Relapse Prevention

The laboratory has been involved in:

Tackling Depressive Relapse in Adults with Continuation Phase Cognitive Therapy

Historical background: Informed consent for depressed adults treated with cognitive therapy (CT) involved suggesting that CT would significantly reduce their chance of relapse and recurrence.

Central finding(s): This report was one of the first to show that the relapse/recurrence rates after response to cognitive therapy was high and clinically unacceptable for some adults. Further, the continuation phase cognitive therapy (C-CT), which we articulated and tested, appeared to reduce risk in CT responders. A cohort design limited interpretations. This controversial report helped to open the field to the importance of studies on relapse prevention for adults with unipolar depression.

Dr. Jarrett’s Role: Principal Investigator and primary author; work spanned 1984-1998. This work was done in collaboration with A. John Rush, M.D. Dr. Jarrett developed continuation phase cognitive therapy which was piloted in this project.

Selected papers:

• Jarrett, R.B. & Kraft, D. (1997). Prophylactic cognitive therapy for major depressive disorder. In Session: Psychotherapy in Practice, 3(3), 65-79. doi: 10.1002/(SICI)1520-6572(199723)3:33.0.CO;2-7 
  Prophylactic cognitive therapy for major depressive disorder
• Jarrett, R.B., Basco, M.R., Risser, R., Ramanan, J., Marwill, M., Kraft, D., & Rush, A.J. (1998). Is there a role for continuation phase cognitive therapy for depressed outpatients? Journal of Consulting and Clinical Psychology, 66(6),1036-1040. doi: 10.1037/0022-006X.66.6.1036 PubMed PMID: 9874918.

Harnessing the Power and Parameters of Relapse Prevention

Historical background: This randomized controlled trial on depressive relapse prevention in cognitive therapy responders followed Contribution 2 with an improved design.

Central finding(s): Continuation phase cognitive therapy (C-CT) reduced relapse significantly more than an assessment only control in adults who responded to acute phase CT and had presented with recurrent major depressive disorder. Responders with unstable remission or with early age of onset appeared to benefit most. This report continued to open the field to the importance of relapse prevention and suggested that a longer course (dose) of CT (with a focus on residual symptoms and skills consolidation) may be necessary for adults at highest risk. Treatment manual was shared with Claudi Bockting, Ph.D. who innovated a similar preventive intervention tested in a randomized controlled trial completed in the Netherlands. Data was shared with Hans Kordy, Ph.D. in order to power a randomized controlled trial on recurrent depression in Germany using internet assisted platforms and support. 

Dr. Jarrett’s Role: Principal Investigator and primary author; study design, implementation, oversight, and interpretation; work spanned 1992-2001.

Selected papers:

• Jarrett, R.B., Kraft, D., Doyle, J., Foster, B.M., Eaves, G.G., & Silver, P.C. (2001). Preventing recurrent depression using cognitive therapy with and without a continuation phase: a randomized clinical trial. Archives of General Psychiatry, 381-388. doi: 10.1001/archpsyc.58.4.381 PubMed PMID:11296099; PubMed Central PMCID: PMC1307495.  
• Vittengl, J.R., Clark, L.A.,Thase, M. E., & Jarrett, R.B. (2005). Multiple measures, methods, and moments: a factor-analytic investigation of change in depressive symptoms during acute-phase cognitive therapy for depression. Psychological Medicine, 35(5), 693-704. doi: 10.1017/S0033291704004143 PubMed PMID: 15918346; PubMed Central PMCID: PMC1410810. 
• Jarrett, R.B., Vittengl, J.R., Doyle, K., & Clark, L.A. (2007). Changes in cognitive content during and following cognitive therapy for recurrent depression: substantial and enduring, but not predictive of change in depressive symptoms. Journal of Consulting and Clinical Psychology, 75(3), 432-446. doi: 1037/0022-006X.75.3.432 PubMed PMID: 432 PubMed PMID: 17563160; PubMed Central PMCID: PMC2605093. 

Extending Relapse Prevention to Children and Adolescents with Continuation Phase Cognitive Therapy

Historical background: Relapse prevention for depressed youth was untested in the mid-2000s. This work adapted and generalized relapse prevention effects found in adults to children and adolescents.

Central finding(s): Continuation phase CT for children and adolescent was developed and appeared promising based on tests of feasibility, acceptability, and safety.

Influence on health and technology: This report opened the field to the importance of relapse prevention in children and adolescents who respond to acute phase antidepressant pharmacotherapy and created the preliminary data for a randomized trial on relapse prevention in youth conducted by Kennard et al., 2014.

Dr. Jarrett’s Role: Co-Investigator and co-author; study design, implementation, and treatment development. This work was done in collaboration with Beth Kennard, Psy.D., who has helped to create the evidence base for relapse prevention in depressed youth.

