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

Factors Associated with Long-term Medication Adherence in Patients Who Participated in a Short-term Group Psychoeducation Program for Bipolar Disorder

Improving adherence to medication and quality of life is a challenge in treating bipolar disorder. Therefore, psychoeducation plays an important role. This study examined factors associated with long-term medication adherence in patients with bipolar disorder who participated in a short-term psychoeducation program. Additionally, the relationships between medication adherence and medication attitudes and quality of life (QOL) were assessed. Multiple regression analysis was conducted on 67 inpatients and outpatients using medication adherence (Brief Evaluation for Medication Influences and Beliefs [BEMIB] score) as the dependent variable and clinical and demographic variables before and after the program as explanatory variables, one year after completion of the program. Pearson's correlation coefficients were calculated for associations between patients' BEMIB score and medication attitudes (Drug Attitude Inventory-10 [DAI-10]) and QOL (World Health Organization QOL-26 [WHOQOL-26] score) before and after the program and one year after program completion. The results showed that the CSQ-8 J (Client Satisfaction Questionnaire-8 Japanese) and DAI-10 scores immediately after the program were significantly related to the BEMIB score one year after program completion. Both the BEMIB and DAI-10 showed significant positive correlations with several items of the WHOQOL-26, both after the program and one year after completion of the program. The results suggest that medication attitudes acquired through psychoeducation and program satisfaction impact long-term medication adherence. The study also indicates that medication attitudes and medication adherence after a psychoeducation program are associated with QOL. Thus, patients' subjective views after a psychoeducation program can play an important role in long-term medication adherence and QOL.

Is cognitive behaviour therapy applicable to individuals diagnosed with bipolar depression or suboptimal mood stabilizer treatment: a secondary analysis of a large pragmatic effectiveness trial

Background

Efficacy trials of medications and/or psychological interventions for bipolar disorders (BD) aim to recruit homogenous samples of patients who are euthymic and such populations show high levels of adherence to the treatments offered. This study describes a secondary analysis of a large-scale multi-centre pragmatic effectiveness randomized controlled trial (RCT) of cognitive behaviour therapy plus treatment as usual (CBT) or treatment as usual alone (TAU) and explores outcomes in individuals who were: (i) recruited in depressive episodes, or (ii) receiving suboptimal doses of or no mood stabilizers (MS).

Methods

Data were extract on two separate subsamples (out of 253 RCT participants). Sample 1 comprised 67 individuals in a depressive episode (CBT: 34; TAU: 33); Sample 2 comprised 39 individuals receiving suboptimal MS treatment (CBT: 19; TAU: 20). Survival analyses (adjusted for confounding variables) were used to explore recovery in Sample 1 and relapse in Sample 2.

Results

In Sample 1 (individuals with depression), Cox proportional hazards regression model revealed that the median time to recovery was significantly shorter in the CBT group (10 weeks; 95% confidence intervals (CI) 8, 17) compared to the TAU group (17 weeks; 95% CI 9, 30) [Adjusted Hazard Ratio (HR) 1.89; 95% CI 1.04, 3.4; p < 0.035]. In Sample 2 (suboptimal MS), the median time to any relapse was significantly longer in the CBT group compared to the TAU group (~ 35 versus ~ 20 weeks; Adjusted HR 2.01; 95% CI 1.01, 3.96; p < 0.05) with the difference in survival time to first depressive relapse also reaching statistical significance (X² = 14.23, df 6, p 0.027).

Conclusions

Adjunctive use of CBT appears to have benefits for individuals diagnosed with BD who are highly representative of the patients seen in routine clinical practice, but often excluded from efficacy RCTs. However, as this is a secondary analysis of 42% of the original RCT sample, it is important to replicate these findings in independent larger scale studies specifically designed for purpose.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40345-022-00259-3.

