Suma P. Chand, PhD Professor Department of Psychiatry and Behavioral Neuroscience Saint Louis University St. Louis, Missouri
Chaitanya Ravi, MD PGY-4 Psychiatry Resident Department of Psychiatry and Behavioral Neuroscience Saint Louis University St. Louis, Missouri
Binu Chakkamparambil, MD PGY-4 Psychiatry Resident Department of Psychiatry and Behavioral Neuroscience Saint Louis University St. Louis, Missouri
Arun Prasad, MD Clinical Extern Zucker Hillside Hospital Long Island Jewish Medical Center Queens, New York
Ankita Vora, MD PGY-4 Clinical Fellow Department of Child and Adolescent Psychiatry Washington University St. Louis, Missouri
Disclosures The authors report no financial relationships with any company whose products are mentioned in this article, or with manufacturers of competing products.
Studies examining CBT as a maintenance treatment—provided alone or in combination with or sequentially with antidepressants—have found it has an enduring effect that extends beyond the end of treatment and equals the impact of continuing antidepressants.24-27 A recent meta-analysis of 10 trials where CBT had been provided to patients after acute treatment found that the risk of relapse was reduced by 21% in the first year and by 28% in the first 2 years.28
Studies have compared the prophylactic impact of maintenance CBT and antidepressants. In an early study, 40 patients who had been successfully treated with antidepressants but had residual symptoms were randomly assigned to 20 weeks of CBT or to clinical management.29 By the end of 20 weeks, patients were tapered off their antidepressant. All patients were then followed for 2 years, during which time they received no treatment. At the 2-year follow-up, the CBT group had a relapse rate of 25%, compared with 80% in the antidepressant group.29 Weaknesses of this study include a small sample size, and the fact that a single therapist provided the CBT.
This study was extended to a 6-year follow-up; antidepressants were prescribed only to patients who relapsed. The CBT group continued to have a significantly lower relapse rate (40%) compared with the antidepressant group (90%).30
In another RCT, patients with depression who had recovered with CBT or medication continued with the same treatment during a maintenance phase.26 The CBT group received 3 booster sessions during the next year and antidepressant group received medication. At the end of the second year (without CBT or medication) CBT patients were less likely to relapse compared with patients receiving antidepressants. The adjusted relapse rates were 17.3% for CBT and 53.6% for antidepressants.26
An RCT that included 452 patients with severe depression used a long intervention period (up to 42 weeks) and a flexible treatment algorithm to more closely model the strategies used in clinical practice.31 Patients were randomly assigned to antidepressants only or in combination with CBT. At the end of 12 months, outcome assessment by blinded interviewers indicated that patients with more severe depression were more likely to benefit from the combination of antidepressants and CBT (76.9% vs 60.3%) and those with severe, non-chronic depression received the most benefit (79.5% vs 62.8%). The lack of a CBT-only group limits the generalizability of these findings. Neither patients nor clinicians were blinded to the treatment assignment, which is a common limitation in psychotherapy studies but could have contributed to the finding that combined treatment was more effective.
