Monthly Maintenance Psychotherapy Helps Ward Off Recurrent Depression

PITTSBURGH, May 7 -- For women with depression who achieved remission with interpersonal psychotherapy, a monthly therapy booster prevented recurrence for 74% of patients over two years, researchers reported.

On the other hand, for patients who required drug therapy coupled with psychotherapy to achieve remission, psychotherapy alone for the few patients who remained in the study was significantly less effective, Ellen Frank, Ph.D., of the University of Pittsburgh, and colleagues, reported online in the May issue of the American Journal of Psychiatry.

Acute interpersonal psychotherapy focuses on grief, role transitions, role disputes, and interpersonal deficits. Maintenance therapy focuses on helping the patient assume responsibility for preventing future depressive episodes, and reinforcing interpersonal coping skills, while still focusing on the four traditional problem areas, the researchers said.

The randomized trial included 233 women, ages 20 to 60, with recurrent unipolar depression who were treated in an outpatient research clinic from September 1992 to April 1999.

After participants had achieved remission with weekly interpersonal psychotherapy or, if required, with psychotherapy plus antidepressant pharmacotherapy, they were randomly assigned to psychological monotherapy on a weekly, twice-monthly, or monthly maintenance schedule for two years or until depression recurrence.

Among 99 participants who achieved remission with psychotherapy alone and entered maintenance treatment, only 19 (26%) of the 74 (95% CI 16-36%) who remained in the study had a recurrence of depression during the two-year maintenance phase.

Attrition time tended to be lower among participants assigned to the twice-monthly condition (weekly, 11 of 33; twice monthly, four of 35; monthly, 10 of 31).

When recurrence was examined over time, most occurred within the first year of maintenance treatment: seven were during the first six months, eight between six and 12 months, two between 12 and 18 months, and two between 18 and 24 months.

Among 90 participants who required the addition of a selective serotonin reuptake inhibitor to achieve remission (typically 10 to 20 mg/day of fluoxetine [Prozac] to start), 32 (37%) sustained that remission through drug discontinuation and began maintenance psychological monotherapy.

Furthermore, of these, 13 (50%) of the 26 (six were withdrawn) who remained in the study experienced a recurrence during the maintenance phase.

Although the 37% remission rate for the group getting psychotherapy and an SSRI was reasonably good, the monotherapy continuation phase was not benign, the researchers said. Of these patients, 29% had a relapse, including 15% who relapsed in the course of combined treatment. Four other relapses occurred in the transition to maintenance with psychotherapy alone, either during the process of discontinuing medication or shortly thereafter, the researchers said.

This points to the potential difficulty of discontinuing medication after successful resolution of acute symptoms. For example, many women of childbearing age opt for nonpharmacologic treatment, and the attempt to withdraw after five months of stable remission seemed reasonable.

However, the researchers said, there is now substantial evidence that the most effective pharmacological approach for treating recurrent depression is to maintain the full dose with which remission was achieved.

This report, Dr. Frank said, adds to the accumulating data supporting the necessity of continuing pharmacological maintenance treatment in those who require drug therapy to achieve remission. However, given the small number of participants in this subgroup who were able to enter the maintenance phase, generalizing from this group about the frequency of psychotherapy is probably not meaningful, the researchers said.

A major limitation of the study's design is that it did not include a no-treatment comparison in the maintenance phase. Having observed high rates among subjects assigned to brief "medication clinic" visits with placebo in their original maintenance trials, the researchers said they felt a no-treatment control would not have been ethical in this study.

Even though a subgroup of the women studied was well served in both acute and maintenance treatment by a depression-specific psychotherapy, none of the traditional measures of severity or other parameters of illness distinguished that group from those who required combination therapy to achieve remission and even to maintain it, the researchers said.

"This field clearly needs new way of distinguishing the various phenotypes of unipolar disorder for which treatment requirements differ. Such a shift is likely to occur only if we develop new and more subtle means of characterizing patients than our current measures of depression severity provide," Dr. Frank concluded.