Change motivation and mindfulness in individual psychotherapy: Examining a sample of adult outpatients with depression and/or anxiety.

OBJECTIVES: Existing literature has demonstrated that both motivation to change and mindfulness are associated with therapy outcomes in samples with mental disorders. Between the constructs of mindfulness and motivation to change occurs some theoretical-related and empirical overlap. However, it is still little known about the association of these two constructs. For this reason, we investigated the relationship of motivation to change and mindfulness in a sample of 116 adult outpatients with a primary diagnosis of depression or anxiety. METHODS: An outpatient sample of 116 depressive and/or anxious patients filled in the German short version of the University of Rhode Island Change Assessment (URICA-S) and the German version of the Kentucky Inventory of Mindfulness Skills (KIMS) before the start of cognitive-behavioral therapy (pre) and after the 25th cognitive-behavioral therapy session (post). To assess the association between change motivation and mindfulness, we calculated correlations, hierarchical regressions and cross-lagged panel models (CLPM). RESULTS: Several positive and negative significant correlations at the premeasurement time point, at the postmeasurement time point, and over time (from pre to postmeasurement time point) demonstrated a relation between the KIMS and the URICA-S. Hierarchical regression analyses and CLPM pointed towards relations between mindfulness and change motivation over time and in both directions for some subscales of the KIMS and the URICA-S. CONCLUSION: A bidirectional relation between motivation to change and mindfulness was supported in our naturalistic psychotherapy setting for several subscales. For a better understanding of the interconnection between the two constructs, future research should focus on the application of interventions to improve either mindfulness or motivation to change in psychotherapy. Additionally, the interactional effects of mindfulness and change motivation on therapy outcomes should be investigated.

Professionals' Perspectives on Substance Use among Refugees in Shared Accommodations: A Qualitative Study.

Refugees are at a higher risk of hazardous substance use due to their traumatic experiences in their country of origin, their flight, and the difficult situation of arriving in the host country. The professionals interviewed in this study describe both the heightened vulnerability and the circumstances refugees live in after arriving in Germany. Evidence was collected by interviewing five professionals who work for and with refugees in the context of a qualitative study. Interviews were conducted with a semistructured interview guideline and analyzed for thematic content. Based on the interview data, the authors identified risk factors for hazardous substance use and possible solutions to improve the situation in shared accommodations for refugees and asylum seekers who see substance use as a resource for coping. In addition, existing barriers impede refugees from finding prevention measures and intervention programs. There is a need for specialized addiction aid with culturally appropriate programs and preventive measures to reach refugees who live in shared accommodations in Germany. Furthermore, interdisciplinary cooperation in the areas of addiction aid, refugee support, and mental healthcare should be improved.

The impact of session-introducing mindfulness and relaxation interventions in individual psychotherapy for children and adolescents: a randomized controlled trial (MARS-CA).

BACKGROUND: The investigation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past years. However, most MBI research with youth focuses on structured, manualized group programs, conducted in school settings. Knowledge about the implementation and effects of MBIs in individual psychotherapy with children and adolescents is scarce. To fill this research gap, the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is designed. It aims to assess the effects of short session-introducing interventions with mindfulness elements on juvenile patients' symptomatic outcome and therapeutic alliance in individual child and adolescent psychotherapy. METHODS: MARS-CA is conducted at a university outpatient training center for cognitive-behavior therapy. Short session-introducing interventions with mindfulness elements will be compared to short session-introducing relaxation interventions and no session-introducing intervention to explore their effects on symptomatic outcome and therapeutic alliance. The session-introducing interventions will take place at the beginning of 24 subsequent therapy sessions. We hypothesize that patients' symptomatic outcome and therapeutic alliance improve more strongly in the mindfulness condition than in the other two conditions and that the mindfulness condition moderates the relationship between therapeutic alliance and symptomatic outcome. Patients and their trainee therapists will be randomized to one of the three treatment arms. Participants aged between 11 and 19 years and having a primary diagnosis of either a depressive disorder, an anxiety disorder, or a hyperkinetic disorder will be included. Therapeutic alliance will be assessed after every therapy session (therapy session 1 to therapy session 24), symptomatic outcome will be assessed before the start of treatment (pre), after the 3rd, the 10th, and the 17th therapy sessions, at the end of treatment (24th therapy session, post), and at a 6-month follow-up. Additionally, mindfulness and mindfulness-related measures as well as demographic data, adherence, allegiance, and therapeutic techniques will be assessed. It is our aim to assess a sample of 135 patients. We will conduct multilevel modeling to address the nested data structure. DISCUSSION: The study can provide information about how add-on MBIs, conducted by trainee therapists, influence therapeutic alliance and symptomatic outcome in individual psychotherapy in children and adolescents. TRIAL REGISTRATION: ClinicalTrials.gov NCT04034576. Registered on July 17, 2019.

