How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study

Abstract

Background: Depression and anxiety disorders are relapse-prone conditions, even after successful treatment with pharmacotherapy or psychotherapy. Cognitive behavioural therapy (CBT) is known to prevent relapse, but there is little evidence of the durability of remission after low intensity forms of CBT (LiCBT).Method: This study aimed to examine relapse rates 12 months after completing routinely-delivered LiCBT. A cohort of 439 LiCBT completers with remission of symptoms provided monthly depression (PHQ-9) and anxiety (GAD-7) measures during 12 months after treatment. Survival analysis was conducted to model time-to-relapse while controlling for patient characteristics.Results: Overall, 53% of cases relapsed within 1 year. Of these relapse events, the majority (79%) occurred within the first 6 months posttreatment. Cases reporting residual depression symptoms (PHQ-9 = 5 to 9) at the end of treatment had significantly higher risk of relapse (hazard ratio = 1.90, p < 0.001). Conclusions:The high rate of relapse after LiCBT highlights the need for relapse prevention, particularly for those with residual depression symptoms.Key words: depression; anxiety; relapse; cognitive behavioural therapy 3 IntroductionDepression is known to have a high recurrence rate, even after the successful treatment of acute-phase symptoms (Burcusa & Iacono, 2007;Yiend et al., 2009;Harter et al., 2007;Hardeveld et al., 2010;Gopinath et al., 2007). For example, after a first episode of depression, the probability of a further episode is approximately 50%; this rises to 70% following two episodes and 90% after a third episode (Burcusa & Iacono, 2007;Kessler et al., 1996). It also appears that with each further episode there is an increase in the severity of depressive symptoms and an increased probability that these symptoms will become resistant to treatment (Kendler et al., 2000).Similarly, research on anxiety disorders suggests high recurrence rates between 39% and 56% after treatment (Bruce et al., 2005;Eisen et al., 1999;Vervliet et al., 2013).Literature in the field draws conceptual distinctions between relapsea deterioration after initial response to treatment-and recurrence -a new episode of the disorder following a period of recovery- (Bockting et al., 2015).Meta-analyses of trials in this area show that accessing cognitive behavioural therapy (CBT) reduces the risk of depression relapse (Vittengl et al., 2007; Cuijpers et al., 2013) by comparison to acute-phase pharmacological treatment. The prophylactic effects of CBT appear to be as durable as to those of long-term maintenance on pharmacological treatment, but better at preventing relapse and recurrence compared to acute-phase pharmacological treatment without a maintenance phase (Hollon et al., 2005). Similarly, CBT is associated with sustained maintenance of improvements after the acute phase of treatment in various anxiety disorders (Otto, Smits, & Reese, 2005). It is, however, unclear if this 4 apparent durability of therapeutic effects primarily applies to conventi...

Relapse and Recurrence of Common Mental Health Problems after Low Intensity Cognitive Behavioural Therapy: The WYLOW Longitudinal Cohort Study

“…117 critical period where the majority (2 out of 3) of relapse-prone cases become apparent. Consistent with earlier studies, we have previously reported that patients who completed therapy with residual depression symptoms (PHQ-9 = 5-9) had double the risk of relapse within the first year [12].…”

“…Mean pre-and post-treatment measures were PHQ-9 = 13.60 (SD = 5.41) and 3.44 (SD = 2.40), respectively, and GAD-7 = 13.20 (SD = 4.38) and 3.19 (SD = 2.17). Full details about recruitment, inclusion criteria, and methods can be found in a preliminary report of 12-month outcomes [12]. The study was approved by the NHS Health Research Authority (Yorkshire and Humber REC; Ref.…”

A naturalistic pilot study assessing the impact of assessment pathways and intake methods within Improving Access to Psychological Therapies services

“…While shorter assessment techniques might help achieve the access rate targets, it is necessary to recall research which reports moderate rates of re‐referral (Cairns, ; Hepgul et al, ) and relapse (Ali et al, ) as well as poor to variable rates of stepping‐up (Clark et al, ; Delgadillo et al, ; Glover et al, ; Richards et al, ), and treatment allocation practices (Bower et al, ; Chan & Adams, ; Goddard et al, ; Hepgul et al, ) within IAPT services. Other factors are of equal importance alongside the drive to increase access volume, including converting referrals from entering to completing treatment, securing representative data and enhancing session attendance (Clark et al, ).…”

“…While this is not necessarily indicative of a negative outcome, it is notable that almost half are discharged having attended one session only (IAPT, ; Richards & Borglin, ). Other evidence finds wide variability in stepped‐care modelling between services (Clark et al, ; Glover et al, ; Richards et al, ), little discrimination in condition severity between low‐ and high‐intensity interventions (Bower et al, ; Chan & Adams, ), highly complex cases including those with personality disorders being referred, assessed and treated (Goddard, Wingrove, & Moran, ; Hepgul et al, ), poor to variable rates of stepping‐up (Clark et al, ; Delgadillo, Gellatly, & Stephenson‐Bellwood, ; Richards et al, ), moderate rates of re‐referral (Cairns, ; Hepgul et al, ) and poor durability of low‐intensity treatments beyond 1 year (Ali et al, ). These findings suggest that referrals might not be receiving adequate treatment initially or during the course of treatment.…”

PI‐E: An Empathy Skills Training Package to Enhance Therapeutic Skills of IAPT and Other Therapists

“…The results from the programme have also been queried, with some claiming that the true costs of the programme have been underestimated and the positive outcomes inflated (Griffiths & Steen, , ). Indeed, about half of low‐intensity therapy patients relapse, most within six months of the end of treatment (Ali et al ., ). Despite these misgivings, the IAPT programme has become firmly established within the NHS and has an ever widening remit that now includes children, people with long‐term conditions and medically unexplained symptoms.…”