Évaluation qualitative de l’implantation de groupes psychoéducatifs pour le trouble bipolaire à Québec

Le trouble bipolaire est une condition chronique ayant des conséquences tangibles sur le fonctionnement et la qualité de vie des personnes atteintes. Des interventions psychologiques reconnues efficaces, comme la psychoéducation, ont le potentiel de pallier certaines lacunes observées lorsque la pharmacothérapie est utilisée comme seule modalité de traitement. Toutefois, il semble que les personnes ayant un trouble bipolaire n’ont pas facilement accès à ce type de programme fondé sur les données probantes. En effet, le transfert des connaissances acquises dans la recherche vers le milieu clinique pose un défi. Ainsi, au-delà de l’évaluation de l’efficacité des traitements en recherche, il est nécessaire de considérer l’implantation de ces traitements dans la pratique clinique. L’objectif de la présente étude est donc de décrire l’implantation d’un programme psychoéducatif pour le traitement du trouble bipolaire, le Life Goals Program (LGP), à l’intérieur de milieux cliniques québécois. Dix-sept groupes de psychoéducation basés sur le LGP ont donc été offerts à l’intérieur de milieux cliniques publics québécois. Les animateurs de ces groupes ont rempli des journaux de bord et participé à une entrevue de groupe. Des analyses de contenu ont été réalisées pour documenter la mise en place du LGP. L’analyse des données qualitatives a permis d’identifier 4 principaux domaines de facteurs qui pourraient être tributaires de la variabilité dans l’implantation : les caractéristiques des intervenants, les caractéristiques des participants, le contexte organisationnel et la facilitation. En particulier, les facteurs déterminants dans les différences observées semblent être le soutien de l’équipe de recherche, le roulement de personnel et la formation des intervenants.

Paper-Based Device for the Facile Colorimetric Determination of Lithium Ions in Human Whole Blood

Lithium carbonate is an effective medicine for the treatment of the bipolar disorder, but the concentration of lithium in the patient's blood must be frequently monitored because of its toxicity. To date, no colorimetric methods of lithium ion detection in whole blood without pretreatment have been reported. Here, we report a colorimetric paper-based device that allows point-of-care testing in one step. This device is composed of two paper-based elements linked to each other: a blood cell separation unit and a colorimetric detection unit. After a portion of whole blood has been placed on the end of the separation unit, plasma in the sample is automatically transported to the detection unit, which displays a diagnostic color. The key feature of this device is its simple, user-friendly operation. The limit of detection is 0.054 mM and the coefficient of variance is below 6.1%, which are comparable to those of conventional instruments using the same colorimetric reaction. Furthermore, we achieved high recovery (>90%) and reproducibility (<9.8%) with spiked human blood samples. Thus, the presented device provides an alternative method for the regular monitoring of lithium concentrations in the treatment of bipolar disorder by augmenting the coefficient of variation (maximum value, 6.1%).

Psychoeducation for bipolar disorder and risk of recurrence and hospitalization - a within-individual analysis using registry data

BACKGROUND

The efficacy of psychoeducation for bipolar disorder has been demonstrated in clinical trials, but it is not known if the results translate into effectiveness in routine clinical practice. The aim was to determine the effectiveness of psychoeducation for bipolar disorder in a routine clinical setting.

METHOD

We identified 2819 patients with at least three registrations in the Swedish Quality Assurance Register for Bipolar Disorder. Among those, 402 had not been exposed to psychoeducation at the first visit, but received psychoeducation during any of the following registrations. Using within-individual analyses, the risk of recurrence after having received psychoeducation was compared with the risk prior to psychoeducation.

RESULTS

In adjusted within-individuals comparisons, periods after psychoeducation was associated with decreased risks of any recurrence [odds ratio (OR) 0.57, 95% CI 0.42-0.78], (hypo-)manic or mixed episodes (OR 0.54, 95% CI 0.39-0.76), depressive episodes (OR 0.63, 95% CI 0.47-0.86), and inpatient care (OR 0.54, 95% CI 0.33-0.86) relative to periods prior to psychoeducation. There was no association with rates of involuntary sectioning or suicide attempts.

