Context Mindfulness Based Cognitive Therapy (MBCT) is a group-based psychosocial intervention designed to enhance self-management of prodromal symptoms associated with depressive relapse. Objective To compare rates of relapse in remitted depressed patients receiving MBCT against maintenance antidepressant pharmacotherapy, the current standard of care Design Patients who met remission criteria following 8 months of algorithm informed antidepressant treatment were randomized to either: Maintenance Antidepressant Medication (M-ADM), MBCT or placebo (PLA) and were followed for 18 months. Setting Outpatient clinics at the Centre for Addiction and Mental Health, Toronto and St. Joseph’s Healthcare, Hamilton. Participants One hundred sixty patients aged 18 to 65 meeting DSM-IV for major depressive disorder with a minimum of 2 past episodes. Of these, 84 achieved remission (52.5%) and were assigned to one of the 3 study conditions. Interventions Remitted patients either discontinued their antidepressants and attended eight weekly group sessions of MBCT, continued on their therapeutic dose of antidepressant medication or discontinued active medication onto placebo. Main Outcome Measure Relapse was defined as a return, for at least 2 weeks, of symptoms sufficient to meet the criteria for major depression on Module A of the SCID. Results Intention to treat analyses revealed a significant interaction between the quality of acute phase remission and subsequent prevention of relapse in randomized patients (p = .03). Among unstable remitters (defined as 1 or more HRSD >7 during remission) patients in both MBCT and M-ADM showed a 73% decrease in hazard compared to PLA (p = .03), whereas for stable remitters (all HRSD ≤ 7 during remission) there were no group differences in survival. Findings remained significant after accounting for the effects of past depressive episodes on relapse. Conclusion For depressed patients who are unwilling or unable to tolerate long term maintenance antidepressant treatment, MBCT offers equivalent protection from relapse.

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The future will see increased medicalization of psychiatry and will demand changes in training that better prepare residents for the realities of practice in a sustained period of physician shortage. Residency programs will need to move from the current apprenticeship model of training to competency-based programs built on the CanMEDS 2000 articulation of physician roles. Training will need to focus on evidence-based treatments, more efficient models of health care delivery, more attentive tracking of resident clinical work, and more reliable and standardized methods of evaluating resident competencies.

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