Rachel Hayes

IMPORTANCE: Relapse prevention in recurrent depression is a significant public health problem, and antidepressants are the current first-line treatment approach. Identifying an equally efficacious nonpharmacological intervention would be an important development. OBJECTIVE: To conduct a meta-analysis on individual patient data to examine the efficacy of mindfulness-based cognitive therapy (MBCT) compared with usual care and other active treatments, including antidepressants, in treating those with recurrent depression. DATA SOURCES: English-language studies published or accepted for publication in peer-reviewed journals identified from EMBASE, PubMed/Medline, PsycINFO, Web of Science, Scopus, and the Cochrane Controlled Trials Register from the first available year to November 22, 2014. Searches were conducted from November 2010 to November 2014. STUDY SELECTION: Randomized trials of manualized MBCT for relapse prevention in recurrent depression in full or partial remission that compared MBCT with at least 1 non-MBCT treatment, including usual care. DATA EXTRACTION AND SYNTHESIS: This was an update to a previous meta-analysis. We screened 2555 new records after removing duplicates. Abstracts were screened for full-text extraction (S.S.) and checked by another researcher (T.D.). There were no disagreements. Of the original 2555 studies, 766 were evaluated against full study inclusion criteria, and we acquired full text for 8. Of these, 4 studies were excluded, and the remaining 4 were combined with the 6 studies identified from the previous meta-analysis, yielding 10 studies for qualitative synthesis. Full patient data were not available for 1 of these studies, resulting in 9 studies with individual patient data, which were included in the quantitative synthesis. RESULTS: Of the 1258 patients included, the mean (SD) age was 47.1 (11.9) years, and 944 (75.0%) were female. A 2-stage random effects approach showed that patients receiving MBCT had a reduced risk of depressive relapse within a 60-week follow-up period compared with those who did not receive MBCT (hazard ratio, 0.69; 95% CI, 0.58-0.82). Furthermore, comparisons with active treatments suggest a reduced risk of depressive relapse within a 60-week follow-up period (hazard ratio, 0.79; 95% CI, 0.64-0.97). Using a 1-stage approach, sociodemographic (ie, age, sex, education, and relationship status) and psychiatric (ie, age at onset and number of previous episodes of depression) variables showed no statistically significant interaction with MBCT treatment. However, there was some evidence to suggest that a greater severity of depressive symptoms prior to treatment was associated with a larger effect of MBCT compared with other treatments. CONCLUSIONS AND RELEVANCE: Mindfulness-based cognitive therapy appears efficacious as a treatment for relapse prevention for those with recurrent depression, particularly those with more pronounced residual symptoms. Recommendations are made concerning how future trials can address remaining uncertainties and improve the rigor of the field.

BACKGROUND: Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months. METHODS: In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654. FINDINGS: Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67-1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial. INTERPRETATION: We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life. FUNDING: National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Several previous experiments have found that newborn and young infants will spend more time looking at attractive faces when these are shown paired with faces judged by adults to be unattractive. Two experimental conditions are described with the aim of finding whether the "attractiveness effect" results from attention to internal or external facial features, or both. Pairs of attractive and less attractive faces (as judged by adults) were shown to newborn infants (mean age 2 days, 9 hours), where each pair had either identical internal features (and different external features) or identical external features (and different internal features). In the latter, but not the former, condition the infants looked longer at the attractive faces. These findings are clear evidence that newborn infants use information about internal facial features in making preferences based on attractiveness. It is suggested that when newborn (and older) infants are presented with facial stimuli, whether dynamic or static, they are able to attend both to internal and external facial features.

Several previous experiments have found that newborn and young infants will spend more time looking at attractive faces when these are shown paired with faces judged by adults to be unattractive. Two experimental conditions are described whose aim was to find whether the ‘attractiveness effect’ is affected by the orientation of the facial stimuli. Pairs of attractive and less attractive faces (as judged by adults) were shown to newborn infants (mean age 2 days 20.5 hours), where each pair was presented both upright and inverted through 180°. In the former (upright) condition, but not the latter (inverted) condition, the infants looked longer at the attractive faces, and the difference in attractiveness preference between the conditions was statistically significant. These findings are clear evidence that infants’ early representation of faces contains information about faces that is orientation‐specific. The results are discussed in terms of innate facial representations and rapid learning about faces in the hours from birth.

In this study the ability of newborn infants to learn arbitrary auditory–visual associations in the absence versus presence of amodal (redundant) and contingent information was investigated. In the auditory‐noncontingent condition 2‐day‐old infants were familiarized to two alternating visual stimuli (differing in colour and orientation), each accompanied by its ‘own’ sound: when the visual stimulus was presented the sound was continuously presented, independently of whether the infant looked at the visual stimulus. In the auditory‐contingent condition the auditory stimulus was presented only when the infant looked at the visual stimulus: thus, presentation of the sound was contingent upon infant looking. On the post‐familiarization test trials attention recovered strongly to a novel auditory–visual combination in the auditory‐contingent condition, but remained low, and indistinguishable from attention to the familiar combination, in the auditory‐noncontingent condition. These findings are a clear demonstration that newborn infants’ learning of arbitrary auditory–visual associations is constrained and guided by the presence of redundant (amodal) contingent information. The findings give strong support to Bahrick’s theory of early intermodal perception.