Psychosocial interventions for the prevention of relapse in bipolar disorder: systematic review of controlled trials

Adjuvant Psychotherapies to Prevent Relapse in Bipolar Disorder: A Randomized Clinical Trial

Importance

Several psychotherapy protocols have been evaluated as adjuncts to pharmacotherapy for patients with bipolar disorder (BD). Little is known about their comparative effectiveness.

Objective

To compare the effectiveness of 2 types of group psychotherapy, skill-oriented, material-based cognitive behavioral therapy (SEKT) and supportive, patient-centered, emotion-focused therapy (FEST), to prevent relapse in patients with euthymic BD.

Design, Setting, and Participants

This was a large, observer-blind, randomized clinical trial conducted over 18 months (posttreatment after 6 months; follow-up at 12 and 18 months). In addition to psychiatric care as usual (including mood-stabilizing medication), each participant at 9 clinical outpatient units in Germany received 24 hours of group psychotherapy over 4, full-day sessions spread over 5 months. Patients with euthymic BD type 1 (BD 1) or BD type 2 (BD 2) between the ages of 18 and 50 years were randomly assigned to 1 of 2 forms of psychotherapy, SEKT or FEST. Independent clinicians blinded to patient grouping performed assessments using structured interviews (Structured Clinical Interview for DSM Disorders and Longitudinal Interval Follow-Up Evaluation) and self-rating and clinician rating for inclusion criteria and outcome. Kaplan-Meier survival curves were calculated for time to relapse. Cox proportional hazards statistics and propensity score matching were calculated for the multivariate analysis. Study data were analyzed from March 2020 to September 2022.

Interventions

SEKT intervention is a structured cognitive behavioral therapy integrating elements of interpersonal social rhythm therapy, and of mindfulness-based cognitive therapy. FEST psychotherapy has its roots in emotion-focused, supportive, and nondirective therapy.

Main Outcomes and Measures

Recurrence of a new affective episode assessed by blinded interviewer with the LIFE interview. In addition, self-rating and clinician rating of depressive and mania symptoms as well as level of social functioning were assessed.

Results

Of 348 screened referrals, 305 patients (median [IQR] age, 34 [18-50] years; 162 male [53%]) with euthymic BD 1 or BD 2 were included in the study. A total of 207 patients (68%) had BD 1, 98 (32%) had BD 2, and 278 (91%) received psychiatric care. Both therapies were equally effective in preventing recurrence of a new episode. Outcome (higher rate of new episodes) was not predicted by kind of treatment (SEKT: 69 [49%] relapse; FEST: 63 [46%] relapse) but was predicted by BD 2, comorbidity, attending all sessions, and the interaction of type of treatment by BD 1 or 2. Patients with BD 2 had the highest rate of relapse (60 [61%] relapse), in particular, when treated by SEKT (39 [70%] relapse).

Conclusions and Relevance

Results of this randomized clinical trial revealed that a structured, skill-oriented, material-based cognitive behavioral therapy (SEKT) and a supportive, patient-centered, emotion-focused therapy (FEST) were equally effective in preventing relapse of affective episodes when delivered in a new, intensive group format. Additionally, there were baseline factors, in particular BD 2, that influenced outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT02506322.

[Relapse prevention of bipolar disorders: an explorative cluster analytical approach in a randomized controlled psychotherapy study]

The aim of this study was to differentiate between types of bipolar disorders and the associated features using explorative analysis. The focus was particularly on the role of bipolar 1 and bipolar 2 disorders as well as the influence of prophylactic interventions for relapse in a randomized, controlled treatment study. A total of 274 of the 305 originally included persons could be investigated in the study. Patients participated in either cognitive behavioral group therapy (SEKT) or supportive, patient-centered group therapy (FEST). Treatment took place over 4 days separated by a 1-month interval (equivalent to 16 double hours). Depressive and manic symptoms were assessed using the longitudinal interval follow-up evaluation (LIFE). The symptoms were retrospectively assessed for the previous 6 months, with respect to each week before and after the intervention phase and for 6‑month and 12-month follow-ups. The results show that the effects of both group therapies were comparable; however, there were statistically significant differences in a multivariate proportional hazards model for the factors bipolar 1 and 2 as well as the interaction of therapy with bipolar 1 and 2. In particular, bipolar 2 patients benefited significantly less from the SEKT intervention than from the FEST intervention. There were three clusters identified that separated bipolar 1 (SEKT, no comorbidity, predominantly no recurrences, younger patients), from bipolar 2 (FEST, no comorbidity, at least 1 often 2 recurrences, older patients) and from a heterogeneous group (SEKT and FEST, comorbidity). The distinction between bipolar 1 and bipolar 2 disorder is important and has so far not received sufficient attention. Bipolar 2 disorders generally have a worse course and respond particularly poorly to cognitive behavioral therapy (SEKT). An open, unstructured, supportive, patient-centered psychotherapy (FEST) is generally effective.

Efficacy of cognitive behavioural therapy for bipolar disorder: A systematic review

INTRODUCTION

Bipolar disorder (BD) is a serious mental illness with a chronic course and significant morbidity and mortality. BD has a lifetime prevalence rate of 1%-1.5% and is characterised by recurrent episodes of mania and depression, or a mixture of both phases. Although it has harmacological and psychotherapeutic treatment, cognitive behavioural therapy (CBT) has shown beneficial effects, but there is not enough clinical information in the current literature.

METHODS

The main aim was to determine the efficacy of CBT alone or as an adjunct to pharmacological treatment for BD. A systematic review of 17 articles was carried out. The inclusion criteria were: quantitative or qualitative research aimed at examining the efficacy of CBT in BD patients with/without medication; publications in English language; and) being 18-65 years of age. The exclusion criteria were: review and meta-analysis articles; articles that included patients with other diagnoses in addition to BD and that did not separate the results based on such diagnoses; and studies with patients who did not meet the DSM or ICD criteria for BD. The PubMed, PsycINFO and Web of Science databases were searched up to 5 January 2020. The search strategy was: "Bipolar Disorder" AND "Cognitive Behavioral Therapy".

RESULTS

A total of 1531 patients both sexes were included. The weighted mean age was 40.703 years. The number of sessions ranged from 8 to 30, with a total duration of 45-120 min. All the studies show variable results in improving the level of depression and the severity of mania, improving functionality, reducing relapses and recurrences, and reducing anxiety levels and the severity of insomnia.