Cognitive Behavior Therapy at the Crossroads.

The early development of cognitive behavior therapy (CBT) can be characterized by the coming together of behavioral and cognitive traditions. However, the past decades have arguably seen more divergences than convergences within the field. The 9th World Congress of Behavioural and Cognitive Therapies was held in Berlin in July 2019 with the congress theme "CBT at the Crossroads." This title reflected in part the coming together of people from all over the world, but also the fact that recent developments raise important questions about the future of CBT, including whether we can in fact treat it as a unified field. In this paper, we briefly trace the history of CBT, then introduce a special issue featuring a series of articles exploring different aspects of the past, present, and future of CBT. Finally, we reflect on the possible routes ahead.

Existential Approaches and Cognitive Behavior Therapy: Challenges and Potential.

Existential concerns such as death, responsibility, meaninglessness, and isolation not only are the hallmark of existential psychotherapy but also are frequently encountered by CBT therapists-nevertheless, due to epistemological and ideological differences, existential and CBT approaches to psychotherapy had little overlap historically. During recent years, existential issues are increasingly discussed in empirical clinical psychology, e.g., the potential role of the fear of death for a variety of mental disorders by Iverach et al. (Clinical Psychology Review, 34(7), 580-593, 2014), and there is increasing experimental evidence for a causal rather than correlational role of death anxiety discussed by Menzies and Dar-Nimrod (Journal of Abnormal Psychology, 126(4), 367-377, 2017). Further, existential concerns are common themes in CBT discussed by Grober et al. (Psychotherapeut, 61(3), 229-236, 2016) and may play an important role in the training of CBT therapists discussed by Worrell et al. (Journal of Psychotherapy and Counselling Psychology Reflections, 3(1), 9-16, 2018) as well as in personal therapy and supervision.

[Mindfulness in Trainee Psychotherapies with Children and Adolescents]. / Achtsamkeit in Ausbildungspsychotherapien bei Kindern und Jugendlichen.

Mindfulness in Trainee Psychotherapies with Children and Adolescents The implementation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past few years. However, there is little research about the implementation of MBIs in individual child and adolescent psychotherapy. The present paper gives an overview of current MBIs and their efficacy in children and adolescents. A depiction of the implementation of MBIs in individual therapy and a description of the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is given. The study aims to examine the effects of short session-introducing interventions with mindfulness elements on juvenile patients' psychopathological symptomatology and therapeutic alliance. For this reason, the authors compare session-introducing interventions with mindfulness elements with session-introducing relaxation interventions and no session-introducing intervention. Qualitative results of the pre-study show that both interventions with mindfulness elements and relaxation interventions work well with juvenile patients.

Long-term effects of mindfulness-based cognitive therapy in patients with obsessive-compulsive disorder and residual symptoms after cognitive behavioral therapy: Twelve-month follow-up of a randomized controlled trial.

We examined the long-term efficacy of mindfulness-based cognitive therapy (MBCT) compared to a psychoeducation group as an active control condition in patients with obsessive-compulsive disorder (OCD) with residual symptoms of OCD after cognitive behavioral therapy. A total of 125 patients were included in a bicentric, interviewer-blind, randomized, and actively controlled trial and were assigned to either an MBCT group (n = 61) or a psychoeducation group (n = 64). Patients' demographic characteristics and the results from our previous assessments have already been reported (Külz et al., 2019). At the 12-month follow-up the completion rate was 80%. OCD symptoms were reduced from baseline to follow-up assessment with a large effect, but no difference was found between groups. Exploratory analyses showed that a composite score of time occupied by obsessive thoughts, distress associated with obsessive thoughts, and interference due to obsessive thoughts differed between groups in the per-protocol analysis, with a stronger reduction in the MBCT group. At the 12-month follow-up, the two groups showed a similar reduction of symptoms. However, preliminary evidence indicates that MBCT has a superior effect on some aspects of OCD. This should be replicated in future studies.

Patients' interpersonal problems as moderators of depression outcomes in a randomized controlled trial comparing mindfulness-based cognitive therapy and a group version of the cognitive-behavioral analysis system of psychotherapy in chronic depression.

