Staying well after depression
(SWAD)
CI Professor Mark Williams
PI Professor Ian Russell
Sholto Radford
Research Officer
s.radford@bangor.ac.uk
Depression
and suicide
• Depression a prevalent
Condition
• Risk of recurrence
90% for individuals with 3 or more previous episodes.
• Suicide ideation is one of the most consistently recurring
symptoms of depression.
• 80% of suicide would not occur without depression.
• Mindfulness-Based Cognitive Therapy (MBCT) is a
promising approach to preventing relapse.
MBCT for preventing
relapse
• 3 centre study (Teasdale et al, 2000)
• Single centre replication study (Ma & Teasdale, 2004)
Summary of results of both trials:
MBCT approximately halved (70% to 39%) the likelihood
of depressive relapse in patients who had had three of
more episodes of depression
MBCT now recommended by NICE as a treatment for
prevention of depression.
MBCT vs Antidepressants (ADs)
123 patients with a history of recurrent depression
MBCT (with or without ADs) was equal if not
slightly better at
preventing relapse than maintenance
antidepressant treatment alone, and better at
improving quality of life.
MBCT is more expensive than maintenance ADs in first 12 mths; then MBCT
becomes more cost effective
(Kuyken et al 2008)
Research questions
• MBCT - effective relapse prevention of major
depression and incidence of suicidal symptoms.
• Comparison with equally plausible treatment
without meditation (CPE) “dismantling”.
• Understand potential moderators and mediators
of treatment outcome.
Design
Multi centre trial (Bangor Oxford) RCT –
Participants randomised to three conditions:• Treatment as usual (TAU)
• Mindfulness-Based Cognitive Therapy (MBCT) + TAU
• Cognitive Psycho Education (CPE) + TAU
Stratification - Centre, cohort, history of suicidality (none,
ideation, attempt), antidepressants in past 7 days
Interventions
Both 8 week courses, 2 hour sessions, 2
MBCT – manualised treatment combines training in
mindfulness with cognitive therapy – 1 hour per day
home practice (meditation + smaller tasks to cultivate
mindfulness.
CPE – Includes all elements of MBCT except experiential
cultivation of mindfulness. Learn psychological process
involved in relapse, mood monitoring, disengaging from
unhelpful patterns of processing.
Assessment
• Assessment – treatment effects monitored
Pre intervention T0, Post intervention T1, 3
months T2, six months T3, nine months T4,
twelve months T5.
Blind assessors – SCID + battery of
questionnaires and cognitive tasks
Sample and recruitment
• Using 2:2:1 ratio – 5% significance level 300 participants
99% power for detection of difference CPE –MBCT with
20% attrition 375 target.
• Referral – advertisements in community, clinics + GP
surgeries, referral from GP’s and mental health
clinicians, talks a t professional meetings.
• Preliminary phone screening - recruiters
• Detailed assessment (SCID) - assessors
Inclusion criteria
Exclusion criteria
Age 18 - 70
History of, schizophrenia, Schizoaffective
disorder, Bipolar 1, current severe
substance abuse, primary diagnosis of
OCD or eating disorder , regular self
harm.
DSM-IV criteria major depression >3
episodes (2 in past 5 years 1 in past 2
years
Positive continuing response to CBT
NIMH guidelines for recovery (1 week in
past 8 of core symptom or suicidal
feelings + 1 other symptom.
Psychotherapy of counselling more than
once per month.
Giving informed consent +
Consent from GP
Cannot complete baseline assessment
Participants randomised
n = 274
did not attend at least one follow up n =19
Variable
Breakdown
Gender
Female =198 (72%) Male =76 (28%)
Age Female
Mean = 42.40 Minimum = 18 Maximum = 68
Age Male
Mean = 46.12 Minimum = 18 Maximum 66
Antidepressants used at
baseline
No = 154 (56%) Yes 120 ( 44%)
Suicidality – history
None = 53 (20%) Ideation =138 (50%)
Attempt =83 (30%)
Number of previous
episodes MDD (n= 240)
Mean = 7 Minimum = 3 Maximum =45
Analysis
Intention to treat analysis (ITT)
• Primary outcome – time to relapse or recurrence of MDD in weeks.
• Continuous quantitative measure of outcome also used (HRSD) for
severity and to strengthen the dichotomised outcome.
• Other quantitative measures used include BDI-II , BHS,BSS, EQ5D.
• Secondary outcome- recurrence of suicidal ideation.
• Firstly - in participants who relapse
• Secondly - severity of suicidal symptoms for all participants Beck scale
for suicide ideation (BSS) + MINNI suicide-tracking measure
• Thirdly – suicidal cognitions between groups with AnCova. T1 and T5
with T0 as covariate
Mediation
Assessing cognitive measures
Mindfulness, suppression, self compassion, rumination,
autobiographical memory and executive capacity
Regression on both the dichotomous outcome (binary
logisitc) of relapse and on worst HRSD score (linear)
during follow up.
Summary
• Recurrent depression is common and serious
particularly for those who become suicidal when
depressed.
• Urgent need to develop treatments that produce
sustainable reductions in risk of recurrence
• And to identify the critical therapeutic factors to
refine the approach for the future