CONCLUSIONS

The use of CBT alone or adjunctive therapy in BD patients is considered to show promising results after treatment and during follow-up. Benefits include reduced levels of depression and mania, fewer relapses and recurrences, and higher levels of psychosocial functioning. More studies are needed.

Distinct brain activity alterations of treatment for bipolar disorders with psychotherapy and drug therapy: activation likelihood estimation meta-analysis

BACKGROUNDS

Many studies suggest that both psychotherapy and drug therapy are effective in the treatment of bipolar disorders (BDs). However, the pathophysiology of both types of intervention has not been established definitively.

METHODS

An activation likelihood estimation meta-analysis was performed to identify the distinct brain activity alterations between psychotherapy and drug therapy for the treatment of BDs. Articles were identified by searching databases including PubMed, Embase, Cochrane Library, and Web of Science databases. Eligible studies on BDs were published up until 10 June 2021.

RESULTS

21 studies were included and we conducted a meta-analysis for different therapies and imaging tasks. After receiving psychotherapy, BD patients showed increased activation in the inferior frontal gyrus (IFG) and superior temporal gyrus. While after taking drug therapy, BD patients displayed increased activation in the anterior cingulate cortex, medial frontal gyrus, IFG, and decreased activation in the posterior cingulate cortex. The regions of brain activity changes caused by psychotherapy were mostly focused on the frontal areas, while drug therapy mainly impacted on the limbic areas. Different type of tasks also affected brain regions which were activated.

CONCLUSIONS

Our comprehensive meta-analysis indicates that these two treatments might have effect on BD in their own therapeutic modes. Psychotherapy might have a top-down effect, while drug therapy might have a bottom-up effect. This study may contribute to differential diagnosis of BDs and would be helpful to finding more accurate neuroimaging biomarkers for BD treatment.

A Meta-Analysis of Group Cognitive Behavioral Therapy and Group Psychoeducation for Treating Symptoms and Preventing Relapse in People Living with Bipolar Disorder

Objectives: This meta-analysis aims to evaluate the treatment outcomes of patients treated with Group cognitive behavioural therapy (GCBT) or group psychoeducation (GPE) as an adjunct to pharmacotherapy. Methods: Systematic search of PubMed, EMBASE, PsycINFO, and CENTRAL from inception till 1 March 2022 was conducted. Randomized-controlled-trials (RCTs) comparing GCBT/GPE with controls (treatment-as-usual/individualized therapy) in adults with bipolar disorder were eligible. The outcomes were relapse rates of any depressive or manic episodes and control of depressive and manic symptoms post-intervention. Overall odds-ratio was used to evaluate the relapse rates. Standard Mean Differences were pooled using a random-effects model for the control of depressive and manic symptoms. Results: 25 articles were assessed full-text independently by two members, and 11 studies were included in this meta-analysis. 601 and 590 participants were randomized into group-therapy (GCBT/GPE) and control, respectively. GPE significantly reduces relapse rates at post-intervention with Odds ratio of 0.43 (95% CI = 0.28-to-0.62, p < 0.0001) (I² = 41%) compared to control, however, no significant results were found for GPE on control of depressive or manic symptoms. No significant results were found for GCBT in all outcomes. Conclusion: This meta-analysis provides some evidence that GPE could be an efficacious treatment as an adjunct to treatment-as-usual in reducing the relapse rates of patients with 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.

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial

Background

Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment.

Objective

A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response.

Methods

The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk.

Results

Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022.

Conclusions

This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders.

Trial Registration

ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462

International Registered Report Identifier (IRRID)

DERR1-10.2196/30710

Empowerment In The Treatment Of Fatigue In Breast Cancer Patients

This review aimed at providing a summary of a collection of literature that covers breast cancer and related phenomena, namely fatigue and the disruption of self-esteem and body image that can occur when a cancer diagnosis is given. As the most common symptom reported by survivors, fatigue is a unique personal symptom that burdened survivors, a consequence as well as an antecedent. Fatigue in cancer is caused by disease processes as well as treatment side effects and becomes a serious problem compared to pain and nausea due to limited physical function, and psychological and social welfare. Facing the problem of fatigue, and poor self-esteem and body image in nursing science contributes to the empowerment of survivors; this is achieved through nursing processes and is a standard that can be used to solve fatigue problems.

What sixty years of research says about the effectiveness of patient education on health: a second order meta-analysis

Although meta-analyses have examined the association between patient education and health, the validity and quality of this evidence have not been comprehensively assessed. This second order meta-analysis combined previous meta-analyses that examined the effectiveness of patient education on health outcomes as an overall weighted grand mean d¯¯. Further, measures of methodological quality, meaningful variability across first order meta-analyses, and evidence for publication bias were examined. Forty meta-analyses were identified, investigating 156 associations between patient education and health summarizing data from over 776 studies including more than 74.947 patients. Quantitative analyses showed that patient education positively affects health outcomes with d¯¯ = 0.316 (95% CI [0.304, 0.329]). Summarizing data exclusively from randomized controlled trials indicated a causal effect. Patient education was effective for patients with neoplasms, diabetes, mental and behavioral disorders, diseases of the circulatory system, the respiratory system, and the musculoskeletal system. Patient education was effective in the reduction of medication use, pain, and visits to medical facilities, and significantly improved physiological, physical, psychological outcomes, and patients' general function. Overall, the findings reveal firm evidence for the effectiveness of patient education on health outcomes. However, theory-based interventions are lacking and need to be implemented to enable a successful transfer from theory to practice.

Efficacy of Cognitive Behavioural Therapy for Bipolar Disorder: a Systematic Review

INTRODUCTION

Bipolar disorder (BD) is a serious mental illness with a chronic course and significant morbidity and mortality. BD has a lifetime prevalence rate of 1% to 1.5% and is characterised by recurrent episodes of mania and depression, or a mixture of both phases. Although it has harmacological and psychotherapeutic treatment, cognitive behavioural therapy (CBT) has shown beneficial effects, but there is not enough clinical information in the current literature.

METHODS

The main aim was to determine the efficacy of CBT alone or as an adjunct to pharmacological treatment for BD. A systematic review of 17 articles was carried out. The inclusion criteria were: quantitative or qualitative research aimed at examining the efficacy of CBT in BD patients with/without medication; publications in English language; and) being 18-65 years of age. The exclusion criteria were: review and meta-analysis articles; articles that included patients with other diagnoses in addition to BD and that did not separate the results based on such diagnoses; and studies with patients who did not meet the DSM or ICD criteria for BD. The PubMed, PsycINFO and Web of Science databases were searched up to 5 January 2020. The search strategy was: "Bipolar Disorder" AND "Cognitive Behavioral Therapy".

