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. Author manuscript; available in PMC: 2016 Aug 1.
Published in final edited form as: Curr Opin Psychol. 2015 Aug 1;4:26–31. doi: 10.1016/j.copsyc.2015.01.016

Cognitive Therapy to Prevent Depressive Relapse in Adults

Jeffrey R Vittengl 1,✉, Robin B Jarrett 2,✉
PMCID: PMC4338917  NIHMSID: NIHMS662498  PMID: 25729758

Abstract

The high prevalence, frequent relapse, and recurrence of major depressive disorder (MDD) increase its personal and societal costs. Cognitive therapy (CT) aims to decrease depressive symptoms and prevent relapse/recurrence. We review prevention evidence for acute, continuation, and maintenance CTs for patients whose depression is active, remitted, and recovered, respectively. Evidence suggests that patients relapse less often after discontinuing acute phase CT versus discontinuing pharmacotherapy. Continuation CT further decreases relapse relative to inactive controls and similarly to active pharmacotherapy. Maintenance CT may decrease recurrence but needs rigorous evaluation. Post-acute CT’s preventive effects appear greater for higher-risk patients (e.g., with residual depressive symptoms, unstable acute-phase treatment response, childhood trauma, more prior depressive episodes), although risks may vary by specific CTs.

Introduction

Major depressive disorder (MDD) is a common illness with a large public health cost (e.g., Vittengl & Jarrett, 2014). A curative treatment for MDD would eliminate underlying pathology, relieve all patients’ depressive symptoms rapidly, restore psychosocial functioning fully, and prevent depressive relapses and recurrences entirely. Current treatments are far from these ideals. However, cognitive and cognitive-behavioral therapy (CT) for MDD reduces depressive symptoms, improves psychosocial functioning, and lowers the probability future depression in many patients. Here we review some of the most important and most recent research on CT for adults with MDD to inform prevention of relapse and recurrence.

What is Major Depressive Disorder?

The experience of at least one major depressive episode (MDE) defines MDD (APA, 2013). MDEs reflect disturbances in mood (e.g., subjectively depressed and/or loss of pleasure in life’s activates) with attendant changes in behavior (e.g., increased or decreased sleep, eating, activity level) and cognition (e.g., reduced concentration, increased guilt, suicidality), last at least two weeks, and produce significant life interference (e.g., as a student, worker, parent, friend, romantic partner; Kessler et al., 2006). Reduced physical capacity (Wells et al., 1989) and increased mortality (Angst et al., 2002; Thomson, 2011) often accompany MDD.

Both the prevalence and recurrence of MDD are high. For example, about 5–7% of the US population has experienced MDD over the past year and 13–17% will experience MDD over the lifetime (Kessler, Berglund, et al., 2005; Kessler, Chiu, et al., 2005; Hasin et al., 2005). Although 15–25% of persons with MDD display chronic depression (Eaton et al, 2008; Satyanarayana et al., 2009), most eventually return to normal (or near-normal) mood, with or without treatment. Although a subset of persons experience only a single episode (Wakefield & Schmitz, 2014), among those who recover, perhaps 85% of patients experience a new MDE with 15 years (Solomon et al., 2000). CT aims to reduce the probability of both relapse (resurgence of an MDE that abated temporarily) and recurrence (a new MDE).

What is Cognitive Behavioral Therapy?

Cognitive behavioral therapies for depression share efforts to change patients’ distress-related cognition as a means to improve mood and functioning. Beck et al.’s (1979) individual, in-person CT is prototypical. During a limited period (e.g., 16–20 one-hour sessions over 3–4 months), Beck’s CT aims to increase patients’ engagement with sources of reinforcement and adaptive functioning (“behavioral activation”) and then to assess and restructure depressive cognition, including negative automatic thoughts (e.g., “I am a loser”) and schema (broader negative views about the self, world, and future; e.g., “Being loved by all is essential for happiness”). Many delivery methods and theoretical variants of CT exist, including treatments administered to groups (e.g., Lewinsohn et al., 1984), via books (e.g., Burns, 1980), and by computer (e.g., de Graaf et al., 2010); as well as treatments using behavioral activation without cognitive restructuring (Dimidjian et al., 2006); emphasizing cognitive restructuring over behavioral activation (Ellis, 1980); monitoring and distancing reactions to negative cognition rather than changing negative cognition itself (e.g., Hayes et al., 1999; Segal et al., 2002; Wells, 2008); and emphasizing social-cognitive development and interpersonal functioning (McCullough, 2003).

