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Rodgers M, Asaria M, Walker S, et al. The Clinical Effectiveness and Cost-Effectiveness of Low-Intensity Psychological Interventions for the Secondary Prevention of Relapse After Depression: A Systematic Review. Southampton (UK): NIHR Journals Library; 2012 May. (Health Technology Assessment, No. 16.28.)

6Conclusions

There is inadequate evidence to determine the clinical effectiveness or cost-effectiveness of low-intensity interventions for the prevention of relapse or recurrence of depression, either unsupported psychological interventions or the type of supported interventions that might be delivered by PWPs (as defined by IAPT) or by similar para-professionals.

A scoping review of interventions using a broader definition of brief high-intensity therapies indicates that some approaches (e.g. MBCT in a group setting) have shown promise in some studies, but findings have not been consistent.

Careful consideration should be given to the scope of future research to inform this issue; it is important to evaluate the broader patient pathway accounting for the entire treatment pathway and consider the wide range of heterogeneous patient groups within those patients in remission or who have recovered from a depressive episode.

Suggested research priorities

Given the lack of relevant evidence identified, many uncertainties remain. The existing evidence does not provide a robust evaluation of the clinical effectiveness or cost-effectiveness of low-intensity interventions for the prevention of relapse or recurrence of depression. Further research is needed to address this issue.

For many individuals, depression must be seen as a relapsing or recurrent condition that requires long-term management to minimise the impact on people's QoL. Approaches to the evaluation of low-intensity therapies and other interventions for depression should therefore consider the management of an individual episode within the broader context of managing the entire course of the condition. Future research should also consider a number of key issues relevant to the evaluation of relapse and recurrence prevention, such as defining the interventions and comparators, outcomes and populations of interest. It is also important that any research question is set in the context of the entire patient pathway accounting, where possible, for the impact of important factors such as initial treatment alternatives and patient characteristics. Treatment interactions may exist between combinations of interventions or between interventions received for the initial depressive episode and subsequent interventions. Adopting a more comprehensive evaluative approach to the whole-patient pathway being considered will allow the use of particular interventions to be optimised within a broader range of alternatives considering the entire treatment pathway of patients.

The definition of low-intensity is unclear and there is likely to be a number of alternative interventions that could be feasible, including unsupported interventions, interventions delivered by those without formal health-care qualifications, or group work (as found in most of the interventions identified in part B studies) delivered by a mental health professional, but potentially providing more efficient use of resources and increased throughput. Some interventions may be more feasible for widespread introduction in the NHS than others. In defining the intervention it is important to provide clarity on the type of practitioner providing the training, including their training and supervision; this will help clarify the extent to which interventions can be considered as low intensity and inform cost-effectiveness evaluations.

It is important to consider carefully what the relevant comparators should be in any future evaluation. There are numerous interventions, including both high-intensity psychological interventions and pharmacological therapies or a combination of interventions, which are used to prevent relapse or recurrence of depression, but any constraints that limit the relevance of interventions will need to be considered, for example the availability of clinicians or the acceptability of long-term medication. TAU may be an appropriate comparator but it is important to detail precisely what this entails.

Relapse or recurrence is a key outcome; however, QoL measures, such as depression-free days, etc., are also important. Other effects, such as the effects of treatment on HRQoL during periods of remission or depressive episodes, should also be considered.

The patient group is not homogeneous and consideration should be given to which subgroups are important in terms of both the clinical effectiveness and cost-effectiveness of low-intensity psychological interventions for the secondary prevention of relapse after depression. Significant factors include the severity of depression, comorbidities and the number of previous episodes. Future evaluations should take account of the differing baseline risk of relapse, and it may also be worth examining if relative treatment effects differ by the number of previous episodes. Patients experiencing depressive episodes may suffer from different severities of the condition, with the associated differences in HRQoL; if the severity of prior depressive episodes is associated with the future severity of depression following relapse then this should be accounted for.

Recent clinical guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) suggest that MBCT in a group setting may be considered as a treatment option to reduce relapse in patients with depression who have had three or more episodes.102 This recommendation was based on a systematic review performed in 2007.103 The current scoping review identified three further RCTs of group-based MBCT which were not included in the 2007 review, two69,71 of which are UK-based and currently ongoing. An updated systematic review of group-based MBCT on completion of these trials may be of value. Any such systematic review should investigate any potential impact of the duration and intensity of the intervention on the relapse and recurrence of depression.

© 2012, Crown Copyright.

Included under terms of UK Non-commercial Government License.

Cover of The Clinical Effectiveness and Cost-Effectiveness of Low-Intensity Psychological Interventions for the Secondary Prevention of Relapse After Depression: A Systematic Review
The Clinical Effectiveness and Cost-Effectiveness of Low-Intensity Psychological Interventions for the Secondary Prevention of Relapse After Depression: A Systematic Review.
Health Technology Assessment, No. 16.28.
Rodgers M, Asaria M, Walker S, et al.
Southampton (UK): NIHR Journals Library; 2012 May.

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