RESULTS

A total of 1,531 patients both sexes were included. The weighted mean age was 40.703 years. The number of sessions ranged from 8-30, with a total duration of 45-120minutes. All the studies show variable results in improving the level of depression and the severity of mania, improving functionality, reducing relapses and recurrences, and reducing anxiety levels and the severity of insomnia.

CONCLUSIONS

The use of CBT alone or adjunctive therapy in BD patients is considered to show promising results after treatment and during follow-up. Benefits include reduced levels of depression and mania, fewer relapses and recurrences, and higher levels of psychosocial functioning. More studies are needed.

A Smartphone-Based Self-management Intervention for Bipolar Disorder (LiveWell): User-Centered Development Approach

BACKGROUND

Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care.

OBJECTIVE

This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions.

METHODS

Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback.

RESULTS

The core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support.

CONCLUSIONS

User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development.

Social cognition in first-degree relatives of bipolar disorder: Theory of Mind and nonverbal sensitivity

Social cognition might be impaired in first degree relatives (FDR) of BD but existing research shows controversial results about social cognitive impairments in this population. The aim of this study was to assess Theory of Mind (ToM) and nonverbal sensitivity in FDR of BD and compare the results with those of two groups of persons with remitted bipolar disorder (BD), type I and II, and a control group. Social cognitive ability was examined in first degree relatives of BD, with a biological parent, offspring or sibling diagnosed with the disorder. For this study, 37 FDRs of bipolar patients, 37 BD I, 40 BD II and 40 control participants were recruited. Social cognition was explored by means of the Reading the Mind in the Eyes Test and the MiniPONS. Results showed a significant impairment in FDR of BD in the ToM task, but not in nonverbal sensitivity. Performance of FDRs in social cognition is better than that of BDs (either type I or type II) but worse when compared with that of healthy individuals without a family history of psychiatric disorders. Nevertheless, no differences were found between BD I and BD II groups. Males and older participants showed a worse performance in all groups. Group family therapy with FDRs of BD might include training in the recognition of nonverbal cues, which might increase the understanding of their familiars with BD, in order to modify communication abilities.

Psychoeducation for psychiatric inpatients following remission of a manic episode in bipolar I disorder: A randomized controlled trial

OBJECTIVE

The aim of the present study was to evaluate the effectiveness of psychoeducation for bipolar I inpatients following remission of a manic episode in a Chinese population.

METHOD

The study recruited currently medicated bipolar I patients, aged 18-60 years, who were in remission from a manic episode, as determined using the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Patients were randomized (1:1) to either eight sessions of group-based psychoeducation (active treatment group) or regular free discussions (control group). The primary outcomes were the rates of any type of recurrence and rehospitalization following treatment. The secondary outcomes were changes in mood symptoms, medication adherence, global functioning, as well as treatment response (as measured using the Clinical Global Impression scale). Subjects were assessed at baseline and then at 2 weeks, and 1, 2, 3, 5, 7, 9, and 12 months following treatment.

RESULTS

At 1 year, patients receiving the psychoeducation treatment demonstrated significantly less recurrence. Those in the treatment group also showed a significant reduction in mania recurrence but not depressive recurrence, and psychoeducation increased time to remission. Notably, lower rates of rehospitalization were found in the active treatment group. Those receiving the psychoeducation treatment also revealed higher change from baseline on measures of depression (17-item Hamilton Rating Scale for Depression), mania (Young Mania Rating Scale), global functioning (Clinical Global Impression-severity scale and World Health Organization Disability Assessment Schedule) (P<.05). However, there were no significant group differences for the medication adherence scores.

CONCLUSION

This preliminary evidence suggests that short, group-based psychoeducation benefits currently medicated inpatients following the remission of mania in bipolar I disorder. This intervention warrants further investigation, especially in other Chinese populations. If future studies confirm its benefits, group-based psychoeducation could be incorporated into routine psychiatric inpatient care for bipolar patients in China.

Bipolar disorder in primary care: a qualitative study of clinician and patient experiences with diagnosis and treatment

OBJECTIVE

To understand primary care patients' and clinicians' experiences with diagnosis and treatment of patients with bipolar disorder in primary care.

METHODS

We conducted a qualitative study using thematic content analysis of individual interviews with nine primary care clinicians and six patients from Federally Qualified Health Centers to understand their experiences with the diagnosis and treatment of bipolar disorder.

RESULTS

Themes of bipolar disorder detection, referral to specialty mental health care and medication treatment emerged from individual interviews with primary care patients and clinicians. Clinicians and patients faced challenges deciding to continue with care in primary care that is easier to access, but less intensive, than specialty care that can be harder to access but at times of higher quality.

CONCLUSIONS

Potential next steps in research include identifying ways to support primary care clinicians in detection of patients with bipolar disorder, and strategies to support treatment of patients in primary care with easier access to specialty care including consultation in primary care or co-management with specialty care.

Internet- and mobile-based aftercare and relapse prevention in mental disorders: A systematic review and recommendations for future research

BACKGROUND

Mental disorders are characterized by a high likelihood of recurrence. Thus, aftercare and follow-up interventions aim to maintain treatment gains and to prevent relapse. Internet- and mobile-based interventions (IMIs) may represent promising instruments in tertiary prevention. This systematic review summarizes and evaluates the research on the efficacy of IMIs as aftercare or follow-up interventions for adults with mental health issues.

METHODS

A systematic database search (PsycInfo, MEDLINE, CENTRAL) was conducted and studies selected according to predefined eligibility criteria (RCTs, adult population, clinical symptoms/disorder, assessed with validated instruments, clinical-psychological intervention rationale, aftercare/follow-up intervention, web-/mobile-based, minimum follow-up measurement of three months, inclusion of a control group). Inspected outcomes were symptom severity, recurrence- and rehospitalization rates, functioning, quality of life and adherence to primary treatment.Systematic review registration: PROSPERO CRD42017055289.

