Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium levels

Evolving trends in the long-term treatment of bipolar disorder

The episodic and chronic nature of bipolar disorder usually requires long-term treatment in all patients, yet there is an unmet need for well-tolerated and clinically effective maintenance therapy with enhanced patient adherence. Few well-tolerated treatment options are currently available that are both effective in all phases of bipolar disorder and prevent recurrence of episodes. Lithium has well-established efficacy in the prevention of further manic episodes and may also be effective in the prevention of depression and suicide, but safety is a concern due to narrow therapeutic window. For valproate and carbamazepine, data appear much less compelling. Lamotrigine has shown to be effective for long-term prevention of depressive episodes. Controlled studies suggest that atypical antipsychotics may also have mood-stabilizing properties and might become standard for long-term therapy in the new future. The role of psychoeducation in improving adherence to medication in long-term treatment and overall patient outcomes is also crucial.

Enhanced relapse prevention for bipolar disorder--ERP trial. A cluster randomised controlled trial to assess the feasibility of training care coordinators to offer enhanced relapse prevention for bipolar disorder

BACKGROUND

Bipolar Disorder (BD) is a common and severe form of mental illness characterised by repeated relapses of mania or depression. Pharmacotherapy is the main treatment currently offered, but this has only limited effectiveness. A recent Cochrane review has reported that adding psycho-social interventions that train people to recognise and manage the early warning signs of their relapses is effective in increasing time to recurrence, improving social functioning and in reducing hospitalisations. However, the review also highlights the difficulties in offering these interventions within standard mental health services due to the need for highly trained therapists and extensive input of time. There is a need to explore the potential for developing Early Warning Sign (EWS) interventions in ways that will enhance dissemination.

METHODS AND DESIGN

This article describes a cluster-randomised trial to assess the feasibility of training care coordinators (CCs) in community mental health teams (CMHTs) to offer Enhanced Relapse Prevention (ERP) to people with Bipolar Disorder. CMHTs in the North West of England are randomised to either receive training in ERP and to offer this to their clients, or to continue to offer treatment as usual (TAU). The main aims of the study are (1) to determine the acceptability of the intervention, training and outcome measures (2) to assess the feasibility of the design as measured by rates of recruitment, retention, attendance and direct feedback from participants (3) to estimate the design effect of clustering for key outcome variables (4) to estimate the effect size of the impact of the intervention on outcome. In this paper we provide a rationale for the study design, briefly outline the ERP intervention, and describe in detail the study protocol.

DISCUSSION

This information will be useful to researchers attempting to carry out similar feasibility assessments of clinical effectiveness trials and in particular cluster randomised controlled trials.

Efficacy of psychoeducational approaches on bipolar disorders: a review of the literature

BACKGROUND

To evaluate the efficacy of psychoeducation in the treatment of bipolar disorder according to specific therapeutic targets such as treatment compliance, patients' and families' knowledge of the illness and its treatments, relapse prevention, symptomatic (depressive or (hypo)manic) phases of the illness or social and occupational functioning.

METHODS

A systematic review of the literature published on psychoeducation up to July 2006 was carried out using the main electronic data bases (Medline, PubMed). The key words employed included bipolar disorder, psychoeducation, depression, mania, relapse prevention and treatment compliance.

RESULTS

Although the methodological shortcomings of the early studies must be taken into account, most data accumulated to date suggest that psychoeducation, used alone or as a component of more complex interventions, makes it possible to improve the course of the illness, notably by increasing the patients' and their families' knowledge of the disorder and of treatment options, by decreasing the risk of (hypo)manic or depressive relapse and of hospitalization and by improving treatment compliance.

LIMITATIONS

More studies based solely on psychoeducation, rather than psychoeducation as part of a multicomponent approach, are needed to confirm the efficacy of PE reported to date.

CONCLUSIONS

Given the results published to date, psychoeducation should be part of the integrated treatment of bipolar disorder. As a complement to pharmacotherapy, psychoeducation delivered individually or in a group setting constitutes a first-line psychological intervention. Applicable to a majority of patients and their families, it can be delivered by a wide range of health professionals trained in this approach.

Adaptation and validation of the Portuguese version of the Lithium Knowledge Test (LKT) of bipolar patients treated with lithium: cross-over study

OBJECTIVE

Adherence problems are a common feature among bipolar patients. A recent study showed that lithium knowledge was the main difference between adherent and non adherents bipolar patients. The Lithium Knowledge Test (LKT), a brief questionnaire, was developed as a means of identifying aspects of patients' practical and pharmacological knowledge which are important if therapy is to be safe and effective. The original English version is validated in psychiatric population, but a validated Portuguese one is not yet available.

