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Staying well after depression (SWAD). CI Professor Mark W illiams PI Professor Ian Russell Sholto Radford Research Officer Depression and suicide . Depression a prevalent Condition Risk of recurrence

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Staying well after depression (SWAD)

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staying well after depression swad

Staying well after depression (SWAD)

CI Professor Mark Williams

PI Professor Ian Russell

Sholto Radford

Research Officer



and suicide

  • Depression a prevalent


  • Risk of recurrence

90% for individuals with 3 or more previous episodes.

  • Suicide ideation is one of the most consistently recurring symptoms of depression.
  • 80% of suicide would not occur without depression.
  • Mindfulness-Based Cognitive Therapy (MBCT) is a promising approach to preventing relapse.
mbct for preventing relapse
MBCT for preventing relapse
  • 3 centre study (Teasdale et al, 2000)
  • Single centre replication study (Ma & Teasdale, 2004)

Summary of results of both trials:

MBCT approximately halved (70% to 39%) the likelihood of depressive relapse in patients who had had three of more episodes of depression

MBCT now recommended by NICE as a treatment for prevention of depression.


MBCT vs Antidepressants (ADs)

123 patients with a history of recurrent depression

MBCT (with or without ADs) was equal if not

slightly better at

preventing relapse than maintenance

antidepressant treatment alone, and better at

improving quality of life.

MBCT is more expensive than maintenance ADs in first 12 mths; then MBCT becomes more cost effective

(Kuyken et al 2008)

research questions
Research questions
  • MBCT - effective relapse prevention of major depression and incidence of suicidal symptoms.
  • Comparison with equally plausible treatment without meditation (CPE) “dismantling”.
  • Understand potential moderators and mediators of treatment outcome.

Multi centre trial (Bangor Oxford) RCT –

Participants randomised to three conditions:-

  • Treatment as usual (TAU)
  • Mindfulness-Based Cognitive Therapy (MBCT) + TAU
  • Cognitive Psycho Education (CPE) + TAU

Stratification - Centre, cohort, history of suicidality (none, ideation, attempt), antidepressants in past 7 days


Both 8 week courses, 2 hour sessions, 2

MBCT – manualised treatment combines training in mindfulness with cognitive therapy – 1 hour per day home practice (meditation + smaller tasks to cultivate mindfulness.

CPE – Includes all elements of MBCT except experiential cultivation of mindfulness. Learn psychological process involved in relapse, mood monitoring, disengaging from unhelpful patterns of processing.

  • Assessment – treatment effects monitored

Pre intervention T0, Post intervention T1, 3 months T2, six months T3, nine months T4, twelve months T5.

Blind assessors – SCID + battery of questionnaires and cognitive tasks

sample and recruitment
Sample and recruitment
  • Using 2:2:1 ratio – 5% significance level 300 participants 99% power for detection of difference CPE –MBCT with 20% attrition 375 target.
  • Referral – advertisements in community, clinics + GP surgeries, referral from GP’s and mental health clinicians, talks a t professional meetings.
  • Preliminary phone screening - recruiters
  • Detailed assessment (SCID) - assessors

Intention to treat analysis (ITT)

  • Primary outcome – time to relapse or recurrence of MDD in weeks.
  • Continuous quantitative measure of outcome also used (HRSD) for severity and to strengthen the dichotomised outcome.
  • Other quantitative measures used include BDI-II , BHS,BSS, EQ5D.
  • Secondary outcome- recurrence of suicidal ideation.
  • Firstly - in participants who relapse
  • Secondly - severity of suicidal symptoms for all participants Beck scale for suicide ideation (BSS) + MINNI suicide-tracking measure
  • Thirdly – suicidal cognitions between groups with AnCova. T1 and T5 with T0 as covariate


Assessing cognitive measures

Mindfulness, suppression, self compassion, rumination, autobiographical memory and executive capacity

Regression on both the dichotomous outcome (binary logisitc) of relapse and on worst HRSD score (linear) during follow up.

  • Recurrent depression is common and serious particularly for those who become suicidal when depressed.
  • Urgent need to develop treatments that produce sustainable reductions in risk of recurrence
  • And to identify the critical therapeutic factors to refine the approach for the future