Metacognitive therapy for bipolar II disorder: A single case series study

Interventions promoting recovery from depression for patients transitioning from outpatient mental health services to primary care: A scoping review

INTRODUCTION

Major Depressive Disorder (MDD) is one of the most prevalent mental disorders worldwide with significant personal and public health consequences. After an episode of MDD, the likelihood of relapse is high. Therefore, there is a need for interventions that prevent relapse of depression when outpatient mental health care treatment has ended. This scoping review aimed to systematically map the evidence and identify knowledge gaps in interventions that aimed to promote recovery from MDD for patients transitioning from outpatient mental health services to primary care.

MATERIALS AND METHODS

We followed the guidance by Joanna Briggs Institute in tandem with the PRISMA extension for Scoping Reviews checklist. Four electronic databases were systematically searched using controlled index-or thesaurus terms and free text terms, as well as backward and forward citation tracking of included studies. The search strategy was based on the identification of any type of intervention, whether simple, multicomponent, or complex. Three authors independently screened for eligibility and extracted data.

RESULTS

18 studies were included for review. The studies had high heterogeneity in design, methods, sample size, recovery rating scales, and type of interventions. All studies used several elements in their interventions; however, the majority used cognitive behavioural therapy conducted in outpatient mental health services. No studies addressed the transitioning phase from outpatient mental health services to primary care. Most studies included patients during their outpatient mental health care treatment of MDD.

CONCLUSIONS

We identified several knowledge gaps. Recovery interventions for patients with MDD transitioning from outpatient mental health services to primary care are understudied. No studies addressed interventions in this transitioning phase or the patient's experience of the transitioning process. Research is needed to bridge this gap, both regarding interventions for patients transitioning from secondary to primary care, and patients' and health care professionals' experiences of the interventions and of what promotes recovery.

REGISTRATION

A protocol was prepared in advance and registered in Open Science Framework (https://osf.io/ah3sv), published in the medRxiv server (https://doi.org/10.1101/2022.10.06.22280499) and in PLOS ONE (https://doi.org/10.1371/journal.pone.0291559).

The relationship between dysfunctional attitudes, maladaptive perfectionism, metacognition and symptoms of mania and depression in bipolar disorder: The role of self-compassion as a mediating factor

BACKGROUND

Maladaptive cognitions appear to be associated with the severity of mood symptoms in bipolar disorder (BD), but findings are mixed and generally cross-sectional in design.

METHOD

This study (n = 331) explored the associations between maladaptive cognitions and mood symptoms in BD over time (3 months), and the potential mediating effect of self-compassion cross-sectionally. Dysfunctional attitudes, maladaptive perfectionism and maladaptive metacognitions were explored separately with depressive and manic symptoms, and with current mood state in BD.

RESULTS

The results showed maladaptive metacognitions to be the only significant predictor of depression at 3-month follow-up (β = 0.31, p < .001), with no relationship to mania over time. Cross-sectionally, self-compassion partially mediated the relationship between all maladaptive cognitions and depression, with higher dysfunctional cognitions and lower self-compassion predicting increased severity of depressive symptoms. Only the relationship between dysfunctional attitudes and mania was partially mediated by self-compassion, however, the relationship was weak and suggestive that higher self-compassion predicted increased mania.

LIMITATIONS

The study duration limited the possible analysis. Future longitudinal research is needed. Also, the study sample was not representative of the clinical population, making results less generalisable. Additionally, limited significant findings regarding manic symptoms supports the need for further research into active cognitions during this phase of BD.

CONCLUSIONS

Maladaptive metacognitions were predictive of future depression severity, therefore, further exploration of metacognitive therapy for BD should be explored. Furthermore, self-compassion was shown to partially mediate the relationship between negative cognitions and mood, therefore further exploration of compassion-based therapies for BD is needed.

The Scope of Metacognitive Therapy in the Treatment of Psychiatric Disorders

Metacognitive therapy (MCT) is a novel and promising transdiagnostic psychotherapy intervention based on the Self-Regulatory Executive Function model of conceptualizing emotional disorders. It was developed by Adrian Wells in 2009. Its therapeutic response occurs by reducing dysfunctional metacognitive beliefs regarding worry and rumination, often seen in patients with psychiatric disorders. Since its inception, it has been increasingly applied to a wide spectrum of psychiatric illnesses, but mainly focusing on mood and anxiety disorders. To our knowledge, no study has detailed its existing therapeutic scope in psychiatry. In this comprehensive narrative review, we describe the various psychiatric illnesses in which MCT has been used, the advantages of MCT, and the limitations of the MCT research. In addition, we propose some solutions to systematically examine its place in psychiatry. We encountered its potential role in treating trauma and stress-related disorders, obsessive-compulsive spectrum disorders, personality disorders, psychotic disorders, substance use disorders, and sexual disorders.

Cognitive attentional syndrome and metacognitive beliefs as potential treatment targets for metacognitive therapy in bipolar disorder

Most treatment guidelines emphasize the use of psychotropic drugs for both the acute and maintenance treatment of bipolar disorder (BD). However, relying only on psychotropics without adjunctive psychosocial interventions may be insufficient in treating patients with BD. Given its unique view in the explanation of psychopathological states, metacognitive therapy (MCT) might be helpful for BD. Metacognitive theory posits that psychopathology is a result of the cognitive attentional syndrome (CAS) and that it is influenced and maintained by dysfunctional metacognitive beliefs, perseverative thinking, attentional biases, and dysfunctional coping strategies. In this review, literature data regarding these areas in BD are examined. Studies suggest that perseverative thinking might be among the emotion regulation strategies endorsed in individuals with BD. Regarding attentional biases, literature data show that state-dependent, mood-changing attentional biases and a ruminative self-focused attention are present. Studies also suggest that cognitive self-consciousness is higher in BD compared to controls. It is seen that maladaptive coping strategies are frequently reported in BD, and that these strategies are associated with depression severity, negative affect and relapse risk. Studies focusing on dysfunctional metacognitive beliefs in BD reported that individuals with BD had higher scores for negative metacognitive beliefs, self-consciousness, need to control thoughts, and a lack of cognitive confidence. Also, dysfunctional metacognitive beliefs were associated with depressive symptomatology. These findings suggest that the components of CAS and dysfunctional metacognitive beliefs are evident in BD. For a subgroup of patients with BD who fail to respond to evidence-based psychopharmacological and adjunctive psychotherapeutic interventions, MCT might be an alternative way to consider as a treatment option. In conclusion, taken the available data together, we propose a sequential treatment protocol for BD, mainly based on the MCT treatment plan of depressive disorders.