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Maintenance Cognitive-Behavioral Therapy and Manualized Psychoeducation in the Treatment of Recurrent Depression: A Multicenter Prospective Randomized Controlled Trial
Ulrich Stangier, Ph.D.; Christine Hilling, M.Sc.; Thomas Heidenreich, Ph.D.; Anne Katrin Risch, Ph.D.; Arnd Barocka, M.D.; Ralf Schlösser, M.D.; Kai Kronfeld, Ph.D.; Christian Ruckes, M.Sc.; Hartmut Berger, M.D.; Joachim Röschke, M.D.; Florian Weck, Ph.D.; Stephan Volk, M.D.; Martin Hambrecht, M.D.; Richard Serfling, M.D.; Ralf Erkwoh, M.D.; Aglaja Stirn, M.D.; Thomas Sobanski, M.D.; Martin Hautzinger, Ph.D.
Am J Psychiatry 2013;170:624-632. doi:10.1176/appi.ajp.2013.12060734
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Funded by the German Research Funding (Deutsche Forschungsgemeinschaft) by grants STA 512/5-1/2, HA 1399/17-2, and HE 2825/1-1.

Dr. Barocka has received educational grants from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Esparma, Janssen-Cilag, Lundbeck, Merz, Neuraxpharm, Pfizer, and Servier. Dr. Serfling has received honoraria or sponsoring from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Janssen-Cilag, Lundbeck, and sMerz. The remaining authors report no financial relationships with commercial interests.

International Standard Randomized Controlled Trial Number Register 81212636 (http://www.controlled-trials.com/ISRCTN81212636).

From the Departments of Psychology, Psychiatry, Psychotherapy, and Psychosomatics, University of Frankfurt, Germany; the Department of Social Work, Health, and Nursing, University of Applied Sciences, Esslingen, Germany; the Departments of Psychology, Psychiatry, and Psychotherapy, University of Jena, Germany; Hohe Mark des Deutschen Gemeinschaftsdiakonieverbands, Oberursel/Frankfurt, Germany; the Interdisciplinary Center for Clinical Trials, University Medical Center Mainz, Germany; the Clinic of Psychiatry and Psychotherapy, Riedstadt, Germany; the Clinic of Psychiatry and Psychotherapy, St. Valentinus, Bad Soden, Germany; the Clinic of Psychiatry and Psychotherapy, Hofheim, Germany; the Clinic of Psychiatry and Psychotherapy, Elisabethenstift, Germany; Thüringen Kliniken, the Clinic of Psychiatry and Psychotherapy, Saalfeld, Germany; Sophien und Hufeland Klinikum, Clinic of Psychiatry and Psychotherapy, Weimar, Germany; Helios-Kliniken, Clinic of Psychiatry, Psychotherapy and Psychosomatics, Erfurt, Germany; the Department of Psychology, University of Tübingen, Baden-Württemberg, Germany.

Address correspondence to Dr. Stangier (stangier@psych.uni-frankfurt.de).

Copyright © 2013 by the American Psychiatric Association

Received June 03, 2012; Revised December 16, 2012; Accepted January 03, 2013.


Objective  This multicenter study compared the relapse and recurrence outcomes of two active treatments, maintenance cognitive-behavioral therapy (CBT) and manualized psychoeducation, both in addition to treatment as usual, in patients in remission from depression.

Method  This was a multicenter prospective randomized observer-blinded study with two parallel groups. The authors assessed 180 patients with three or more previous major depressive episodes who met remission criteria over a 2-month baseline period and who were randomly assigned to 16 sessions of either maintenance CBT or manualized psychoeducation over 8 months and then followed up for 12 months. The main outcome measure was time to first relapse or recurrence of a major depression, based on DSM-IV criteria, as assessed by blinded observers with the Longitudinal Interval Follow-Up Evaluation.

Results  Cox regression analysis showed that time to relapse or recurrence of major depression did not differ significantly between treatment conditions, but a significant interaction was observed between treatment condition and number of previous episodes (<5 or ≥5). Within the subsample of patients with five or more previous episodes, maintenance CBT was significantly superior to manualized psychoeducation, whereas for patients with fewer than five previous episodes, no significant treatment differences were observed in time to relapse or recurrence.

Conclusions  The results indicate that maintenance CBT has significant effects on the prevention of relapse or recurrence only in patients with a high risk of depression recurrence. For patients with a moderate risk of recurrence, nonspecific effects and structured patient education may be equally effective.

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FIGURE 1. Flow of Patients Randomly Assigned to Maintenance Cognitive-Behavioral Therapy (CBT) or Manualized Psychoeducation in a Study of Treatments for Recurrent Depression

FIGURE 2. Time to Relapse (New Major Depressive Episode) in Patients With Previous Major Depressive Episodesa

a For individuals who dropped out of the study, the reason for discontinuation was classified as relapse or censored according to the reason.

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TABLE 1.Characteristics of the Intention-to-Treat Sample in a Study of Treatments for Recurrent Depression


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