METHODS

One hundred six patients selected were diagnosed with bipolar disorder (I or II) according to DSM-IV criteria and had to be on lithium treatment for at least one month. The LKT was administered on only one occasion. We analysed the internal consistency, concurrent validity, sensitivity and specificity of the LKT for the detection of the knowledge about lithium treatment of bipolar patients.

RESULTS

The internal consistency, evaluated by Cronbach's alpha was 0.596. The mean of total score LKT by bipolar patients was 9.0 (SD: 0.75) for men and 8.74 (SD: 0.44) for women. Concurrent validity based on plasma lithium concentration showed a significant correlation between the total LKT score and plasma lithium (r = 0.232; p = 0.020). The sensitivity was 84% and specificity was 81%.

CONCLUSION

LKT is a rapid, reliable instrument which appears to be as effective as a lengthier standard interview with a lithium clinic doctor, and which has a high level of acceptability to lithium patients. We found that the psychometric assessment of the Portuguese version of LKT showed good internal consistency, sensitivity and specificity.

An update on the role of psychotherapy in the management of bipolar disorder

Recent studies have examined the value of combining structured forms of psychotherapy with medication maintenance for patients with bipolar disorder. These studies have been influenced by the growing body of literature on stress in the elicitation of manic and depressive episodes. Randomized trials published within the past 5 years indicate positive benefits of cognitive-behavioral therapy, interpersonal and social rhythm therapy, family-focused therapy, and group psychoeducation as adjuncts to mood stabilizers in delaying recurrences, stabilizing symptoms, and improving medication adherence. Open trials of family interventions for pediatric-onset bipolar patients also have yielded promising results. Questions remain about the relative advantages of one psychosocial approach over the others, whether there are subgroups of patients who respond to each type of intervention, the impact of psychotherapy on role functioning, mediators of treatment effects, and the potential utility of early intervention as a means of delaying the onset and/or severity of the disorder.

Validation of the Portuguese version of the Lithium Attitudes Questionnaire (LAQ) in bipolar patients treated with lithium: cross-over study

BACKGROUND

Poor adherence to lithium is very common in bipolar patients and it is a frequent cause of recurrence during prophylactic treatment. Several reports suggest that attitudes of bipolar patients interfere with adherence to lithium. The Lithium Attitudes Questionnaire (LAQ) is a brief questionnaire developed as a means of identifying and grouping the problems patients commonly have with taking lithium regularly. The original version is validated in patients, but a validated version in Portuguese is not yet available.

METHODS

One-hundred six patients with bipolar disorder (DSM-IV criteria) criteria under lithium treatment for at least one month were assessed using LAQ. LAQ is a brief questionnaire administered under interview conditions, which includes 19 items rating attitudes towards prophylactic lithium treatment. We analysed the internal consistency, concurrent validity, sensitivity and specificity of the Portuguese version of LAQ.

RESULTS

The internal consistency, evaluated by Cronbach's alpha was 0.78. The mean total LAQ score was 4.1. Concurrent validity was confirmed by a negative correlation between plasma lithium concentration and total LAQ score (r = -0,198; p = 0.048). We analysed the scale's discriminative capacity revealing a sensitivity of 69% and a specificity of 71% in the identification of negative attitudes of bipolar patients.

CONCLUSION

The psychometric assessment of the Portuguese version of LAQ showed good internal consistency, sensitivity and specificity. The results were similar to the original version in relation to attitudes of bipolar patients towards lithium therapy.

Impact of the life goals group therapy program for bipolar patients: an open study

BACKGROUND

To evaluate the level of satisfaction of bipolar patients participating in the structured group Life Goals Program (LGP), as well as the impact of this psychoeducative program on mood stability, treatment compliance and relapse prevention.

METHODS

Forty-five patients (30 females and 15 males) with bipolar disorder were included. Their level of satisfaction was evaluated at the end of the 6-week phase 1 of LGP and after one-year participation in phase 2 (median duration 366 days, range 68-483). The impact of the LGP was also evaluated with respect to mood stability, compliance with pharmacological treatment and ability to prevent and cope with relapse. Participants' mood was rated at study entry, end of phase 1 and end of phase 2 with the Montgomery and Asberg Depression Rating Scale (MADRS) and Bech-Rafaelsen Mania Scale.

RESULTS

Thirty-six participants (80.0%) completed phase 1 and 17 entered phase 2. A majority of participants (82.4%) were very satisfied with the information delivered during phase 1. After attending phase 2, participants reported a subjective improvement in mood stability, relapse prevention strategies as well as coping with relapse. MADRS score decreased significantly between the beginning of phase 1 and end of phase 2 (p=0.016).

LIMITATIONS

This is an open study and results need to be replicated in a randomized controlled trial.

CONCLUSIONS

Results of this open study suggest that the life goals psychoeducative program is well perceived by bipolar patients and has a positive impact on mood stability, relapse prevention and ability to go beyond symptoms in order to reach specific goals.