RESULTS

Sixteen RCTs met the inclusion criteria, covering trials on depression (n = 5), eating disorders (n = 4) and transdiagnostic interventions (n = 7). The majority of the interventions were based on Cognitive Behavioral Therapy (CBT) principles and were web-based (n = 11). Methodological quality of included studies was suboptimal. Limitations included attrition bias and non-specification of routine care co-interventions. IMIs yielded small to medium post-treatment effects for symptom severity (d = -0.08 - d = -0.45) in comparison to control groups. Best evidence base was found for symptom severity of depression and anxiety. Study results regarding recurrence and rehospitalization were inconsistent.

DISCUSSION

There is some evidence, that IMIs are feasible instruments for maintaining treatment gains for some mental disorders. However, further high quality, large-scale trials are needed to expand research fields, improve adherence to and uptake of IMIs and facilitate implementation of effective interventions into routine care.

Memory performance predicts response to psychotherapy for depression in bipolar disorder: A pilot randomized controlled trial with exploratory functional magnetic resonance imaging

OBJECTIVE

This pilot randomized controlled trial compared Cognitive Behavior Therapy (CBT) and Supportive Psychotherapy (SP) for the treatment of depression in bipolar I disorder. We also examined whether exploratory verbal memory, executive functioning, and neural correlates of verbal memory during functional magnetic resonance imaging (fMRI) predicted change in depression severity.

METHODS

Thirty-two adults (ages 18-65) with DSM-IV bipolar I disorder meeting current criteria for a major depressive episode were randomized to 18 weeks of CBT or SP. Symptom severity was assessed before, at the mid-point, and after the 18-week intervention. All participants completed a brief pre-treatment neuropsychological testing battery (including the California Verbal Learning Test-2nd Edition, Delis Kaplan Executive Functioning System [DKEFS] Trail-making Test, and DKEFS Sorting Test), and a sub-set of 17 participants provided usable fMRI data while completing a verbal learning paradigm that consisted of encoding word lists.

RESULTS

CBT and SP yielded comparable improvement in depressive symptoms from pre- to post-treatment. Better retention of learned information (CVLT-II long delay free recall vs. Trial 5) and recognition (CVLT-II hits) were associated with greater improvement in depression in both treatments. Increased activation in the left dorsolateral prefrontal cortex and right hippocampus during encoding was also related to depressive symptom improvement.

LIMITATIONS

Sample size precluded tests of clinical factors that may interact with cognitive/neural function to predict treatment outcome.

CONCLUSION

Neuropsychological assessment and fMRI offer additive information regarding who is most likely to benefit from psychotherapy for bipolar depression.

Psychoeducation for bipolar disorder

Bipolar disorder is a complex disorder of mood and behaviour that requires a multimodal treatment approach. In the past 10 years there has been growing interest in psychoeducational interventions delivered as adjuncts to conventional management. Several studies have tested the effectiveness of psychoeducational treatments delivered in a variety of formats. In this article we assess the evidence for the efficacy of these interventions and consider the likely future role of structured psychoeducational treatments in clinical practice.

Digital Platforms in the Assessment and Monitoring of Patients with Bipolar Disorder

This paper aims to review the application of digital platforms in the assessment and monitoring of patients with Bipolar Disorder (BPD). We will detail the current clinical criteria for the diagnosis of BPD and the tools available for patient assessment in the clinic setting. We will go on to highlight the difficulties in the assessment and monitoring of BPD patients in the clinical context. Finally, we will elaborate upon the impact that diital platforms have made, and have the potential to make, on healthcare, mental health, and specifically the management of BPD, before going on to evaluate the benefits and drawbacks of the use of such technology.

Internet- and mobile-based aftercare and follow-up for mental disorders: protocol of a systematic review and meta-analysis

INTRODUCTION

Mental disorders are characterised by a high likelihood of symptom recurrence or chronicity. Thus, in the vulnerable post-discharge phase, aftercare and follow-up aim at stabilising treatment effects, promoting functionality and preventing relapse or readmission. Internet- and mobile-based interventions may represent low threshold and effective extensions to aftercare in tertiary prevention of mental disorders.

OBJECTIVES

The planned systematic review and meta-analysis aims to synthesise and analyse existing evidence on the effectiveness of psychological internet- and mobile-based aftercare or follow-up in maintaining treatment effects and/or preventing recurrence in adults with mental disorders.

METHODS AND ANALYSIS

Electronic databases (PsycInfo, MEDLINE and Cochrane Central Register of Controlled trials) will be searched systematically, complemented by a hand-search of ongoing trials and reference lists of selected studies. Data extraction and evaluation will be conducted by two independent researchersand quality will be assessed with the Cochrane risk of bias tool. Eligibility criteria for selecting studies will be: randomised controlled trials of internet-based and mobile-based, psychological aftercare and follow-up for the tertiary prevention of mental disorders in an adult population. Primary outcome will be symptom severity. Secondary outcomes will be symptom or disorder recurrence rate, rehospitalisation rate, functionality, quality of life or adherence to primary treatment. Further data items to be extracted will be: study design, intervention and technical characteristics, type of mental disorder or clinical symptom to be treated, target population items, setting, treatment engagement and assessment of additional outcome variables. Meta-analytic pooling will be conducted when data of included studies are comparable in terms of study design, intervention type, endpoints, assessments and target mental disorder. Cumulative evidence will be evaluated according to the Grading of Recommendations Assessment, Development and Evaluation framework.

ETHICS AND DISSEMINATION

Ethics approval is not required. Results from this review will be published in peer-reviewed journals and presented at international conferences.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42017055289.

Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials

BACKGROUND

Although cognitive behavioral therapy (CBT) is considered a promising adjuvant to pharmacotherapy for treating bipolar disorder (BD), its efficacy is unproven. The present review and meta-analysis evaluated the treatment outcomes of patients with BD treated with CBT plus medication and compared these data with the outcomes of those who received standard care alone.

METHODS

Electronic searches from inception to July 31, 2016, were performed using PubMed, Medline OVID, Cochrane Library, EMBASE, CINAHL plus, and PsycINFO. In the extensive electronic literature search, keywords such as "bipolar disorder," "manic-depressive psychosis," "bipolar affective disorder," "bipolar depression," "cognitive therapy," "cognitive-behavioral therapy," and "psychotherapy" were transformed into MeSH terms, and only randomized controlled trials (RCTs) were included. The pooled odds ratios (ORs) of relapse rates and Hedges's g, along with 95% confidence intervals (CIs), for the mean differences in the levels of depression, mania, and psychosocial functioning were calculated. Further subgroup analyses were conducted according to the characteristics of the CBT approaches, patients, and therapists, if the data were available.