CONCLUSIONS

The results suggest that psychoeducation for bipolar disorder reduces the risk of mood episodes and inpatient care also when implemented in routine clinical practice.

The Long-Term Effectiveness of Psychoeducation for Bipolar Disorders in Mental Health Services. A 4-Year Follow-Up Study

Aims: The aims of the present study were to assess: the effectiveness of psychoeducation in mental health service (MHSs) in terms of time to first hospitalization during 4-year follow-up; the number and the days of hospitalizations, and the number of people hospitalized at 4-year follow-up; and variables associated with better outcome in BD patients. Methods: This is a controlled study involving an experimental group (N = 57) and a control group (N = 52). The treatment phase consists of 21 weeks, in which all participants received TAU, while the experimental group received additional psychoeducation. Results: The survival analysis showed significant differences in terms of time to first hospitalization of up to 4-year follow-up: the patients in the psychoeducation group showed a longer time free from hospitalizations than the control group. Concerning the predictors of time to first hospitalization, the only factor that showed a trend to statistical significance was psychoeducation. Conclusions: This is one of few studies assessing the long-term effectiveness of psychoeducation in a naturalistic setting. The data confirm that psychoeducation can impact illness course, in terms of longer time free from hospitalizations. Trial registration: ISRCTN17827459.

Outcomes of patient education practices to optimize the safe use of lithium: A literature review

Introduction:

Lithium is commonly used to treat various psychiatric disorders and is particularly effective in the maintenance phase of bipolar disorder. Unfortunately, this drug has a narrow therapeutic index and, if not monitored regularly, can result in toxicity. Therefore, for lithium to be prescribed safely, clinicians must ensure that patients are well educated on lithium toxicity, its prevention, and symptom recognition. This article summarizes studies that investigated lithium education strategies to help promote the safe use of lithium.

Methods:

Four electronic databases were searched using key terms and subject headings. Reference lists of relevant papers were also reviewed. The search was limited to literature published in English, without year limits. Eligible studies examined lithium patient education and the impact on patients' knowledge of safe lithium use.

Results:

Of a total of 517 citations that were retrieved from the electronic database search, 12 were selected for inclusion in this review. Most of the studies included assessed the effect of lithium education on various aspects of patients' knowledge, including but not limited to, lithium toxicity. Of the studies assessing the correlation between lithium knowledge and lithium levels, most demonstrated a positive correlation between lithium knowledge and lithium levels that were more stable and within the higher end of the recommended therapeutic range.

Conclusions:

Studies evaluating lithium patient education and its effect on improving the safe use of lithium are limited. Nevertheless, this literature review highlights that lithium patient education is critical to promote its safe use.

An update on adjunctive treatment options for bipolar disorder

OBJECTIVES

Bipolar disorder is a complex illness often requiring combinations of therapies to successfully treat symptoms. In recent years, there have been significant advancements in a number of therapies for bipolar disorder. It is therefore timely to provide an overview of current adjunctive therapeutic options to help treating clinicians to inform their patients and work towards optimal outcomes.

METHODS

Publications were identified from PubMed searches on bipolar disorder and pharmacotherapy, nutraceuticals, hormone therapy, psychoeducation, interpersonal and social rhythm therapy, cognitive remediation, mindfulness, e-Health and brain stimulation techniques. Relevant articles in these areas were selected for further review. This paper provides a narrative review of adjunctive treatment options and is not a systematic review of the literature.

RESULTS

A number of pharmacotherapeutic, psychological and neuromodulation treatment options are available. These have varying efficacy but all have shown benefit to people with bipolar disorder. Due to the complex nature of treating the disorder, combination treatments are often required. Adjunctive treatments to traditional pharmacological and psychological therapies are proving useful in closing the gap between initial symptom remission and full functional recovery.