In addition, CT can be staged by depression’s course (Frank et al., 1991). Patients experiencing an MDE receive acute phase treatment with the goal of producing an initial treatment response (e.g., responders experience substantive reductions in depressive symptom severity and no longer meets criteria for an MDE). Ideally, acute phase treatment would fully prevent relapse (resurgence of the index MDE) and recurrence (experience of a new MDE). However, additional treatment is often beneficial for acute phase treatment responders with risk factors such as residual symptoms (sub-diagnostic but impairing depressive symptoms) and unstable response (transiently elevated depressive symptoms late in acute phase treatment). In particular, acute phase treatment responders may receive continuation phase treatment to prevent relapse and promote remission and recovery (e.g., periods of several weeks and months, respectively, with minimal or absent depressive symptoms). Patients who have recovered from their index MDE may then receive maintenance phase treatment to sustain recovery and prevent recurrence. Following we review evidence about CTs’ effects on relapse, recurrence, remission, and recovery. We organize our review by acute, continuation, and maintenance CT, although researchers have not always followed these theoretical and terminological distinctions (e.g., some studies of “maintenance” fit our definition of “continuation” treatment).

To What Extent Does Cognitive Behavioral Therapy Reduce Relapse, Recurrence, and Residual Symptoms of Major Depressive Disorder?

Acute phase CT

Roughly 60–70% of patients no longer meet criteria for MDD after completing acute phase CT (Cuipers et al., 2014; Vittengl & Jarrett, 2014), and average symptom levels are comparable after acute phase CT versus pharmacotherapy (Cuijpers, Berking, et al., 2013). Although CT and pharmacotherapy produce similar short-term outcomes, CT’s preventive effects exceed pharmacotherapy after either acute phase treatment ends.

In an earlier meta-analysis of studies reporting follow-up data after response then discontinuation of acute phase treatment, relapse/recurrence frequency over an average of 68 weeks was 39% for CT compared to 61% for pharmacotherapy (Vittengl et al., 2007). The 22% lower frequency of relapse/recurrence after CT versus after pharmacotherapy was similar to the 23% lower frequency of relapse/recurrence after acute phase CT plus pharmacotherapy versus after pharmacotherapy alone. However, based on a small number of studies, CT did not show lower relapse/recurrence compared to other psychotherapies (interpersonal, psychodynamic, behavioral activation; Vittengl et al., 2007).

An updated meta-analysis (Cuijpers, Hollon, et al., 2013) replicated these advantages for acute phase CT. In particular, in follow-ups of 6–18 months, the odds of relapse after discontinuing pharmacotherapy were about 2.6 times higher than after discontinuing acute phase CT. Stated another way, for every 5 patients treated with CT instead of with pharmacotherapy, 1 patient’s relapse will be prevented. In addition, the odds of dropping out of acute phase CT were only about 0.6 versus dropping out of acute phase pharmacotherapy. Thus, patients are more likely to stay in CT, and so respond to CT, and then less likely to relapse after CT compared to after pharmacotherapy.

Acute phase CT responders vary in their risk for relapse/recurrence, and thus perhaps also in their need for continuation treatment to prevent relapse/recurrence. Arguably the strongest and best-replicated predictors of relapse are the extent and quality of remission during acute phase treatment. These predictors include unstable response (e.g., Jarrett et al., 2001; Thase et al., 1992; Segal et al., 2010; Jarrett et al., under review) and residual symptoms (e.g., Fava, Fabbri, & Sonino, 2002; Jarrett, Vittengl, & Clark, 2008). Additional predictors of relapse have included indicators of more severe illness, including MDD onset at younger ages, more prior depressive episodes, “double depression” (dysthymic disorder comorbid with MDD), family history of depression, more depressive cognitive content, high neuroticism, and poor social support (e.g., Burcusa & Iacono, 2007; Vittengl, Clark, & Jarrett, 2010; Jarrett et al., under review; Vittengl et al., under review).

