Staying well after depression (SWAD)

CI Professor Mark WilliamsPI Professor Ian Russell

Sholto RadfordResearch Officer s.radford@bangor.ac.uk

• Depression a prevalent Condition

• Risk of recurrence 90% for individuals with 3 or more previous episodes.

• Suicide ideation is one of the most consistently recurring symptoms of depression.

• 80% of suicide would not occur without depression.

• Mindfulness-Based Cognitive Therapy (MBCT) is a promising approach to preventing relapse.

Depression and suicide

MBCT for preventing relapse

• 3 centre study (Teasdale et al, 2000) • Single centre replication study (Ma & Teasdale,

2004)

Summary of results of both trials: MBCT approximately halved (70% to 39%) the

likelihood of depressive relapse in patients who had had three of more episodes of depression

MBCT now recommended by NICE as a treatment for prevention of depression.

MBCT vs Antidepressants (ADs)

123 patients with a history of recurrent depression

MBCT (with or without ADs) was equal if not slightly better at preventing relapse than maintenance antidepressant treatment alone, and better at improving quality of life.

MBCT is more expensive than maintenance ADs in first 12 mths; then MBCT becomes more cost effective

(Kuyken et al 2008)

Research questions

•MBCT - effective relapse prevention of major depression and incidence of suicidal symptoms.

•Comparison with equally plausible treatment without meditation (CPE) “dismantling”.

•Understand potential moderators and mediators of treatment outcome.

DesignMulti centre trial (Bangor Oxford) RCT –

Participants randomised to three conditions:-

• Treatment as usual (TAU)• Mindfulness-Based Cognitive Therapy (MBCT) + TAU• Cognitive Psycho Education (CPE) + TAU

Stratification - Centre, cohort, history of suicidality (none, ideation, attempt), antidepressants in past 7 days

Interventions Both 8 week courses, 2 hour sessions, 2

MBCT – manualised treatment combines training in mindfulness with cognitive therapy – 1 hour per day home practice (meditation + smaller tasks to cultivate mindfulness.

CPE – Includes all elements of MBCT except experiential cultivation of mindfulness. Learn psychological process involved in relapse, mood monitoring, disengaging from unhelpful patterns of processing.

Assessment •Assessment – treatment effects monitored Pre intervention T0, Post intervention T1, 3

months T2, six months T3, nine months T4, twelve months T5.

Blind assessors – SCID + battery of questionnaires and cognitive tasks

Sample and recruitment • Using 2:2:1 ratio – 5% significance level 300

participants 99% power for detection of difference CPE –MBCT with 20% attrition 375 target.

• Referral – advertisements in community, clinics + GP surgeries, referral from GP’s and mental health clinicians, talks a t professional meetings.

• Preliminary phone screening - recruiters• Detailed assessment (SCID) - assessors

Inclusion criteria Exclusion criteria

Age 18 - 70 History of, schizophrenia, Schizoaffective disorder, Bipolar 1, current severe substance abuse, primary diagnosis of OCD or eating disorder , regular self harm.

DSM-IV criteria major depression >3 episodes (2 in past 5 years 1 in past 2 years

Positive continuing response to CBT

NIMH guidelines for recovery (1 week in past 8 of core symptom or suicidal feelings + 1 other symptom.

Psychotherapy of counselling more than once per month.

Giving informed consent +Consent from GP

Cannot complete baseline assessment

Participants randomised n = 274 did not attend at least one follow up n =19 Variable BreakdownGender Female =198 (72%) Male =76 (28%)

Age Female Mean = 42.40 Minimum = 18 Maximum = 68

Age Male Mean = 46.12 Minimum = 18 Maximum 66

Antidepressants used at baseline

No = 154 (56%) Yes 120 ( 44%)

Suicidality – history None = 53 (20%) Ideation =138 (50%) Attempt =83 (30%)

Number of previous episodes MDD (n= 240)

Mean = 7 Minimum = 3 Maximum =45

AnalysisIntention to treat analysis (ITT)

• Primary outcome – time to relapse or recurrence of MDD in weeks. • Continuous quantitative measure of outcome also used (HRSD) for

severity and to strengthen the dichotomised outcome.

• Other quantitative measures used include BDI-II , BHS,BSS, EQ5D.

• Secondary outcome- recurrence of suicidal ideation.• Firstly - in participants who relapse • Secondly - severity of suicidal symptoms for all participants Beck scale for

suicide ideation (BSS) + MINNI suicide-tracking measure• Thirdly – suicidal cognitions between groups with AnCova. T1 and T5 with

T0 as covariate

Mediation

Assessing cognitive measures Mindfulness, suppression, self compassion,

rumination, autobiographical memory and executive capacity

Regression on both the dichotomous outcome (binary logisitc) of relapse and on worst HRSD score (linear) during follow up.

Summary •Recurrent depression is common and

serious particularly for those who become suicidal when depressed.

•Urgent need to develop treatments that produce sustainable reductions in risk of recurrence

•And to identify the critical therapeutic factors to refine the approach for the future