Relief From Lingering Depressive Symptoms Just a Click Away?

Batya Swift Yasgur, MA, LSW

February 19, 2020

Online mindfulness-based cognitive therapy (MBCT) can improve residual depressive symptoms (RDS) in patients who remain symptomatic despite antidepressants and/or psychotherapy, new research shows

Results of a randomized trial of more than 400 adults with RDS showed patients who received web-based Mindful Mood Balance (MMB) plus usual depression care had significantly higher remission rates than those who only received usual care.

"We found that by adding the [online] treatment, we could significantly reduce the percentage of people reporting residual depressive symptoms and it could be done cheaply and in a way that increased access," Zindel Segal, PhD, professor of psychology, University of Toronto, Scarborough, told Medscape Medical News.

He added that the online format is "very user friendly" and allows patients to be treated from home, at their convenience.

The study was published online January 29 in JAMA Psychiatry.

Left Behind

Patients with depression who experience moderate gains from treatment but are left with lingering depressive symptoms "are often left behind," said Segal.

"They're not ill enough to require re-treatment, but are not out of the woods either and are still dragging themselves around," Segal said.

He noted that there is "good evidence" that mindfulness-based practices help develop meaningful connections and mitigate common residual depressive symptoms such as anxiety and insomnia.

Given this background, the investigators set out to test whether an online treatment module of MBCT, where patients simultaneously learn mindfulness and receive cognitive therapy, may alleviate RDS and fill this care gap.

"We looked at people for whom antidepressants and behavioral therapy did not lead to complete remission — people who had been treated but had a mediocre response to treatment," said Segal.

The randomized trial included 460 depressed patients from Kaiser Permanente Colorado (mean [SD] age, 48.3 [14.9] years; 75.6% female; 91.9% white). Participants were randomized to receive MMB plus usual care (n = 230) or usual care alone (n = 230) for 3 months.

The intent to treat sample consisted of 362 participants who were evaluated immediately following the intervention at 3 months and 330 who were evaluated 1 year later (15 months after completing the intervention).

Self-Guided

MMB was entirely self-guided, consisting of eight self-administered online sessions that were digital versions of the type of in-person MBCT administered in hospitals and other care settings, said Segal.

Sessions included experiential practice, video-based learning, and didactic intervention, with support of a coach who provided motivational as well as technical support as needed.

The usual care alone intervention consisted of antidepressant therapy or individual or group psychotherapy, with the treatment choice based on symptom severity level.

The study had three primary outcomes — reduction in RDS severity, rates of remission, and rates of relapse, all based on the Patient Health Questionnaire-9 (PHQ-9).

Secondary outcomes included a reduction in anxiety symptoms, as assessed by the Generalized Anxiety Disorder-7 (GAD-7), and mental functioning based on the SF-12 subscale score.

Participants in the MMB plus usual care group completed a mean of almost five sessions, with almost all participants completing ≥ 1 session and over a quarter (27.4%) completing all eight sessions.

Differences in usual care between the two study groups were not significant.

Participants who received MMB plus usual care had significantly greater reductions in residual depressive symptoms than those who received usual care only (mean [SE] PHQ-9 score, 0.95 [0.39]; P < .02).

In addition, investigators found that a significantly greater proportion of patients achieved remission in the MMB plus usual care vs the usual care only group (PHQ-9 score, < 5: β [SE], 0.38 [0.14]; P = .008).

Similarly, relapse rates were significantly lower in the MMB plus usual care group (hazard ratio, 0.61; 95% CI, 0.39 - 0.95; P < .03).

Lower Relapse Rate

The investigators also found that patients who received MMB plus usual care had a significantly greater reduction in residual depressive symptoms and were less likely to relapse compared with the usual care only group.

The intervention group also experienced more depression-free days, decreased anxiety and improved mental functioning. There was no difference in physical functioning between the two groups.

Although patients in the MMB plus usual group maintained their initial gains and experienced more improvements at 12-month follow-up, these improvements were not statistically significant (mean increase of 0.15 [0.26]).

On the other hand, participants in the usual care only group experienced continued improvement (−0.84 [0.24]) that was significantly greater than that achieved in the MMB plus usual group (0.98 [0.35]; P = .003).

The MMB plus usual care was significantly superior to the usual care alone group with higher remission (59.4% vs 47.0%) and relapse rates (13.5 % vs 53%).

The intervention group also experienced decreased anxiety and had more depression-free days and improved mental functioning compared with those in the usual care alone group.

"Benefits of MMB were evident within the 3-month intervention period and were maintained across the 12-month follow-up period," the authors report.

"Unlike most web-based interventions that address acute phase disorders, MMB targets psychological vulnerability after initial treatment and teaches skills to reverse symptom perpetuation and return," the investigators add.

Low-Cost, Scalable

Commenting on the study for Medscape Medical News, Michael Thase, MD, professor of psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, said, "This is a small finding, but a nice one."

He called the intervention "inexpensive and not too time-consuming," and noted that there was a "real effect at 3 months."

However, "the slow fade of benefit is a little discouraging, but it is likely that people could sustain benefit if there was ongoing work to support the program," added Thase, who was not involved with the study.

Also commenting on the study for Medscape Medical News, Helen Christensen, MPsychol (Hons), PhD, scientia professor and director and chief scientist, Black Dog Institute, Randwick, Australia, called it a "substantial trial with sufficient power to demonstrate an effect," whose findings "are robust and illustrate both improvements and remission in symptoms."

Christensen, who was not involved with the study, added that the study was "scalable at lower cost."

According to Segal, "that was one of the main purposes of the study — to see how scalable this intervention was, and how easy to provide to people or clinicians so that they could, in turn, offer it to their patients."

The study was funded by a grant from the National Institute of Mental Health. Segal reported being a co-developer of Mindfulness Based Cognitive Therapy (MBCT) and receiving royalties from Guilford Press for the MBCT treatment manual and patient books; presenting keynote addresses at conferences and MBCT clinical training workshops where he has received a fee; and receiving revenue from online MBCT therapist training tools available on mindfulnoggin.com. The other authors' disclosures are listed on the original paper. Segal and Christensen have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online January 29, 2020. Abstract

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