CONCLUSIONS

Given that response to monotherapy is often inadequate, combination regimens for bipolar disorder are typical. Correspondingly, psychiatric research is working towards a better understanding of the disorder's underlying biology. Therefore, treatment options are changing and adjunctive therapies are being increasingly recognized as providing significant tools to improve patient outcomes. Towards this end, this paper provides an overview of novel treatments that may improve clinical outcomes for people with bipolar disorder.

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.

Is a SIMPLe smartphone application capable of improving biological rhythms in bipolar disorder?

BACKGROUND

Biological rhythms (BR) disturbance has been suggested as a potential mediator of mood episodes in Bipolar Disorder (BD). The Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN) was designed as an assessment tool to evaluate BR domains comprehensively. In the context of a trial evaluating a smartphone application delivering personalized psychoeducational contents for BD (SIMPLe 1.0), the main aim of this study is to evaluate the potential impact of SIMPLe 1.0 in BR regulation using the BRIAN scale.

METHODS

51 remitted BD patients were asked to use the application for 3 months. Paired t-test analyses were employed to compare baseline and follow-up BRIAN´s total and domains scores. The sample was divided into completers and non-completers of the study to evaluate differences between groups regarding BRIAN scores using ANCOVA analyses.

RESULTS

The BRIAN's mean total score of the whole sample significantly decreased from baseline to post-intervention (35.89 (SD 6.64) vs. 31.18 (SD 6.33), t = 4.29, p = 0.001). At post-intervention, there was a significant difference between groups regarding the total BRIAN mean score (29.47 (SD 6.21) completers vs. 35.92 (SD 3.90) non-completers, t = 2.50, p = 0.02). This difference was maintained after conducting a one-way ANCOVA controlling for pre-intervention BRIAN scores, F (1, 46) = 10.545, p=0.002.

LIMITATIONS

A limited sample, pre-post measures, and a short study timeframe could have affected the results. Additional factors affecting BR, such as medication, could not be ruled out.

CONCLUSION

Our results suggest that there are potential positive effects of a psychoeducational smartphone application as an adjunctive to treatment as usual on BD patients' BR.

Does the "Silver Bullet" Lose its Shine Over the Time? Assessment of Loss of Lithium Response in a Preliminary Sample of Bipolar Disorder Outpatients

Background:

Though often perceived as a “silver bullet” treatment for bipolar disorder (BD), lithium has seldom reported to lose its efficacy over the time.

Objective:

The aim of the present study was to assess cases of refractoriness toward restarted lithium in BD patients who failed to preserve maintenance.

Method:

Treatment trajectories associated with re-instituted lithium following loss of achieved lithium-based maintenance in BD were retrospectively reviewed for 37 BD-I patients (median age 52 years; F:M=17:20 or 46% of the total) over an 8.1-month period on average.

Results:

In our sample only 4 cases (roughly 11% of the total, of whom F:M=2:2) developed refractoriness towards lithium after its discontinuation. Thirty-three controls (F:M=15:18) maintained lithium response at the time of re-institution. No statistically significant difference between cases and controls was observed with respect to a number of demographic and clinical features but for time spent before first trial ever with lithium in life (8.5 vs. 3 years; U=24.5, Z=-2.048, p=.041) and length of lithium discontinuation until new therapeutic attempt (5.5 vs. 2 years; U=8, Z=-2.927, p=.003) between cases vs. controls respectively. Tapering off of lithium was significantly faster among cases vs. controls (1 vs. 7 days; U=22, Z=-2.187), though both subgroups had worrisome high rates of poor adherence overall.

Conclusion:

Although intrinsic limitations of the present preliminary assessment hamper the validity and generalizability of overall results, stating the clinical relevance of the topic further prospective research is warranted. The eventual occurrence of lithium refractoriness may indeed be associated with peculiar course trajectories and therapeutic outcomes ultimately urging the prescribing clinicians to put efforts in preserving maintenance of BD in the absence of any conclusive research insight on the matter.