RESULT

A total of 19 RCTs comprising 1384 patients with type I or II BD were enrolled in our systematic review and meta-analysis. The main analysis revealed that CBT could lower the relapse rate (pooled OR = 0.506; 95% CI = 0.278 -0.921) and improve depressive symptoms (g = -0.494; 95% CI = -0.963 to -0.026), mania severity (g = -0.581; 95% CI = -1.127 to -0.035), and psychosocial functioning (g = 0.457; 95% CI = 0.106-0.809).

CONCLUSIONS

CBT is effective in decreasing the relapse rate and improving depressive symptoms, mania severity, and psychosocial functioning, with a mild-to-moderate effect size. Subgroup analyses indicated that improvements in depression or mania are more potent with a CBT treatment duration of ≥90 min per session, and the relapse rate is much lower among patients with type I BD.

The Effect of Group Psychoeducation Program on Medication Adherence in Patients with Bipolar Mood Disorders: a Randomized Controlled Trial

Introduction: Medication nonadherence is highly prevalent in patients with bipolar disorders and often results in worsening disease prognosis. The purpose of this study was to investigate the effect of group psychoeducation on medication adherence in female patients with bipolar mood disorder type I.

Methods: This randomized controlled trial was conducted on 76 patients with bipolar mood disorder admitted in female psychiatric wards of Razi teaching hospital, Tabriz, Iran. The participants were selected by convenience sampling method and were randomly assigned to experimental and control groups. Patients in experimental group received 10 continuous 90 minutes sessions of psychoeducation, two times a week. Medication adherence was measured using the medicine check list and medication adherence rating scale (MARS) before and after intervention. Data analysis was performed with SPSS ver.13.

Results: There was no significant difference between two groups regarding medication adherence before the intervention. After the study intervention, the mean scores of medication adherence check list and medication adherence rating scale in the experimental group were significantly higher than the control group.

Conclusion: Since group psychoeducation was effective in improving patients' medication adherence, it could be recommended for psychiatric nurses to apply this intervention in the clinical setting.

Effectiveness of cognitive behavioral therapy in treating bipolar disorder: An updated meta-analysis with randomized controlled trials

AIM

The aim of this updated meta-analysis was to further assess the effectiveness of cognitive behavioral therapy (CBT) in treating bipolar disorder (BD).

METHODS

We carried out a literature search on PubMed, Embase, and the Cochrane Library up to October 2015. We calculated the pooled relative risk of relapse rate and standard mean difference (SMD) of mean change (data at a follow-up time-point - baseline) of the Beck Depression Inventory, Beck Hopelessness Scale, Hamilton Rating Scale for Depression, Young Mania Rating Scale (YMRS) and Mania Rating Scale scores with their 95% confidence interval (95%CI). Subgroup analyses based on follow-up time were performed.

RESULTS

Nine randomized controlled trials with 520 bipolar I or II disorder patients were reanalyzed. Overall analysis showed that CBT did not significantly reduce the relapse rate of BD or improve the level of depression. However, significant efficacy of CBT in improving severity of mania was proved based on the YMRS (SMD = -0.54, 95%CI, -1.03 to -0.06, P  = 0.03) but not based on MRS. Subgroup analyses showed that CBT had short-term efficacy in reducing relapse rate of BD (at 6 months' follow-up: relative risk = 0.49, 95%CI: 0.29-0.81, P  = 0.006) and improving severity of mania based on YMRS score (post-treatment: SMD = -0.30, 95%CI, -0.59 to -0.01, P  = 0.04).

CONCLUSION

Short-term efficacy of CBT in reducing relapse rate of BD and improving the severity of mania was proved. But these effects could be weakened by time. In addition, there was no effect of CBT on level of depression in BD.

Combined treatment: impact of optimal psychotherapy and medication in bipolar disorder

OBJECTIVES

The current study investigated the longitudinal course of symptoms in bipolar disorder among individuals receiving optimal treatment combining pharmacotherapy and psychotherapy, as well as predictors of the course of illness.

METHODS

A total of 160 participants with bipolar disorder (bipolar I disorder: n = 115; bipolar II disorder: n = 45) received regular pharmacological treatment, complemented by a manualized, evidence-based psychosocial treatment - that is, cognitive behavioral therapy or psychoeducation. Participants were assessed at baseline and prospectively for 72 weeks using the Longitudinal Interval Follow-up Evaluation (LIFE) scale scores for mania/hypomania and depression, as well as comparison measures (clinicaltrials.gov identifier: NCT00188838).

RESULTS

Over a 72-week period, patients spent a clear majority (about 65%) of time euthymic. Symptoms were experienced more than 50% of the time by only a quarter of the sample. Depressive symptoms strongly dominated over (hypo)manic symptoms, while subsyndromal symptoms were more common than full diagnosable episodes for both polarities. Mixed symptoms were rare, but present for a minority of participants. Individuals experienced approximately six significant mood changes per year, with a full relapse on average every 7.5 months. Participants who had fewer depressive symptoms at intake, a later age at onset, and no history of psychotic symptoms spent more weeks well over the course of the study.

CONCLUSIONS

Combined pharmacological and adjunctive psychosocial treatments appeared to provide an improved course of illness compared to the results of previous studies. Efforts to further improve the course of illness beyond that provided by current optimal treatment regimens will require a substantial focus on both subsyndromal and syndromal depressive symptoms.

Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges

Treating pregnant women with bipolar disorder is among the most challenging clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no approach is without risk. Stopping effective pharmacotherapy during pregnancy exposes the patient and her baby to potential harms related to bipolar relapses and residual mood symptom-related dysfunction. Continuing effective pharmacotherapy during pregnancy may prevent these occurrences for many; however, some of the most effective pharmacotherapies (such as valproate) have been associated with the occurrence of congenital malformations or other adverse neonatal effects in offspring. Very little is known about the reproductive safety profile and clinical effectiveness of atypical antipsychotic drugs when used to treat bipolar disorder during pregnancy. In this paper, we provide a clinically focused review of the available information on potential maternal and fetal risks of untreated or undertreated maternal bipolar disorder during pregnancy, the effectiveness of interventions for bipolar disorder management during pregnancy, and potential obstetric, fetal, and neonatal risks associated with core foundational pharmacotherapies for bipolar disorder.

