are suppressed by the concurrent use of medication, as has been shown in studies of CBT for anxiety disorders,” DeRubeis said.

In a related editorial, Marlene P. Freeman, MD, of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital, underscored additional areas for future research.

“This study leaves some important questions unanswered,” Freeman wrote. “It is not known how the combination therapy group who recovered in phase 1 would have fared if randomized to continue or discontinue treatment with CBT. We also do not know if and how much better the combination therapy would have been in preventing relapse in phase 2, which is important because relapse rates were relatively high, even with medication maintenance.” – by Joe Gramigna

Disclosures: DeRubeis reports grants from the National Institute of Mental Health. Please see the study and editorial for all other authors’ relevant financial disclosures.