Feasibility and acceptability of integrated psychological therapy versus treatment as usual for people with bipolar disorder and co-morbid alcohol use: A single blind randomised controlled trial

Compassion Focused Group Therapy for People With a Diagnosis of Bipolar Affective Disorder: A Feasibility Study

Background

Compassion focused therapy (CFT) is an evolutionary informed, biopsychosocial approach to mental health problems and therapy. It suggests that evolved motives (e.g., for caring, cooperating, competing) are major sources for the organisation of psychophysiological processes which underpin mental health problems. Hence, evolved motives can be targets for psychotherapy. People with certain types of depression are psychophysiologically orientated towards social competition and concerned with social status and social rank. These can give rise to down rank-focused forms of social comparison, sense of inferiority, worthlessness, lowered confidence, submissive behaviour, shame proneness and self-criticism. People with bipolar disorders also experience elevated aspects of competitiveness and up rank status evaluation. These shift processing to a sense of superiority, elevated confidence, energised behaviour, positive affect and social dominance. This is the first study to explore the feasibility of a 12 module CFT group, tailored to helping people with a diagnosis of bipolar disorder understand the impact of evolved competitive, status-regulating motivation on their mental states and the value of cultivating caring and compassion motives and their psychophysiological regulators.

Methods

Six participants with a history of bipolar disorder took part in a CFT group consisting of 12 modules (over 25 sessions) as co-collaborators to explore their personal experiences of CFT and potential processes of change. Assessment of change was measured via self-report, heart rate variability (HRV) and focus groups over three time points.

Results

Although changes in self-report scales between participants and across time were uneven, four of the six participants consistently showed improvements across the majority of self-report measures. Heart rate variability measures revealed significant improvement over the course of the therapy. Qualitative data from three focus groups revealed participants found CFT gave them helpful insight into: how evolution has given rise to a number of difficult problems for emotion regulation (called tricky brain) which is not one's fault; an evolutionary understanding of the nature of bipolar disorders; development of a compassionate mind and practices of compassion focused visualisations, styles of thinking and behaviours; addressing issues of self-criticism; and building a sense of a compassionate identity as a means of coping with life difficulties. These impacted their emotional regulation and social relationships.

Conclusion

Although small, the study provides evidence of feasibility, acceptability and engagement with CFT. Focus group analysis revealed that participants were able to switch from competitive focused to compassion focused processing with consequent improvements in mental states and social behaviour. Participants indicated a journey over time from 'intellectually' understanding the process of building a compassionate mind to experiencing a more embodied sense of compassion that had significant impacts on their orientation to (and working with) the psychophysiological processes of bipolar disorder.

Do psychological interventions reduce symptoms of depression for patients with bipolar I or II disorder? A meta-analysis

BACKGROUND

Psychological therapies may play an important role in the treatment of bipolar disorders. Several meta-analyses that examine the effectiveness of psychotherapies for patients with bipolar disorder include conclusions about the impact upon bipolar depression. However, these tend not to consider differences in depression outcome depending upon whether the therapy primarily targets acute depression, nor severity of baseline depression. This may affect the conclusions drawn about the effectiveness of these therapies for acute bipolar depression treatment.

OBJECTIVES

This meta-analysis explored the effectiveness of psychological therapies in reducing bipolar depression, in particular examining whether: (1) the effect of therapy is greater when baseline depressive symptoms are more severe, and (2) the effect of therapy is greater when the primary focus of the therapy is the treatment of acute bipolar depression?

DATA SOURCES

A systematic search was conducted using the following electronic databases; Cochrane Controlled Register of Trials (1996), MEDLINE (1966 onwards), EMBASE (1980 onwards), PsycINFO (1974 onwards), Scopus, Web of Science and Clinical Trials Registries (listed at:https://www.hhs.gov/ohrp/international/clinical-trial-registries/index.html).

ELIGIBILITY CRITERIA

Eligible studies were randomized controlled trials evaluating a psychological intervention for adults diagnosed with Bipolar I or II disorder. The comparators were usual care, wait-list, placebo, active treatment control. Post-treatment depression status was required to be measured continuously using a validated self- or observer- report measure, or categorically by a validated diagnostic instrument or clinical diagnosis by a suitably qualified person.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were screened, followed by full texts. Two reviewers conducted each stage until agreement was reached, and both independently extracted study information. Means, standard deviations (SDs) and number of participants were retrieved from articles and used to perform a meta-analysis. The primary outcome was depressive symptom score.