OBJECTIVES: Interpersonal problems were examined as moderators of depression outcomes between mindfulness-based cognitive therapy (MBCT) and cognitive behavioral analysis system of psychotherapy (CBASP) in patients with chronic depression. METHODS: Patients received treatment-as-usual and, in addition, were randomized to 8-weeks of MBCT (n = 34) or 8-weeks of CBASP (n = 34). MBCT and CBASP were given in a group format. The Hamilton depression rating scale (HAM-D) was the primary and the Beck Depression Inventory (BDI-II) the secondary outcome. The subscales of the Inventory of interpersonal problems (IIP-32) were moderators. Multilevel models were performed. RESULTS: Higher scores on the "vindictive/self-centered" subscale were associated with a better outcome in MBCT than in CBASP (HAM-D: p < .01; BDI-II: p < .01). Higher scores on the "nonassertive" subscale were associated with a better outcome in CBASP than in MBCT (HAM-D: p < .01; BDI-II: p < .01). CONCLUSIONS: If these results can be replicated in larger trials, MBCT should be preferred to CBASP in chronically depressed patients being vindictive/self-centered, whereas CBASP should be preferred to MBCT in chronically depressed patients being nonassertive.

Assessment of campus community readiness for tailoring implementation of evidence-based online programs to prevent risky substance use among university students in Germany.

Research suggests that online interventions preventing risky substance use can improve student health. There is an increasing interest in transferring evidence-based online programs into university health promotion practice. However, little is known about how to best tailor the implementation process to capacities and context of individual universities. The purpose of this study was to assess the level of readiness (capacity) of German universities concerning the implementation of evidence-based online programs for risky substance use prevention employing an adapted Community Readiness Assessment (CRA) and to develop tailored action plans for implementation. The CRA involved 43 semi-structured interviews with key persons at 10 German universities. The interviews addressed five dimensions (knowledge of efforts, leadership, community climate, knowledge of the issue, and resources) at nine possible readiness stages (no awareness-ownership) and additional contextual factors. Overall, readiness for implementing online interventions across universities was rather low. Universities readiness levels ranged between the denial stage with a score of 2.1 and the preplanning stage with a score of 4.4. University-specific readiness was very heterogeneous. On the basis of the results of the CRA, universities received feedback and options for training on how to take the necessary steps to increase readiness and to prepare program implementation. The adapted version of the CRA was well suited to inform future implementation of evidence-based online programs for the prevention of risky substance use at participating universities.

Mindfulness and progressive muscle relaxation as standardized session-introduction in individual therapy: A randomized controlled trial.

OBJECTIVE: There is scarce research on the effects of mindfulness in individual therapy. As many practitioners integrate mindfulness exercises into individual therapy, empirical evidence is of high clinical relevance. METHOD: We investigated the effects of a session-introducing intervention with mindfulness elements (SIIME) in a randomized, controlled design. The effects of SIIME on therapeutic alliance and symptomatic outcome were compared with progressive muscle relaxation (PMR) and treatment-as-usual (TAU) control conditions. The sample comprised 162 patients with anxiety and depression. RESULTS: Multilevel modeling revealed a significant symptom reduction and significant increase of alliance over the course of therapy. There were no significant time-condition interactions on outcome and alliance, indicating the comparable efficiency of all three treatment conditions. CONCLUSIONS: We found no advantage of SIIME versus PMR and TAU. Add-on mindfulness might not improve individual therapy related to alliance and outcome.

Mindfulness-based cognitive therapy (MBCT) in patients with obsessive-compulsive disorder (OCD) and residual symptoms after cognitive behavioral therapy (CBT): a randomized controlled trial.

Up to one-third of individuals with obsessive-compulsive disorder (OCD) do not benefit from evidence-based psychotherapy. We examined the efficacy of mindfulness-based cognitive therapy (MBCT) as a complementary treatment option. In a prospective, bicentric, assessor-blinded, randomized, and actively controlled clinical trial, 125 patients with OCD and residual symptoms after cognitive behavioral therapy (CBT) were randomized to either an MBCT group (n = 61) or to a psychoeducational group (OCD-EP; n = 64) as an active control condition. At post-treatment, there was no significant benefit of MBCT over OCD-EP with the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) as the primary outcome measure, but with the Obsessive-Compulsive Inventory [OCI-R; F(1, 101) = 5.679, p = .036, effect size η2partial = 0.053]. Moreover, the response rate and the improvement on secondary outcomes such as obsessive beliefs and quality of life was significantly larger in the MBCT group. Non-completion rates were below 10%. At the 6-month follow-up, OC symptoms were further improved in both groups; group differences were no longer significant. Our findings suggest that MBCT, compared to a psychoeducational program, leads to accelerated improvement of self-reported OC symptoms and secondary outcomes, but not of clinician-rated OC symptoms. In the midterm, both interventions yield similar and stable, but small improvements, suggesting that additional treatment options may be necessary.

Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis.

Mindfulness-based interventions (MBIs) are currently well established in psychotherapy with meta-analyses demonstrating their efficacy. In these multifaceted interventions, the concrete performance of mindfulness exercises is typically integrated in a larger therapeutic framework. Thus, it is unclear whether stand-alone mindfulness exercises (SAMs) without such a framework are beneficial, as well. Therefore, we conducted a systematic review and meta-analysis regarding the effects of SAMs on symptoms of anxiety and depression. Systematic searching of electronic databases resulted in 18 eligible studies (n = 1150) for meta-analyses. After exclusion of one outlier SAMs had small to medium effects on anxiety (SMD = 0.39; CI: 0.22, 0.56; PI: 0.07, 0.70; p < .001, I2 = 18.90%) and on depression (SMD = 0.41; CI: 0.19, 0.64; PI: -0.05, 0.88; p < .001; I2 = 33.43%), when compared with controls. Summary effect estimates decreased, but remained significant when corrected for potential publication bias. This is the first meta-analysis to show that the mere, regular performance of mindfulness exercises is beneficial, even without being integrated in larger therapeutic frameworks.

Effects of a stand-alone web-based electronic screening and brief intervention targeting alcohol use in university students of legal drinking age: A randomized controlled trial.

BACKGROUND: Many intervention efforts targeting student drinking were developed to address US college students, which usually involves underage drinking. It remains unclear, if research evidence from these interventions is generalizable to university and college students of legal drinking age, e.g., in Europe. OBJECTIVE: To evaluate the effectiveness of a translated and adapted version of the eCHECKUP TO GO, applied as stand-alone web-based electronic screening and brief intervention (e-SBI), in German university students at risk for hazardous drinking. METHODS: A fully automated web-based two-arm parallel-group randomized controlled trial was conducted. Participants were randomized to an e-SBI or assessment-only (AO) condition. The current paper analyzed students with baseline AUDIT-C scores ≥3 for women and ≥4 for men (sample at baseline: e-SBI [n=514], AO [n=467]; 3-month follow-up: e-SBI [n=194], AO [n=231]; 6-month follow-up: e-SBI [n=146], AO [n=200]). The primary outcome was prior four weeks' alcohol consumption. Secondary outcomes were frequency of heavy drinking occasions, peak blood alcohol concentration, and number of alcohol-related problems. RESULTS: Mixed linear model analyses revealed significant interaction effects between groups and time points on the primary outcome after 3 and 6months. Compared to students in the AO condition, students in the e-SBI condition reported consuming 4.11 fewer standard drinks during the previous four weeks after 3months, and 4.78 fewer standard drinks after 6months. Mixed results were found on secondary outcomes. CONCLUSIONS: The results indicate that evidence on and knowledge of web-based e-SBIs based on US college student samples is transferable to German university students of legal drinking age. However, knowledge of what motivates students to complete programs under voluntary conditions, although rare, is needed.

Including sustainability issues in nurse education: A comparative study of first year student nurses' attitudes in four European countries.