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.

Psychoeducation and online mood tracking for patients with bipolar disorder: A randomised controlled trial

BACKGROUND

Psychoeducation is an effective adjunct to medications in bipolar disorder (BD). Brief psychoeducational approaches have been shown to improve early identification of relapse. However, the optimal method of delivery of psychoeducation remains uncertain. Here, our objective was to compare a short therapist-facilitated vs. self-directed psychoeducational intervention for BD.

METHODS

BD outpatients who were receiving medication-based treatment were randomly assigned to 5 psychoeducation sessions administered by a therapist (Facilitated Integrated Mood Management; FIMM; n=60), or self-administered psychoeducation (Manualized Integrated Mood Management; MIMM; n=61). Follow-up was based on patients' weekly responses to an electronic mood monitoring programme over 12 months.

RESULTS

Over follow-up, there were no group differences in weekly self-rated depression symptoms or relapse/readmission rates. However, knowledge of BD (assessed with the Oxford Bipolar Knowledge questionnaire (OBQ)) was greater in the FIMM than the MIMM group at 3 months. Greater illness knowledge at 3 months was related to a higher proportion of weeks well over 12 months.

LIMITATIONS

Features of the trial may have reduced the sensitivity to our psychoeducation approach, including that BD participants had been previously engaged in self-monitoring.

CONCLUSIONS

Improved OBQ score, while accelerated by a short course of therapist-administered psychoeducation (FIMM), was seen after both treatments. It was associated with better outcome assessed as weeks well. When developing and testing a new psychosocial intervention, studies should consider proximal outcomes (e.g., acquired knowledge) and their short-term impact on illness course in bipolar disorder.

Improving medication adherence in bipolar disorder: A systematic review and meta-analysis of 30 years of intervention trials

BACKGROUND

Medication non-adherence in bipolar disorder is a significant problem resulting in increased morbidity, hospitalisation and suicide. Interventions to enhance adherence exist but it is not clear how effective they are, or what works and why.

METHODS

We systematically searched bibliographic databases for RCTs of interventions to support adherence to medication in bipolar disorder. Study selection and data extraction was performed by two investigators. Data was extracted on intervention design and delivery, study characteristics, adherence outcomes and study quality. The meta-analysis used pooled odds ratios for adherence using random effects models.

RESULTS

Searches identified 795 studies, of which 24 met the inclusion criteria, 18 provided sufficient data for meta-analysis. The pooled OR was 2.27 (95% CI 1.45-3.56) equivalent to a two-fold increase in the odds of adherence in the intervention group relative to control. Smaller effects were seen where the control group consisted of an active comparison and with increasing intervention length. The effects were robust across other factors of intervention and study design and delivery.

LIMITATIONS

Many studies did not report sufficient information to classify intervention design and delivery or judge quality and the interventions were highly variable. Therefore, the scope of moderation analysis was limited.

CONCLUSIONS

Even brief interventions can improve medication adherence. Limitations in intervention and study design and reporting prevented assessment of which elements of adherence support are most effective. Applying published guidance and quality criteria for designing and reporting adherence interventions is a priority to inform the implementation of cost-effective adherence support.

Management of bipolar disorders in women by nonpharmacological methods

Several reasons justify the need for nonpharmacological interventions for bipolar disorder (BD) in women. This review focuses on psychosocial therapies for BDs in women. The research evidence for a wide range of psychosocial interventions for the management of BDs in women has been presented. All the interventions have some common components like targeting disease management, information regarding illness, and coping skills. There also are distinctive features like cognitive restructuring and self-rated mood charts in cognitive behavior therapy, regulation of sleep/wake cycles and daily routines in interpersonal sleep regulation therapy, and communication skill training in family treatments. Many psychosocial interventions hold promise as adjunctive therapies for bipolar patients. In India, there is a considerable dearth of literature in this area due lack of skilled staff for psychosocial interventions. Future trials need to: Clarify which populations are most likely to benefit from which strategies; identify putative mechanisms of action; systematically evaluate costs, benefits, and generalizability of effects, and record adverse effects.