Continuation phase CT

Although patients relapse less after acute phase CT than after discontinuing pharmacotherapy (Cuijpers, Hollon, et al., 2013), many responders do eventually relapse or recur. For example, among MDD patients who respond and then discontinue acute phase CT, roughly one-quarter relapse/recur within a year and one-half within two years (Vittengl et al., 2007). Continuation phase CT aims to prevent relapse among responders to acute phase treatments, and a growing literature supports continuation CT’s efficacy (e.g., Beshai et al., 2011; Vittengl & Jarrett, 2014). Meta-analyses suggest that continuation CT reduces relapse and recurrence by roughly 25–35% compared to inactive control conditions over 10–18 months, on average (Piet & Hougaard, 2011; Vittengl et al., 2007), comparable to (if not somewhat larger than) the average benefit of continuation pharmacotherapy versus placebo (e.g., Borges et al., 2014). However, the benefits of continuation CT may be larger for patients with greater illness liabilities (e.g., more prior MDEs, unstable response or remission of the index episode, greater residual symptoms; Piet & Hougaard, 2011; Vittengl et al., 2010) and when it is preceded by acute phase treatment (Biesheuvel-Leliefeld et al., 2015).

Recent studies of continuation CT bolster these conclusions. For example, among patients with recurrent MDD who showed unstable remission to acute phase CT, 8 months of continuation CT or fluoxetine reduced relapse (from 33% to 18%) and residual symptoms (by about 0.2 SD) compared to pill placebo (Jarrett et al., 2013; Vittengl et al., 2014). Similarly, among remitted MDD patients with a greater history of childhood trauma, 8 weeks of treatment as usual plus continuation CT reduced relapse over one year compared to treatment as usual alone (41% vs. 65%; Williams et al., 2014).

Recent studies also support the viability of different continuation treatment delivery modalities, sequences, and combinations. For example, MDD patients randomized to 10 weeks of internet-based continuation CT or control (assessment and non-specific support by email) showed less relapse during six-month (11% vs. 38%; Holländare et al., 2010) and two-year (14% vs. 61%; Holländare et al., 2013) follow-ups. In addition, after response to acute phase electro-convulsive therapy, MDD patients randomized to 6 months of continuation pharmacotherapy plus CT (77%) showed more frequent sustained response (no relapse and no drop-out) than patients receiving pharmacotherapy plus electro-convulsive therapy (40%) or pharmacotherapy alone (44%; Brakemeier et al., 2014). Moreover, acute then continuation CT plus pharmacotherapy increased recovery (defined as 1 month of remission followed by 6 months without relapse) compared to pharmacotherapy-alone overall (73% vs. 63%) and especially for the subset of participants with severe non-chronic depression (81% vs. 52%; Hollon et al., 2014). Finally, mindfulness-based CT applied perinatally shows potential to reduce postpartum relapse/recurrence among women with a history of depression (Dimidjian et al., 2014).

The durability of continuation and maintenance CTs’ preventive effects once discontinued is uncertain but may be limited. For example, Jarrett et al. (2013) found that continuation CT or continuation pharmacotherapy reduced relapse compared to pill placebo at the end of 8 months of continuation treatment but not at follow-ups 1 and 2 years later. Similarly, Kashner et al. (2007) found declining but detectable benefits of continuation CT versus assessment control for 19 weeks after ending continuation CT. In addition, Gelenberg et al. (2003) reported that the frequency of relapse/recurrence over one year did not differ significantly between patients who had received 16 weeks of continuation CT plus pharmacotherapy or pharmacotherapy alone. Finally, Paykel et al. (2005) found benefits of continuation CT plus pharmacotherapy versus pharmacotherapy alone ending 3.5 years after discontinuation.

Maintenance phase CT

Even after response to acute phase treatment, and sustained absence of major depression through continuation treatment, many patients remain vulnerable to relapse and recurrence. For example, after unstable response to acute phase CT and 8 months of continuation treatment, the proportion of patients with relapse/recurrence increased from 18% to 41% among continuation fluoxetine patients, and from 18% to 45% among continuation CT patients, from months 8 to 32 after acute phase CT (Jarrett et al., 2013). Consequently, maintenance CT has an important role in keeping patients well as long as possible. Although the research base is smaller than for continuation CT, maintenance CT applied after several earlier treatments reduces relapse/recurrence, but only among higher-risk patients in some studies.

