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Meta-Analysis
. 2021 Aug 1;78(8):868-875.
doi: 10.1001/jamapsychiatry.2021.0823.

Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression: An Individual Participant Data Meta-analysis

Josefien J F Breedvelt  1 , Fiona C Warren  2 , Zindel Segal  3 , Willem Kuyken  4 , Claudi L Bockting  1
Affiliations
Meta-Analysis

Continuation of Antidepressants vs Sequential Psychological Interventions to Prevent Relapse in Depression: An Individual Participant Data Meta-analysis

Josefien J F Breedvelt et al. JAMA Psychiatry. .

Abstract

Importance: Depression frequently recurs. To prevent relapse, antidepressant medication is often taken in the long term. Sequentially delivering a psychological intervention while undergoing tapering of antidepressant medication might be an alternative to long-term antidepressant use. However, evidence is lacking on which patients may benefit from tapering antidepressant medication while receiving a psychological intervention and which should continue the antidepressant therapy. A meta-analysis of individual patient data with more power and precision than individual randomized clinical trials or a standard meta-analysis is warranted.

Objectives: To compare the associations between use of a psychological intervention during and/or after antidepressant tapering vs antidepressant use alone on the risk of relapse of depression and estimate associations of individual clinical factors with relapse.

Data sources: PubMed, the Cochrane Library, Embase, and PsycInfo were last searched on January 23, 2021. Requests for individual participant data from included randomized clinical trials (RCTs) were sent.

Study selection: Randomized clinical trials that compared use of a psychological intervention while tapering antidepressant medication with antidepressant monotherapy were included. Patients had to be in full or partial remission from depression. Two independent assessors conducted screening and study selection.

Data extraction and synthesis: Of 15 792 screened studies, 236 full-text articles were retrieved, and 4 RCTs that provided individual participant data were included.

Main outcomes and measures: Time to relapse and relapse status over 15 months measured via a blinded assessor using a diagnostic clinical interview.

Results: Individual data from 714 participants (mean [SD] age, 49.2 [11.5] years; 522 [73.1%] female) from 4 RCTs that compared preventive cognitive therapy or mindfulness-based cognitive therapy during and/or after antidepressant tapering vs antidepressant monotherapy were available. Two-stage random-effects meta-analysis found no significant difference in time to depressive relapse between use of a psychological intervention during tapering of antidepressant medication vs antidepressant therapy alone (hazard ratio [HR], 0.86; 95% CI, 0.60-1.23). Younger age at onset (HR, 0.98; 95% CI, 0.97-0.99), shorter duration of remission (HR, 0.99; 95% CI, 0.98-1.00), and higher levels of residual depressive symptoms at baseline (HR, 1.07; 95% CI, 1.04-1.10) were associated with a higher overall risk of relapse. None of the included moderators were associated with risk of relapse.

Conclusions and relevance: The findings of this individual participant data meta-analysis suggest that regardless of the clinical factors included in these studies, the sequential delivery of a psychological intervention during and/or after tapering may be an effective relapse prevention strategy instead of long-term use of antidepressants. These results could be used to inform shared decision-making in clinical practice.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Breedvelt reported receiving grants from the Amsterdam Public Health–Research Alliance Fund during the conduct of the study. Dr Segal reported receiving grants from the National Institute of Mental Health during the conduct of the study, and royalties from Guilford Press outside the submitted work; and serving as the cofounder of MindfulNoggin.com, a digital platform for the delivery of online mindfulness-based cognitive therapy. Dr Kuyken reported receiving author royalties from Guilford Press outside the submitted work. Dr Bockting reported serving as a coeditor of PLoS One Clinical Psychology Europe, for which she received no honorarium; serving as a codeveloper of the Dutch Multidisciplinary Guideline for Anxiety and Depression, for which she receives no remuneration; and serving as a member of the Scientific Advisory Board of the National Insurance Institute for which she receives an honorarium, although this role has no direct relation to this study. Dr Bockting has also presented keynote addresses at conferences, such as the European Psychiatry Association, for which she sometimes receives an honorarium and has presented clinical training workshops, some of which include a fee. She also receives royalties from her books and coedited books. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of Study Selection Procedure
Figure 2.
Figure 2.. Forest Plot of Random-Effects Analysis With Hazard Ratios (HRs) Comparing Psychological Intervention During and/or After Tapering vs Antidepressants
ADM indicates antidepressant medication; +/ADM, tapering and/or stopping ADM; MBCT, mindfulness-based cognitive therapy; PCT, preventive cognitive therapy.
See this image and copyright information in PMC

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