a control condition [6], and I thought that comparing the two strategies (CBT and WBT) could be the first step.
Twenty patients with affective disorders [major depression, panic disorder with agoraphobia, social phobia, generalized anxiety disorder (GAD), obsessive-compulsive disorder] who had been successfully treated by behavioral (anxiety disorders) or pharmacological (mood disorders) methods were randomly assigned to either WBT or CBT for residual symptoms [7]. Both WBT and CBT were associated with a significant reduction of residual symptoms as measured by the CID [2] and in PWB well-being [1]. However, when residual symptoms of the two groups were compared after treatment, a significant advantage of WBT over CBT was observed with the CID. WBT was also associated with a significant increase in PWB well-being, particularly in the personal growth scale. The small number of subjects suggested caution in interpreting this difference and the need for further studies with larger samples of patients with specific mood or anxiety disorders.
These preliminary results pointed to the feasibility of WBT in the residual stage of these disturbances. The improvement in residual symptoms may be explained on the basis of the balance between positive and negative affect [7]. If treatment of psychiatric symptoms induces improvement of well-being - and indeed subscales describing well-being are more sensitive to drug effects than subscales describing symptoms [3] - it is conceivable that changes in well-being may affect the balance of positive and negative affect. In this sense, the higher degree of symptomatic improvement that was observed with WBT in this study is not surprising: in the acute phase of affective illness, removal of symptoms may yield the most substantial changes, but the reverse may be true in its residual phase.
The Big Challenge
As other investigators in the field of depression, I was particularly concerned about the high risk of relapse [8]. It was not easy to make the patients better, but it was even more difficult to keep them well. We had performed a small controlled study on the effects of addressing residual symptomatology with cognitive behavioral methods on relapse rates. Compared to a control condition, there were significant differences after 4 years [9], but not after 6 years [10]. I felt that what I had introduced (a sequential strategy: first treatment with antidepressant drugs and then CBT of residual symptoms) was good, but it was not sufficient. I wanted to repeat the study in patients with a severe form of recurrent depression defined as the occurrence of three or more episodes of unipolar depression, with the immediately preceding episode being no more than 2.5 years before the onset of the current episode [11]. This time, however, I wanted to include WBT in the treatment package, together with cognitive behavior treatment of residual symptoms and lifestyle modification. Forty patients with recurrent major depression, who had been successfully treated with antidepressant drugs, were randomly assigned to either this package including WBT or clinical management. In clinical management, the same number of sessions that was used in the experimental condition was given. Clinical management consisted of reviewing the patient's clinical status and providing the patient with support and advice, if necessary. Specific interventions such as exposure strategies, diary work, and cognitive restructuring were proscribed. The scope was to compare the experimental condition with a group that receives the nonspecific therapeutic ingredients shared by most forms of psychotherapy (table 1) [12, 13].
Table 1. Nonspecific therapeutic ingredients common to most forms of psychotherapy
| Ingredient | Characteristics |
| 1 Attention | The therapist's full availability for specific times |
| 2 Disclosure | The patient's opportunity to share thoughts and feelings |
| 3 High arousal | An emotionally charged, confiding relationship with a helping person |
| 4 Interpretation | A plausible explanation for the patient's problems and difficulties |
| 5 Rituals | A procedure that requires the active participation of both patient and therapist |
In both groups, antidepressant drugs were tapered and discontinued. The group that received CBT and WBT had a significantly lower level of residual symptoms after drug discontinuation in comparison with the clinical management group. CBT also resulted in a significantly lower relapse rate (25%) at a 2-year follow-up than did clinical management (80%). At the 6-year follow-up [14], the relapse rate was 40% in the former group and 90% in the latter. Further, the group treated with CBT and WBT had a significantly lower number of recurrences when multiple relapses were taken into account. Even though it was a small and preliminary study, the results were quite impressive: more than half of the patients treated with CBT and WBT were well and drug-free at the 6-year follow-up [14].
The findings were replicated by three independent studies. In a multicenter trial performed in Germany, 180 patients with three or more episodes of major depression were randomized to a combination of CBT, WBT, and mindfulness-based cognitive therapy, or to manualized psychoeducation [15]. Even though the follow-up was limited to 1 year (in our study the most substantial differences emerged later) and medication was continued, there was a significant effect of the experimental condition on the relapse rate of the patients with a high risk of recurrence.
In the United States, Kennard et al. [16] applied the sequential treatment we had introduced in adults [11] to 144 children and adolescents with major depression. They were treated with fluoxetine for 6 weeks, and those who displayed an adequate response were randomized to receive continued medication management or CBT to address residual symptoms and WBT in addition to fluoxetine. The CBT/WBT combination was effective in reducing the risk of relapse, a finding that was quite exceptional in the literature concerned with children and adolescents with major depression. Unfortunately, unlike in our original study [11], medication was continued also in the CBT/WBT group, despite the problems that are related to long-term treatment with antidepressant drugs in that patient population [17].
A third confirmation came from an Iranian study by Moeenizadeh and Salagame [18]. Forty high school and university students suffering from depression were randomly assigned to WBT or CBT. The results unequivocally showed that WBT was more effective than CBT in improving symptoms of depression [18]. The