INTRODUCTION: Education in sustainable development is a goal recognised by a large number of countries and a vital concept in healthcare. It is therefore important that nurse education incorporates elements of sustainable development into nursing education curricula. However, there is limited research on student nurses' attitudes towards sustainability and no comparison of attitudes towards sustainability and its inclusion in the nursing curriculum across Europe. AIM: This project aims to assess student nurses' attitudes towards sustainability, its relevance to nursing and its inclusion in the nursing curricula. 1. To assess base-line attitudes at the start of nursing and midwifery training; 2. To compare sustainability awareness between students participating in training in a number of European universities. DESIGN: A comparative survey design using the Sustainability Attitudes in Nursing Survey (SANS_2) questionnaire. SETTINGS: Nursing classes of Universities and Nursing Schools in four European countries were investigated using a questionnaire consisting of five sustainability-related items. PARTICIPANTS: 916 nursing students (UK: 450, Germany: 196, Spain: 124, Switzerland: 146). DATA ANALYSIS: Standard descriptive and inferential statistical methods were used to establish psychometric quality (Principal Components Analysis, Cronbach's alpha, Pearson correlations) and compare student nurses from the four countries. RESULTS: The reliability of SANS_2 was good (Cronbach's alpha=.82) and the five items loaded on a single factor which explained 58% of variance. ANOVA of the SANS_2 total score showed significant differences between countries with German nursing students showing more sustainability awareness than students from the UK and Spain. CONCLUSIONS: SANS_2 is a reliable instrument to assess nursing students' sustainability awareness; there are significant differences in sustainability awareness of students of different European countries. Limitations of the study include non-random sampling, possible method effects and social desirability effects. RELEVANCE TO CLINICAL PRACTICE: Sustainability will become increasingly important in clinical practice; greater knowledge about the attitudes of nurses towards sustainability can support the development and testing of sustainability-focused teaching and learning materials.

A randomized controlled trial on the efficacy of mindfulness-based cognitive therapy and a group version of cognitive behavioral analysis system of psychotherapy for chronically depressed patients.

OBJECTIVE: Mindfulness-based cognitive therapy (MBCT) has recently been proposed as a treatment option for chronic depression. The cognitive behavioral analysis system of psychotherapy (CBASP) is the only approach specifically developed to date for the treatment of chronically depressed patients. The efficacy of MBCT plus treatment-as-usual (TAU), and CBASP (group version) plus TAU, was compared to TAU alone in a prospective, bicenter, randomized controlled trial. METHOD: One hundred and six patients with a current DSM-IV defined major depressive episode and persistent depressive symptoms for more than 2 years were randomized to TAU only (N = 35), or to TAU with additional 8-week group therapy of either 8 sessions of MBCT (n = 36) or CBASP (n = 35). The primary outcome measure was the Hamilton Depression Rating Scale (24-item HAM-D, Hamilton, 1967) at the end of treatment. Secondary outcome measures were the Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996) and measures of social functioning and quality of life. RESULTS: In the overall sample as well as at 1 treatment site, MBCT was no more effective than TAU in reducing depressive symptoms, although it was significantly superior to TAU at the other treatment site. CBASP was significantly more effective than TAU in reducing depressive symptoms in the overall sample and at both treatment sites. Both treatments had only small to medium effects on social functioning and quality of life. CONCLUSIONS: Further studies should inquire whether the superiority of CBASP in this trial might be explained by the more active, problem-solving, and interpersonal focus of CBASP.

The Process-Outcome Mindfulness Effects in Trainees (PrOMET) study: protocol of a pragmatic randomized controlled trial.

BACKGROUND: Mindfulness has its origins in an Eastern Buddhist tradition that is over 2500 years old and can be defined as a specific form of attention that is non-judgmental, purposeful, and focused on the present moment. It has been well established in cognitive-behavior therapy in the last decades, while it has been investigated in manualized group settings such as mindfulness-based stress reduction and mindfulness-based cognitive therapy. However, there is scarce research evidence on the effects of mindfulness as a treatment element in individual therapy. Consequently, the demand to investigate mindfulness under effectiveness conditions in trainee therapists has been highlighted. METHODS/DESIGN: To fill in this research gap, we designed the PrOMET Study. In our study, we will investigate the effects of brief, audiotape-presented, session-introducing interventions with mindfulness elements conducted by trainee therapists and their patients at the beginning of individual therapy sessions in a prospective, randomized, controlled design under naturalistic conditions with a total of 30 trainee therapists and 150 patients with depression and anxiety disorders in a large outpatient training center. We hypothesize that the primary outcomes of the session-introducing intervention with mindfulness elements will be positive effects on therapeutic alliance (Working Alliance Inventory) and general clinical symptomatology (Brief Symptom Checklist) in contrast to the session-introducing progressive muscle relaxation and treatment-as-usual control conditions. Treatment duration is 25 therapy sessions. Therapeutic alliance will be assessed on a session-to-session basis. Clinical symptomatology will be assessed at baseline, session 5, 15 and 25. We will conduct multilevel modeling to address the nested data structure. The secondary outcome measures include depression, anxiety, interpersonal functioning, mindful awareness, and mindfulness during the sessions. DISCUSSION: The study results could provide important practical implications because they could inform ideas on how to improve the clinical training of psychotherapists that could be implemented very easily; this is because there is no need for complex infrastructures or additional time concerning these brief session-introducing interventions with mindfulness elements that are directly implemented in the treatment sessions. TRIAL REGISTRATION: From ClinicalTrials.gov, Identifier: NCT02270073 (registered October 6, 2014).

