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Am Fam Physician. 1999;59(4):976

Most patients diagnosed with major depressive disorders experience recurrent episodes, despite treatment with antidepressant drugs or psychotherapy. Cognitive behavioral therapy has also been shown to be of benefit and results in lower relapse rates than standard clinical management. Fava and colleagues compared the effectiveness of cognitive behavioral therapy with that of clinical management in patients with recurrent depression.

Adults with a diagnosis of major depression that was confirmed by a psychiatrist and a clinical psychologist were eligible for the study. To be included in the study, patients had to have a history of three or more episodes of depression, with the immediately preceding episode occurring within the last 2 1/2 years, at least 10 weeks of remission between episodes and a minimum global severity score of 7 for the current episode of depression. Exclusion criteria included a history of manic, hypomanic or cyclothymic episodes, a history of active drug or alcohol abuse, and any active medical illness. Patients also had to have shown a successful response to a tricyclic antidepressant or a selective serotonin reuptake inhibitor. Patients with ratings of “better” or “much better” on a global scale of improvement following drug therapy were included in the study.

Patients were randomized to one of two treatment groups: pharmacotherapy plus cognitive behavioral therapy or pharmacotherapy plus standard clinical management. Patients in both groups attended 10 sessions of 30 minutes each, conducted every other week for 20 weeks. During that time, the medication was tapered so that by the last two sessions, none of the patients was receiving medication. Patients were then assessed every three months for the next two years, during which time no new medications or psychotherapeutic interventions were prescribed. Relapse was defined as the occurrence of an episode of major depression as established by the Research Diagnostic Criteria for a selected group of functional disorders.

Groups were composed of 20 patients. Demographic information and clinical characteristics were similar between groups. Patients in the group receiving cognitive behavioral therapy demonstrated significant improvement in residual symptoms of depression compared with patients in the group receiving standard clinical management. During the two-year follow-up period, five (25 percent) patients in the group receiving cognitive behavioral therapy experienced a relapse of major depression compared with 16 (80 percent) in the group receiving standard clinical management.

The authors conclude that cognitive behavioral therapy following successful treatment with antidepressants is effective in preventing relapses in patients with chronic depression. This conclusion challenges the assumption that long-term, high-dose drug treatment is the only way to prevent relapse in patients with recurrent depression. The amelioration of residual symptoms after successful medical therapy, as was accomplished with cognitive behavioral therapy, may be a key component in preventing relapse in patients with chronic depression.

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