Mindfulness based cognitive therapy for depression
We, the undersigned, write as physicians and scientists committed to optimising the benefi cial eff ects of vaccines to reduce infant mortality worldwide. In settings with high childhood mortality, live vaccines such as oral polio vaccine (OPV) BCG vaccine, and measles vaccine might have heterologous (non specific) effects that reduce mortality from diseases other than poliomyelitis, tuberculosis, and measles, respectively, whereas inactivated vaccines might increase all cause mortality. The importance of these eff ects is controversial. In 2014, the WHO Special Advisory Group of Experts (SAGE) reviewed the evidence regarding the non specific effects of vaccines and concluded that further research is warranted. On average, about 75 cases of vaccine associated paralytic poliomyelitis are reported each year worldwide, and WHO has suggested that OPV be gradually replaced by inactivated polio vaccine (IPV) to reduce the number of such cases. Results from a randomised trial in 2015 suggest that OPV might have benefi cial non specific effects that reduce allcause mortality by 17% possibly to a greater extent in boys than in girls, whereas previous evidence suggests that IPV increases all cause mortality by 10% Consequently, the proposed change from OPV to IPV might lead to increased all cause mortality through loss of the beneficial non specific eff ects of the live vaccine, and adverse non specifi c eff ects of the inactivated vaccine. Replacement of OPV with IPV could translate to approximately 4000 deaths for each case of vaccineassociated paralytic poliomyelitis prevented, and might cause more than 300 000 additional deaths each year. In view of the possible effects on all cause mortality, more data need week 6 of MBCT so tapering and MBCT treatment obviously overlapped to some extent. Since evidence is accumulating that withdrawal symptoms after discontinuation of selective serotonin reuptake inhibitors (SSRIs) are more detrimental and prolonged than assumed (up to 1 year) we suggest that the discontinuation process might have interfered with the therapeutic effects of MBCT. In a systematic review, gradual tapering did not eliminate withdrawal reactions. We do not know what the predominant class of medication was in the study by Kuyken and colleagues, but it seems likely that SSRIs were involved to a large extent. Thus, we argue that, by consecutively undertaking medication tapering followed by a longer washout period before starting MBCT, even stronger eff ects of MBCT might be observed. In other studies, responders to cognitive behavioral therapy showed relapse rates of 39% in the 68 weeks after psychotherapy and 68% after discontinuation of medication; therefore, the discontinuation syndrome might explain the relatively high relapse rate of 44% in Kuyken and colleagues' study of MBCT.
The Lancet