Robin B Jarrett Jeffrey R Vittengl Lee Anna Clark

Relapse and recurrence prevention are essential to improving treatments for depressed individuals. In this chapter, we describe how to reduce the likelihood of relapse by using "continuation-phase cognitive therapy" (C-CT) for adults with recurrent major depressive disorder (Jarrett, 1989; Jarrett & Kraft, 1997), and we present an overview of the conceptual and empirical foundations of C-CT. We show why many patients may benefit from C-CT; how to begin implementing this treatment to reduce relapse, and to promote remission and recovery; and why diagnostic evaluation is central in caring for patients with recurrent major depressive disorder across their lifespan.

MULTIFACTORIAL MODEL OF RISK AND PREVENTION OF MOOD DISORDERS

While developing C-CT, Jarrett (1989) constructed an integrative, multifactorial, model of vulnerability for—and prevention of—mood disorders.

FIGURE 6.1. Multifactorial model of depression onset and prevention.

This biopsychosocial model is organized into three overlapping domains of risk factors that identify the conditions that increase the chance of an initial major depressive episode (MDE), of relapse (MDE prior to recovery from the index episode), and of recurrence (MDE after recovery from the index episode), and specify the key goals of preventive intervention. Vulnerability for first onset, relapse, and recurrence of depression is associated with dysfunction in (1) genetic, biological, familial, and developmental functioning; (2) personality, interpersonal, and social functioning; and (3) cognitive functioning. In this model, risk for developing depressive episodes is highest when dysfunction overlaps across domains (Figure 6.1a) and preventive intervention is not used (Figure 6.1b). In short, relapse and recurrence are probable when the patient (1) has untreated or unresolved genetic, biological, or developmental dysfunction; (2) continues to experience residual depressive symptoms and/or impairment in cognitive processing or in personality, interpersonal, or social functioning; (3) experiences a "challenge" (e.g., stressful life event), or set of challenges, that exceed coping skills, thus activating previous ideas and behaviors associated with distress or unhealthy outcomes; and/or (4) either did not learn or no longer practices the coping skills taught during CT (Figure 6.1b). The goals of preventive interventions, including C-CT and other therapies, are to reduce residual symptoms across risk domains, to improve coping with adversity, to decrease the probability of stressful events, and to enhance behavioral and cognitive strengths (Figure 1.6c). An underlying premise of this model is that vulnerability for and prevention of mood disorders are influenced by risk, and by what people learn and experience.

The preventive model of C-CT focuses on lowering the strength of—— and possibly eliminating—dynamic, changeable risk factors (e.g., negative cognitions) and reducing the impact of static, unchangeable ones (e.g., basic temperament). In C-CT, learning centers on recognizing when to activate new coping or compensatory skills. The more the patient understands the interrelations of risk factors, recognizes that challenges such as stressful life events (e.g., familial conflict) or symptoms (e.g., transient insomnia) increase risk, and uses compensatory skills when these occur, the lower the chance of relapse and recurrence (Figure 6.1b).

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