For example, patients randomized to two years of continuation/maintenance CT or pharmacotherapy experienced similar rates of relapse/recurrence (26% vs. 31%; Blackburn & Moore, 1997). Also consistent with maintenance CT and pharmacotherapy’s comparable prevention, patients with unstable remission showed less relapse/recurrence when randomized to 18 months of maintenance MBCT (28%) or pharmacotherapy (27%) compared to placebo (71%), whereas groups did not differ significantly among patients with stable remission (Segal et al., 2010) In addition, over 5.5 years of follow-up, 8 weeks of maintenance CT plus treatment as usual (chosen by patients naturalistically) reduced relapse/recurrence significantly compared to treatment as usual alone (75% vs. 95%; Bockting et al., 2009). Finally, patients with a history of ≥5 MDEs benefited from 8 months of maintenance CT compared to psychoeducation control (50% vs. 73% relapsed/recurred by during a follow-up year), whereas patients with fewer MDEs did not benefit significantly (51% vs. 60%; Strangier et al., 2013).

The benefit of combining maintenance CT and pharmacotherapy is uncertain and may vary by subpopulation of patient. For example, patients randomized to 80 weeks of maintenance CT with placebo, CT with pharmacotherapy, pharmacotherapy only, or placebo did not vary significantly in the frequency of recurrence during maintenance treatment (40%, on average; Petersen et al., 2010). However, a pilot study suggested that augmenting the same pharmacotherapy dose with maintenance CT may prevent relapse/recurrence more so than increasing the pharmacotherapy dose (1/4 vs. 4/4 patients relapsed/recurred within one year), among patients who cycled between remission and relapse on pharmacotherapy previously (Fava et al., 2002).

Conclusions and Future Directions

Major depressive disorder is often recurrent and treatment with CT increases patients’ periods of relative wellness, with important clinical trials ongoing (e.g., Bockting et al., 2011; Kuyken et al., 2014). Research shows that acute, continuation, and maintenance CTs have preventive effects against relapse and/or recurrence, although none is fully efficacious. Refined treatments and treatment-application protocols may profitably focus on maximizing individual-and population-level benefits of CT and on identifying mechanisms.

For example, given limited treatment resources, understanding which patients most need relapse-prevention and benefit from CT relative to clinical alternatives (e.g., watchful waiting, pharmacotherapy; Piet & Hougaard, 2011; Vittengl et al., 2010; Vittengl et al., under review), and whether some treatment sequences and combinations are more helpful (Fava & Tomba, 2010; Oestergaard & Møldrup, 2011), may provide routes to increase CT’s overall benefits. Second, understanding how CT produces its preventive benefits may provide insights into improving the potency of the treatment. Past research suggests that the quality of the therapeutic relationship (Weck et al., 2013) and CT skill development (Vittengl et al., under review) may be important. Finally, reducing the cost and increasing the availability of continuation CT via computerized delivery (e.g., Boggs et al., 2014) may yield important gains in public health.

Highlights.

  • Several cognitive therapies reduce relapse compared to no additional treatment.

  • Patients relapse less after acute phase cognitive therapy versus after medication.

  • After acute symptom reduction, cognitive therapy can be used to prevent relapse.

  • We review prevention evidence for acute, continuation, and maintenance therapies.

  • Relapse-prevention appears greater for higher-risk patient populations.

Acknowledgments

This report was supported by Grants Number K24 MH001571, R01 MH58397, R01 MH69619 to Robin B. Jarrett, PhD, from the National Institute of Mental Health (NIMH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIMH or the National Institutes of Health.

Footnotes

Dr. Vittengl has no financial interest or conflict of interest in the research. Dr. Jarrett’s medical center collects the payments from the cognitive therapy she provides to patients. Dr. Jarrett is a paid consultant to the NIMH.

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Contributor Information

Jeffrey R. Vittengl, Email: vittengl@truman.edu.

Robin B. Jarrett, Email: Robin.Jarrett@UTSouthwestern.edu.

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*of special interest

**of outstanding interest

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