Does a home treatment acute relapse prevention strategy reduce admissions for people with mania in bipolar affective disorder?

Aims and method To assess whether a home treatment team acute relapse prevention (ARP) strategy reduces admissions to hospital with mania. A retrospective design was used to analyse records for manic admissions since 2002. The number and length of admissions and detentions pre- and post-ARP were determined and rates of admissions and detentions calculated from this.

Results We found reductions in admission and detention rates following the introduction of the ARP: 0.3 fewer admissions per person per year (95% bootstrap CI 0.09–0.62) and 0.25 fewer detentions per person per year (95% bootstrap CI 0.0–0.48). Wilcoxon signed-rank tests gave P<0.0001.

Clinical implications A person-centred care plan such as the ARP which enables quick action in response to relapse-warning signs of mania appears to reduce rates of admission to hospital. The ARP could be used anywhere in the UK and fits with current mental health policy.

A novel cognitive behaviour therapy for bipolar disorders (Think Effectively About Mood Swings or TEAMS): study protocol for a randomized controlled trial

Background

Existing psychological therapies for bipolar disorders have been found to have mixed results, with a consensus that they provide a significant, but modest, effect on clinical outcomes. Typically, these approaches have focused on promoting strategies to prevent future relapse. An alternative treatment approach, termed ‘Think Effectively About Mood Swings’ (TEAMS) addresses current symptoms, including subclinical hypomania, depression and anxiety, and promotes long-term recovery. Following the publication of a theoretical model, a range of research studies testing the model and a case series have demonstrated positive results. The current study reports the protocol of a feasibility randomized controlled trial to inform a future multi-centre trial.

Methods/Design

A target number of 84 patients with a diagnosis of bipolar I or II disorder, or bipolar disorder not-otherwise-specified are screened, allocated to a baseline assessment and randomized to either 16 sessions of TEAMS therapy plus treatment-as-usual (TAU) or TAU. Patients complete self-report inventories of depression, anxiety, recovery status and bipolar cognitions targeted by TEAMS. Assessments of diagnosis, bipolar symptoms, medication, access to services and quality of life are conducted by assessors blind to treatment condition at 3, 6, 12 and 18 months post-randomization. The main aim is to evaluate recruitment and retention of participants into both arms of the study, as well as adherence to therapy, to determine feasibility and acceptability. It is predicted that TEAMS plus TAU will reduce self-reported depression in comparison to TAU alone at six months post-randomization. The secondary hypotheses are that TEAMS will reduce the severity of hypomanic symptoms and anxiety, reduce bipolar cognitions, improve social functioning and promote recovery compared to TAU alone at post-treatment and follow-up. The study also incorporates semi-structured interviews about the experiences of previous treatment and the experience of TEAMS therapy that will be subject to qualitative analyses to inform future developments of the approach.

Discussion

The design will provide preliminary evidence of efficacy, feasibility, acceptability, uptake, attrition and barriers to treatment to design a definitive trial of this novel intervention compared to treatment as usual.

Trial registration

This trial was registered with Current Controlled Trials (ISRCTN83928726) on registered 25 July 2014.

The predictive validity of bipolar at-risk (prodromal) criteria in help-seeking adolescents and young adults: a prospective study

OBJECTIVES

There are no established tools to identify individuals at risk for developing bipolar disorder. We developed a set of ultra-high-risk criteria for bipolar disorder [bipolar at-risk (BAR)]. The primary aim of the present study was to determine the predictive validity of the BAR criteria.

METHODS

This was a 12-month prospective study that was conducted at Orygen Youth Health Clinical Program, a public mental health program for young people aged 15-24 years in metropolitan Melbourne, Australia. At intake, BAR screen-positive individuals and a matched group of individuals who did not meet BAR criteria were observed over a period of 12 months. The BAR criteria include general criteria such as being in the peak age range for the onset of the disorder, as well as sub-threshold mania, depression plus cyclothymic features, and depression plus genetic risk. Conversion to first-episode mania/hypomania was defined by the presence of DSM-IV manic symptoms for more than four days, in line with the DSM-IV definition of hypomania/mania.

RESULTS

A total of 559 help-seeking patients were screened. Of the eligible participants, 59 (10.6%) met BAR criteria. Thirty-five participants were included in the BAR group and 35 matched participants were selected to be in the control group. During the follow-up, five BAR patients out of 35 (14.3%) converted to first-episode hypomania/mania as opposed to none in the non-BAR group [χ(2) (1) = 5.38, p = 0.020]. Four out of these five converters had a DSM-IV diagnosis of bipolar I or bipolar II disorder.

CONCLUSIONS

These findings support the possibility of identification of persons prior to the onset of mania/hypomania. The proposed criteria need further evaluation in larger, prospective studies with longer follow-up periods.

Bipolar Disorder in the Postpartum Period: Management Strategies and Future Directions

Bipolar I and II disorder are chronic and severe psychiatric illnesses that affect many women. Furthermore, women are at increased risk for mood episodes during the postpartum period compared with non-postpartum periods. Unfortunately, identification of clinically significant depressive or (hypo)manic episodes can be challenging. Delays in detection, as well as misdiagnosis, put women at risk of many negative consequences, such as symptom exacerbation and treatment refractoriness. Early and accurate detection of bipolar I or II disorder in the postpartum period is critical to improve prognosis. At this time, limited recommendations can be made due to a paucity of research. Further research on postpartum bipolar I or II disorder focusing on its identification, consequences and treatment is urgently needed to allow for empirically informed clinical decision-making.

A qualitative investigation of hypomania and depression in bipolar II disorder

Psychological treatments may have differential impacts on bipolar (BP) sub-types, yet little is known about psychological processes in BP II disorder. We explored cognitive processes and behaviors mediating hypomania and depression in participants diagnosed with BP II disorder. Semi-structured interviews with 13 participants were analysed using interpretative phenomenological analysis. The majority were able to detect hypomanic and depressive prodromes, and describe behavioral responses to these mood states. Qualitative analyses revealed four theme clusters. Hypomania ascent beliefs described beliefs regarding identity, positioning hypomania as an enjoyable state preferable to depression. Hypomania descent beliefs referred to hypomania as a signal for depression, causing interpersonal difficulties. Beliefs about depression positioned depression as an abnormal, fearful state, impacting negatively interpersonally, occupationally and on self-perceptions. Finally, The impact of chronicity referred to shifts in coping strategies over time, moving from maladaptive to adaptive behavioral responses. Themes were interpreted within the framework of a cognitive model of BP disorder. Clinical implications for BP II disorder were discussed.

