Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial.

BACKGROUND: Although there is good evidence that cognitive therapy (CBT) lessens relapse and recurrence in unipolar depression, the duration of this effect is not known. METHOD: One hundred and fifty-eight subjects, from a randomized controlled trial of CBT plus medication and clinical management versus medication and clinical management alone, were followed 6 years after randomization (4 1/2 years after completion of CBT) and the longitudinal course assessed. RESULTS: Effects in prevention of relapse and recurrence were found to persist, with weakening, and were not fully lost until 3 1/2 years after the end of CBT. Residual symptoms were also lessened. CONCLUSIONS: The effect of CBT in reduction of relapse and recurrence persists for several years. The potential value of subsequent additional CBT some time after cessation should be explored.

Which clinical practice guidelines for depression? An overview for busy practitioners.

BACKGROUND: Many policy and research documents on the treatment of depression in primary care suggest that general practitioners (GPs) should make use of clinical guidelines. AIM: To describe the content of peer-reviewed guidelines for the detection and treatment of depression in primary care and help GPs identify the one most useful to their own needs. METHOD: Guidelines were evaluated by an explicit method using the Institute of Medicine assessment instrument and according to six key clinical management questions identified as important by GPs and psychiatrists. RESULTS: Only five (30%) of the published guidelines identified met all the pre-defined inclusion criteria. Total scores for development process and content ranged from 54% to 82%. Validity scores ranged from 52% to 88%. No guideline answered all the key questions identified by clinicians. CONCLUSIONS: Only two guidelines conform to the quality standard of a clinical practice guideline. One covers all aspects of detection and management of depression in primary care but gives no advice on first-line choice of antidepressant, while the other focuses only on medication and fails to explore problems of case detection or to consider non-pharmacological treatments. However, taken together they do cover most of the key clinical issues in a reliable and valid manner. The identified guidelines vary considerably in both utility and clinical applicability.

Prevention of relapse in residual depression by cognitive therapy: a controlled trial.

BACKGROUND: Previous studies indicate that depressed patients with partial remission and residual symptoms following antidepressant treatment are common and have high rates of relapse. There is evidence that cognitive therapy may reduce relapse rates in depression. METHODS: One hundred fifty-eight patients with recent major depression, partially remitted with antidepressant treatment (mean daily doses equivalent to 185 mg of amitriptyline or 33 mg of fluoxetine) but with residual symptoms of 2 to 18 months' duration, were included in a controlled trial. Subjects were randomized to receive clinical management alone or clinical management plus cognitive therapy for 16 sessions during 20 weeks, with 2 subsequent booster sessions. Subjects were assessed regularly throughout the 20 weeks' treatment and for a further year. They received continuation and maintenance antidepressants at the same dose throughout. RESULTS: Cognitive therapy reduced relapse rates for acute major depression and persistent severe residual symptoms, in both intention to treat and treated per protocol samples. The cumulative relapse rate at 68 weeks was reduced significantly, from 47% in the clinical management control group to 29% with cognitive therapy (hazard ratio 0.54; 95% confidence interval, 0.32-0.93; intention to treat analysis). Cognitive therapy also increased full remission rates at 20 weeks but did not significantly improve symptom ratings. CONCLUSION: In this difficult-to-treat group of patients with residual depression who showed only partial response despite antidepressant treatment, cognitive therapy produced worthwhile benefit.

Partial remission in depressive disorders.

Although the concept of partial or incomplete remission from depression has been noted in the literature for many decades, it is only recently that a precise definition of partial remission has been formulated (1). This paper reviews publications relating to this concept, in terms of prevalence, clinical characteristics and implications for prognosis. There have been too few studies to allow conclusive evidence to be presented, but partial remission may affect one third of subjects treated for depression, and may increase the risk of further depressive relapse and adversely affect social and work performance. This paper highlights the need to increase awareness of this concept among clinicians so that residual symptoms may be aggressively treated, and also comments on the need for researchers to consider this important group in all treatment and outcome studies.

Burden of care, psychological distress and satisfaction with services in the relatives of acutely mentally disordered adults.

This project aimed to examine the views of relatives nominated as the "most significant other person" by acutely mentally disordered patients who were newly referred to either a community-based (n = 24) or a district general hospital based (n = 17) psychiatric service. Relatives were asked about their satisfaction with these services, the psychological impact on them of caring for a mentally disordered relative, and levels of subjective and objective burden of care at the time of referral and 6 months later. The findings of this study suggested that the initial severity of an acute psychiatric disorder rather than the type of psychiatric service provided is more strongly associated with objective and subjective levels of burden. At follow-up, psychological distress as measured on the General Health Questionnaire (GHQ) was associated with the objective burden of caring for a relative with psychosis or major affective disorder, but not other conditions. Dissatisfied relatives tended to be those who remained distressed at 6 months according to GHQ scores or those recording continually high levels of subjective burden on the Burden of Care Schedule (BCS). Interventions to reduce subjective and objective burden should be targeted at the group demonstrating persistent stress.