RESULTS

The database search identified 6388 studies. After removing the duplicates, 3298 studies remained, of which, 28 studies were included in the qualitative review and 22 in the meta-analysis. Effect sizes range from -1.99 [-2.50, -1.49] to 0.89 [-0.12, 1.90]. There was low quality evidence of a significant effect on symptoms of depression for cognitive behavioral therapy and dialectical behavior therapy. Trials of psychoeducation, mindfulness-based therapy, family therapy and interpersonal and social rhythm therapy showed no evidence of any effect on depression. We found no significant relationship between baseline depression score and depression outcome post-treatment when we controlled for therapy type and comparator. The result also showed that the effect sizes for studies targeting acute depression to be tightly clustered around a small overall effect size.

CONCLUSIONS

Some psychological therapies may reduce acute bipolar depression although this conclusion should be viewed with caution given the low quality of evidence. More research using similar therapy types and comparators is needed to better understand the relationship between depression status at baseline and outcome.

Preventive Medication Patterns in Bipolar Disorder and Their Relationship With Comorbid Substance Use Disorders in a Cross-National Observational Study

OBJECTIVE

The potential role of sub-optimal pharmacological treatment in the poorer outcomes observed in bipolar disorder (BD) with vs. without comorbid substance use disorders (SUDs) is not known. Thus, we investigated whether patients with BD and comorbid SUD had different medication regimens than those with BD alone, in samples from France and Norway, focusing on compliance to international guidelines.

METHODS

Seven hundred and seventy patients from France and Norway with reliably ascertained BD I or II (68% BD-I) were included. Medication information was obtained from patients and hospital records, and preventive treatment was categorized according to compliance to guidelines. We used Bayesian and regression analyses to investigate associations between SUD comorbidity and medication. In the Norwegian subsample, we also investigated association with lack of medication.

RESULTS

Comorbid SUDs were as follows: current tobacco smoking, 26%, alcohol use disorder (AUD), 16%; cannabis use disorder (CUD), 10%; other SUDs, 5%. Compliance to guidelines for preventive medication was lacking in 8%, partial in 44%, and complete in 48% of the sample. Compliance to guidelines was not different in BD with and without SUD comorbidity, as was supported by Bayesian analyses (highest Bayes Factor = 0.16). Cross national differences in treatment regimens led us to conduct country-specific adjusted regression analyses, showing that (1) CUD was associated with increased antipsychotics use in France (OR = 2.4, 95% CI = 1.4-3.9, p = 0.001), (2) current tobacco smoking was associated with increased anti-epileptics use in Norway (OR = 4.4, 95% CI = 1.9-11, p < 0.001), and (3) AUD was associated with decreased likelihood of being medicated in Norway (OR = 1.2, 95% CI = 1.04-1.3, p = 0.038).

CONCLUSION

SUD comorbidity in BD was overall not associated with different pharmacological treatment in our sample, and not related to the level of compliance to guidelines. We found country-specific associations between comorbid SUDs and specific medications that warrant further studies.

The course of bipolar disorder as a function of the presence and sequence of onset of comorbid alcohol use disorders in outpatients attending the Fondamental Advanced Centres of Expertise

OBJECTIVES

The comorbidity of alcohol use disorder (AUD) and bipolar disorder (BD) has been repeatedly associated with poorer clinical outcomes than BD without AUD. We aimed to extend these findings by focusing on the characteristics associated with the sequence of onset of BD and AUD.

METHODS

3,027 outpatients from the Fondamental Advanced Centres of Expertise were ascertained for BD-1, BD-2 and AUD diagnoses, including their respective ages at onset (AAOs, N =2,804). We selected the variables associated with both the presence and sequence of onset of comorbid AUD using bivariate analyses corrected for multiple testing to enter a binary regression model with the sequence of onset of BD and AUD as the dependent variable (AUD first - which also included 88 same-year onsets, vs. BD first).

RESULTS

BD patients with comorbid AUD showed more severe clinical profile than those without. Compared to BD-AUD (N =269), AUD-BD (N =276) was independently associated with a higher AAO of BD (OR =1.1, p <0.001), increased prevalence of comorbid cannabis use disorder (OR =2.8, p <0.001) a higher number of (hypo)manic/mixed BD episodes per year of bipolar illness (OR =3, p <0.01).

LIMITATIONS

The transversal design prevents from drawing causal conclusions.

CONCLUSION

Increased severity of BD with AUD compared to BD alone did not differ according to the sequence of onset. A few differences, though, could be used to better monitor the trajectory of patients showing either one of these disorders.