The presentation, recognition and management of bipolar depression in primary care

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

The effects of mindfulness-based cognitive therapy in patients with bipolar disorder: a controlled functional MRI investigation

BACKGROUND

Preliminary research findings have shown that mindfulness-based cognitive therapy improves anxiety and depressive symptoms in bipolar disorder. In this study, we further investigated the effects of MBCT in bipolar disorder, in a controlled fMRI study.

METHOD

Twenty three patients with bipolar disorder underwent neuropsychological testing and functional MRI. Sixteen of these patients were tested before and after an eight-week MBCT intervention, and seven were wait listed for training and tested at the same intervals. The results were compared with 10 healthy controls.

RESULTS

Prior to MBCT, bipolar patients reported significantly higher levels of anxiety and symptoms of stress, scored significantly lower on a test of working memory, and showed significant BOLD signal decrease in the medial PFC during a mindfulness task, compared to healthy controls. Following MBCT, there were significant improvements in the bipolar treatment group, in measures of mindfulness, anxiety and emotion regulation, and in tests of working memory, spatial memory and verbal fluency compared to the bipolar wait list group. BOLD signal increases were noted in the medial PFC and posterior parietal lobe, in a repeat mindfulness task. A region of interest analysis revealed strong correlation between signal changes in medial PFC and increases in mindfulness.

LIMITATIONS

The small control group is a limitation in the study.

CONCLUSION

These data suggest that MBCT improves mindfulness and emotion regulation and reduces anxiety in bipolar disorder, corresponding to increased activations in the medial PFC, a region associated with cognitive flexibility and previously proposed as a key area of pathophysiology in the disorder.

Clinical assessment and crisis intervention for the suicidal bipolar disorder patient

OBJECTIVE

Suicidal behaviour is common in people suffering with bipolar disorder, and suicide is a leading cause of death in this group. Our aim in this review is to provide an overview of key assessment and management strategies, highlight research findings relevant to suicide prevention, and identify important areas for future research.

METHODS

We reviewed the published literature regarding the risk factors for and management of suicida\l behaviour in individuals with bipolar disorder using the Pubmed and PsychINFO databases. Where available, we focused our search on systematic reviews.

RESULTS

Suicide is usually associated with a depressive phase, although mixed affective states also convey increased risk. All individuals with bipolar disorder should have an up-to-date crisis management plan which outlines the action to be taken should suicidal behaviour emerge. Timely clinical assessment is essential in ensuring that those at high risk are identified. This should include mental state examination, consideration of risk factors, and evaluation of issues such as access to means, preparatory acts before suicide, and also protective factors. While pharmacological approaches are the mainstay of management, less specific measures, such as the removal of access to means, are also important in ensuring safety in the acute situation. Intensifying the clinical support of both patients and relatives, and the sharing of risk information with other health agencies are essential in management. Specific psychological treatments are likely to be helpful in preventing crises, although the evidence base is limited.

CONCLUSIONS

The aetiology of suicidal behaviour in bipolar disorder is multifactorial and requires proactive crisis planning and management. A range of issues need to be addressed in the assessment of at-risk patients. Determining the efficacy of interventions specific to reducing suicidality in bipolar disorder should be a research priority.

Frequency and relevance of psychoeducation in psychiatric diagnoses: results of two surveys five years apart in German-speaking European countries

BACKGROUND

Psychoeducation has been shown to reduce relapse rates in several psychiatric disorders. Studies investigating for which psychiatric diagnoses psychoeducation is offered and assessing its perceived relevance compared to other interventions are lacking.

METHODS

A two-part questionnaire addressing these questions was sent to the heads of all psychiatric hospitals in Germany, Austria and Switzerland. Results were compared with those from a similar survey 5 years earlier.

RESULTS

289 of 500 (58%) institutions responded. Significantly (p = 0,02) more institutions (93%) offer any type of psychoeducation as compared to 5 years before (86%). Psychoeducation is mainly offered for schizophrenia (86%) and depression (67%) and less frequently for anxiety disorders (18%) and substance abuse (17%). For the following specific diagnoses it is offered by less than 10% of the institutions: Personality disorder, bipolar disorder, posttraumatic stress disorder, dementia, obsessive compulsive disorder, sleeping disorders, eating disorders, schizophrenia plus substance abuse, pain, attention deficit hyperactivity disorder and early psychosis. 25% offer diagnosis-unspecific psychoeducation. 'Pharmacotherapy' (99%), 'basic occupational therapy' (95%) and 'psychoeducation for patients' (93%) were the therapies being most often, 'light therapy' (24%) and 'sleep deprivation' (16%) the therapies being least often perceived as relevant by the respondents when asked about the value of different interventions offered in their hospitals. Art therapy (61%) and psychoanalytically oriented psychotherapy (59%), two therapies with a smaller evidence base than light therapy or sleep deprivation, were perceived as relevant by more than the half of the respondents.

CONCLUSION

Psychoeducation for patients is considered relevant and offered frequently in German-speaking countries, however, mostly only for schizophrenia and depression. The ranking of the perceived relevance of different treatment options suggests that the evidence base is not considered crucial for determining their relevance.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder

OBJECTIVES

These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults.

METHODS

Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A-F) and different grades of recommendation to ensure practicability were assigned.

RESULTS

Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios.

CONCLUSIONS

Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.

The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses

Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a variety of problems. The goal of this review was to provide a comprehensive survey of meta-analyses examining the efficacy of CBT. We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.

Cognitive behaviour therapy and supportive therapy for bipolar disorders: relapse rates for treatment period and 2-year follow-up

BACKGROUND

The efficacy of adjunctive psychosocial interventions such as cognitive behaviour therapy (CBT) for bipolar disorder (BD) has been demonstrated in several uncontrolled and controlled studies. However, these studies compared CBT to either a waiting list control group, brief psycho-education or treatment as usual (TAU). Our primary aim was to determine whether CBT is superior to supportive therapy (ST) of equal intensity and frequency in preventing relapse and improving outcome at post-treatment. A secondary aim was to look at predictors of survival time.

METHOD

We conducted a randomized controlled trial (RCT) at the Department of Psychology, University of Tübingen, Germany (n=76 patients with BD). Both CBT and ST consisted of 20 sessions over 9 months. Patients were followed up for a further 24 months.