• Kennard, B.D., Stewart, S.M., Hughes, J.L., Jarrett, R.B., & Emslie, G.J. (2008). Developing Cognitive Behavioral Therapy to Prevent Depressive Relapse in Youth. Cognitive and Behavioral Practice, 15(4), 387-399. doi: 10.1016/j.cbpra.2008.02.006 PubMed PMID: 20535241; PubMed Central PMCID: PMC2882305. 
• Kennard, B.D., Emslie, G.J., Mayes, T.L., Nightingale-Teresi, J., Nakonezny, P.A., Hughes, J.L.,…& Jarrett, R.B. (2008). Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 47(12), 1395-1404. doi: 10.1097/CHI.0b013e31818914a1 
  PubMed PMID: 18978634; PubMed Central PMCID: PMC2826176.

Demonstrating the Effects of Continuation Phase Cognitive Therapy and Pharmacology in Relapse Prevention for Adults with Recurrent Depression

Historical background: This randomized controlled trial followed Contribution 3 in adults at highest risk for relapse and recurrence, given unstable remission during acute phase CT. We addressed the extent to which continuation phase cognitive therapy: (a) prevents relapse compared to continuation phase pill placebo and match continuation phase fluoxetine (Prozac; a serotonin reuptake inhibitor) and (b) has enduring preventive effects.

Central finding(s): Both continuation phase cognitive therapy and fluoxetine prevented relapse in highest risk adults who showed partial remission after acute phase CT significantly more than pill placebo. Effects of the two active treatments (C-CT and fluoxetine) did not differ. Results from follow-up over 32 months post randomization did not differ significantly in adult CT responders.

Influence on health and technology: These results: (a) increased the array of options available to people who prefer to lower relapse risk without pharmacotherapy, (b) showed that cognitive therapy responders, when educated about depressive risk, are willing to take pharmacotherapy as a preventive treatment, (c) underscored the importance of longitudinal assessment to monitor depressive risk, (d) laid the groundwork for efficacy tests on maintenance phase cognitive therapy to lower the risk of recurrence; and (e) suggested that acute phase CT has prophylactic effects in some adult responders albeit for a limited time (and more than 1 year). We also developed the Skills of Cognitive Therapy (SoCT) to measure the patients’ comprehension and use of cognitive therapy skills.

Dr. Jarrett’s Role: Principal Investigator; study design, implementation, oversight, interpretation, and author; work spanned 1999-2013. This two site trial was done in collaboration with Michael Thase, M.D., who was the Principal Investigator at University of Pittsburgh.

Selected papers:

• Jarrett, R.B. & Thase, M.E. (2010). Comparative efficacy and durability of continuation phase cognitive therapy for preventing recurrent depression: design of a double-blinded, fluoxetine- and pill placebo-controlled, randomized trial with 2-year follow-up. Contemporary Clinical Trials, 31(4), 355-377. doi: 10.1016/j.cct.2010.04.004 PubMed PMID: 20451668; PubMed Central PMCID: PMC2936266. 
• Jarrett, R.B., Vittengl, J.R., Clark, L.A., & Thase, M.E. (2011). Skills of Cognitive Therapy (SoCT): a new measure of patients' comprehension and use. Psychological Assessment, 23(3), 578-586. doi: 10.1037/a0022485 PubMed PMID: 21319902; PubMed Central PMCID: PMC3144321.
• Jarrett, R.B., Minhajuddin, A., Kangas, J.L., Friedman, E.S., Callan, J.A., & Thase, M.E. (2013). Acute phase cognitive therapy for recurrent major depressive disorder: who drops out and how much do patient skills influence response? Behaviour Research and Therapy, 51(4-5), 221-230. doi: 10.1016/j.brat.2013.01.006 PubMed PMID: 23485420; PubMed Central PMCID: PMC3685278. 
• Jarrett, R.B., Minhajuddin, A., Gershenfeld, H., Friedman, E.S., & Thase, M.E. (2013). Preventing depressive relapse and recurrence in higher-risk cognitive therapy responders: a randomized trial of continuation phase cognitive therapy, fluoxetine, or matched pill placebo. JAMA Psychiatry, 70(11), 1152-1160. doi: 10.1001/jamapsychiatry.2013.1969 PubMed PMID: 24005123; PubMed Central PMCID: PMC4204630. 
• Jarrett, R. B., Minhajuddin, A., Vittengl, J. R., Clark, L. A., & Thase, M. E. (2016). Quantifying and qualifying the preventive effects of acute phase cognitive therapy: Pathways to personalizing care. Journal of Consulting and Clinical Psychology, 84(4), 365-376. doi.org/10.1037/ccp0000069. PMCID: PMC4807431
• Vittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett, R. B. (2017). Initial steps to inform selection of continuation cognitive therapy or fluoxetine for higher risk responders to cognitive therapy for recurrent major depressive disorder. Psychiatry Research, 253, 174-181. doi: 10.1016/j.psychres.2017.03.032 PubMed PMID: 28388454; PMCID: PMC5481171.
• Vittengl, J. R., Clark, L. A., Thase, M. E., & Jarrett R. B. (2015). Predictors of longitudinal outcomes after unstable response to acute-phase cognitive therapy for major depressive disorder [Special issue]. Psychotherapy, 52(2), 268–277. doi:10.1037/pst0000021. PMCID: PMC4438278.