Evaluation of Treatment Integrity: The Treatment Specificity Index.

OBJECTIVE: To differentiate between treatments in a randomized controlled trial (RCT), therapies need to display not only high purity but also high specificity. The aim of this study was to demonstrate the benefits of calculating a treatment specificity index for the evaluation of treatment differentiation. METHOD: Based on an RCT of relapse prevention in depression, comparing a cognitive with a psychoeducational treatment, the specificity and the purity index were calculated. RESULTS: As indicated by the specificity index, both conditions differed in their levels of implemented specific and common interventions. A significant relationship was found between symptom change before a therapy session and treatment specificity. CONCLUSIONS: The specificity index is an appropriate method for enhancing the internal validity of RCTs in evaluating treatment integrity.

Mindfulness-based cognitive therapy in obsessive-compulsive disorder: protocol of a randomized controlled trial.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a very disabling condition with a chronic course, if left untreated. Though cognitive behavioral treatment (CBT) with or without selective serotonin reuptake inhibitors (SSRI) is the method of choice, up to one third of individuals with obsessive-compulsive disorder (OCD) do not respond to treatment in terms of at least 35% improvement of symptoms. Mindfulness based cognitive therapy (MBCT) is an 8-week group program that could help OCD patients with no or only partial response to CBT to reduce OC symptoms and develop a helpful attitude towards obsessions and compulsive urges. METHODS/DESIGN: This study is a prospective, bicentric, assessor-blinded, randomized, actively-controlled clinical trial. 128 patients with primary diagnosis of OCD according to DSM-IV and no or only partial response to CBT will be recruited from in- and outpatient services as well as online forums and the media. Patients will be randomized to either an MBCT intervention group or to a psycho-educative coaching group (OCD-EP) as an active control condition. All participants will undergo eight weekly sessions with a length of 120 minutes each of a structured group program. We hypothesize that MBCT will be superior to OCD-EP in reducing obsessive-compulsive symptoms as measured by the Yale-Brown-Obsessive-Compulsive Scale (Y-BOCS) following the intervention and at 6- and 12-months-follow-up. Secondary outcome measures include depressive symptoms, quality of life, metacognitive beliefs, self-compassion, mindful awareness and approach-avoidance tendencies as measured by an approach avoidance task. DISCUSSION: The results of this study will elucidate the benefits of MBCT for OCD patients who did not sufficiently benefit from CBT. To our knowledge, this is the first randomized controlled study assessing the effects of MBCT on symptom severity and associated parameters in OCD. TRIAL REGISTRATION: German Clinical Trials Register DRKS00004525 . Registered 19 March 2013.

Maintenance cognitive-behavioral therapy and manualized psychoeducation in the treatment of recurrent depression: a multicenter prospective randomized controlled trial.

OBJECTIVE: This multicenter study compared the relapse and recurrence outcomes of two active treatments, maintenance cognitive-behavioral therapy (CBT) and manualized psychoeducation, both in addition to treatment as usual, in patients in remission from depression. METHOD: This was a multicenter prospective randomized observer-blinded study with two parallel groups. The authors assessed 180 patients with three or more previous major depressive episodes who met remission criteria over a 2-month baseline period and who were randomly assigned to 16 sessions of either maintenance CBT or manualized psychoeducation over 8 months and then followed up for 12 months. The main outcome measure was time to first relapse or recurrence of a major depression, based on DSM-IV criteria, as assessed by blinded observers with the Longitudinal Interval Follow-Up Evaluation. RESULTS: Cox regression analysis showed that time to relapse or recurrence of major depression did not differ significantly between treatment conditions, but a significant interaction was observed between treatment condition and number of previous episodes (<5 or ≥5). Within the subsample of patients with five or more previous episodes, maintenance CBT was significantly superior to manualized psychoeducation, whereas for patients with fewer than five previous episodes, no significant treatment differences were observed in time to relapse or recurrence. CONCLUSIONS: The results indicate that maintenance CBT has significant effects on the prevention of relapse or recurrence only in patients with a high risk of depression recurrence. For patients with a moderate risk of recurrence, nonspecific effects and structured patient education may be equally effective.