RESULTS

Although changes over time were observed in some variables, they were not differentially associated with CBT or ST. CBT showed a non-significant trend for preventing any affective, specifically depressive episode during the time of therapy. Kaplan-Meier survival analyses revealed that 64.5% of patients experienced a relapse during the 33 months. The number of prior episodes, the number of therapy sessions and the type of BD predicted survival time.

CONCLUSIONS

No differences in relapse rates between treatment conditions were observed, suggesting that certain shared characteristics (e.g. information, systematic mood monitoring) might explain the effects of psychosocial treatment for BD. Our results also suggest that a higher number of prior episodes, a lower number of therapy sessions and a diagnosis of bipolar II disorder are associated with a shorter time before relapse.

Incorporating the treatment of medical and psychiatric disorders in the critical care area

Critical care areas are fast moving, often chaotic, and therefore confusing, even frightening, to patients attempting to understand what has happened to them. The nurse acts to mitigate these reactions by understanding the range of possibilities that can occur with patients, including potential psychiatric issues, and serving as patient advocate to ensure that appropriate treatment is initiated. Certainly there may be other psychiatric problems not described in the preceding text. The main possibilities are covered in this article. Assessing and acting early are tools the critical care nurse uses to meet patient needs and prevent behavioral problems that can interfere with life-preserving care.

How close is evidence to truth in evidence-based treatment of mental disorders?

Given the importance of the term 'evidence' in evidence-based medicine (EBM), the meaning of this term is evaluated, going back to the philosophical tradition and current meaning of the terms 'evidence' and 'truth'. Based on this, current problems in the definition of evidence and in the grading of evidence in EBM are described, taking examples from the field of psychiatry and especially pharmacopsychiatry. These problems underline that the use of the term evidence in EBM is inconsistent and inconclusive. This should be fairly stated in all EBM-related publications, especially in EBM-based guidelines, to avoid severe misunderstandings in and outside the field of psychiatry. Although EBM might have increased empirically driven rational decision-making in psychiatry/medicine, the current limitations should be carefully considered.

Maintenance therapies in bipolar disorders

OBJECTIVE

Bipolar disorder is an inherently recurrent disorder, requiring maintenance preventive treatments in the vast majority of patients. The authors review the data on maintenance treatments in bipolar disorder, highlighting the controlled trial literature.

METHODS

Literature review using PubMed, Medline, and a hand search of relevant literature.

RESULTS

Over the last decade, a number of effective maintenance treatments for bipolar disorder have been developed with an evidence base for second-generation antipsychotics and some anticonvulsants. Increasing numbers of patients, therefore, are appropriately treated with multiple medications as a maintenance regimen. For some medications, maintenance treatment has been demonstrated in randomized controlled trials for both monotherapy and in combination with other mood stabilizers. Lithium continues as our oldest well-established maintenance treatment in bipolar disorder with somewhat better efficacy in preventing mania than depression. Lamotrigine, olanzapine, and quetiapine have bimodal efficacy in preventing both mania and depression, although lamotrigine's efficacy is more robust in preventing depression and olanzapine's efficacy is greater in preventing mania. Aripiprazole, ziprasidone, and risperidone long-acting injection all prevent mania, but not depression. Less controlled investigations have suggested some evidence of maintenance mood stabilization with carbamazepine, oxcarbazepine, and adjunctive psychotherapy.

CONCLUSIONS

Despite the number of agents with demonstrated efficacy as maintenance treatments in bipolar disorder, optimal treatment regimens are still a combination of evidence-based therapy in combination with individualized creative treatment algorithms.

Early intervention for bipolar disorder: current imperatives, future directions

OBJECTIVES: The objective of this article is to discuss the rationale/background for early intervention in bipolar disorder. METHOD: Narrative review. RESULTS: There are often significant delays before the diagnosis of bipolar disorder is made and effective management initiated. Growing evidence from both preclinical and clinical literature points to a clear need for improved early identification and early intervention in bipolar disorder. Increasing efforts are being applied to the identification of those at high risk of onset of bipolar disorder. It is hoped that identification of an early prodrome of illness will allow preventative measures to be taken. CONCLUSIONS: There is a clear rationale for improved early identification and early intervention in bipolar disorder.

A systematic review of measures of therapeutic engagement in psychosocial and psychological treatment

This article reports a systematic review of engagement measures for psychosocial therapy. MEDLINE, EMBASE, and PsycINFO databases were searched to identify English-language studies (published 1980 to February 2010) that reported on an instrument/rating scale to measure engagement in psychosocial treatment for mental health difficulties. Forty-seven studies were identified, reporting information on 40 measures of treatment engagement. Although our findings suggest that therapeutic engagement appears to be considered an important construct to assess, they also reveal that there is little consensus in the definition of engagement employed. Few measures are generalizable across treatment settings and clinical populations, and limited information is reported on the indices of reliability and validity. It is concluded that further work is required to develop adequate measures of therapeutic engagement.

The role of psychotherapy in bipolar disorder

Adjunctive psychosocial interventions for bipolar disorder target many of the issues that are not addressed by medication alone, including non-adherence, efficacy-effectiveness gap and functionality. Psychosocial interventions have been found to reduce relapse, particularly for the depressive pole, and improve functionality. Approaches such as psychoeducation, cognitive behaviour therapy, interpersonal and social rhythm therapy, and family therapy have shown benefits as adjunctive treatments. Each of the various psychosocial interventions has a unique emphasis, but they share common elements. These include: providing information and education; developing a personal understanding of the illness, such as triggers and early warning signs; having prepared strategies in place for early intervention, should symptoms of illness develop; and promoting a collaborative approach. Evidence to date supports the use of adjunctive psychosocial interventions in the management of bipolar disorder.

Using systemic reflective practice to treat couples and families with alcohol problems

In the UK, an adult with a drinking problem is generally treated from an individual perspective with minimal involvement of carers and relatives. In response to this gap in service provision, a systemic reflecting intervention was introduced to assist couples and families experiencing alcohol-related difficulties. The article documents the background and development of this initiative. Findings from evaluation and clinical outcome studies are reviewed and demonstrate how the use of the approach proved to be effective in facilitating positive change both in drinking and family behaviour. In conclusion, the paper explores the implications of how systemic reflective practice with family groups may be extended and be usefully used in wider addiction, diverse mental and general health-care settings.