Psychoeducation for relapse prevention in bipolar disorder: a systematic review of efficacy in randomized controlled trials

OBJECTIVES

Previous reviews have concluded that interventions including psychoeducation are effective in preventing relapse in bipolar disorder, but the efficacy of psychoeducation itself has not been systematically reviewed. Our aim was to evaluate the efficacy of psychoeducation for bipolar disorder in preventing relapse and other outcomes, and to identify factors that relate to clinical outcomes.

METHODS

We employed the systematic review of randomized controlled trials of psychoeducation in participants with bipolar disorder not in an acute illness episode, compared with treatment-as-usual, and placebo or active interventions. Pooled odds ratios (ORs) for non-relapse into any episode, mania/hypomania, and depression were calculated using an intent-to-treat (ITT) analysis, assigning dropouts to relapse, with a sensitivity analysis in which dropouts were assigned to non-relapse (optimistic ITT).

RESULTS

Sixteen studies were included, eight of which provided data on relapse. Although heterogeneity in the data warrants caution, psychoeducation appeared to be effective in preventing any relapse [n = 7; OR: 1.98-2.75; number needed to treat (NNT): 5-7, depending on the method of analysis] and manic/hypomanic relapse (n = 8; OR: 1.68-2.52; NNT: 6-8), but not depressive relapse. Group, but not individually, delivered interventions were effective against both poles of relapse; the duration of follow-up and hours of therapy explained some of the heterogeneity. Psychoeducation improved medication adherence and short-term knowledge about medication. No consistent effects on mood symptoms, quality of life, or functioning were found.

CONCLUSIONS

Group psychoeducation appears to be effective in preventing relapse in bipolar disorder, with less evidence for individually delivered interventions. Better understanding of mediating mechanisms is needed to optimize efficacy and personalize treatment.

Psychosocial treatment and interventions for bipolar disorder: a systematic review

BACKGROUND

Bipolar disorder (BD) is a chronic disorder with a high relapse rate, significant general disability and burden and with a psychosocial impairment that often persists despite pharmacotherapy. This indicates the need for effective and affordable adjunctive psychosocial interventions, tailored to the individual patient. Several psychotherapeutic techniques have tried to fill this gap, but which intervention is suitable for each patient remains unknown and it depends on the phase of the illness.

METHODS

The papers were located with searches in PubMed/MEDLINE through May 1st 2015 with a combination of key words. The review followed the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.

RESULTS

The search returned 7,332 papers; after the deletion of duplicates, 6,124 remained and eventually 78 were included for the analysis. The literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and only in a selected subgroup of patients at an early stage of the disease who have very good, if not complete remission, of the acute episode. Cognitive-behavioural therapy and interpersonal and social rhythms therapy could have some beneficial effect during the acute phase, but more data are needed. Mindfulness interventions could only decrease anxiety, while interventions to improve neurocognition seem to be rather ineffective. Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes.

CONCLUSION

The current review suggests that the literature supports the usefulness only of specific psychosocial interventions targeting specific aspects of BD in selected subgroups of patients.

Psychosocial interventions in bipolar disorder: what, for whom, and when

BACKGROUND

Bipolar disorder (BD) is a chronic condition with a high relapse rate, morbidity and psychosocial impairment that often persist despite pharmacotherapy, highlighting the need for adjunctive psychosocial treatments. It is still unclear which populations are most likely to benefit from which approach and the best timing to implement them.

METHODS

A review was conducted with the aim to determine what the efficacious psychological treatments are, for whom and when. Randomized-controlled trials and key studies in adults with BD published until June 2013 were included

RESULTS

The adjunctive psychological treatments most commonly tested in BD were cognitive-behavioral therapy, psychoeducation, interpersonal and social rhythm therapy, and family intervention. The efficacy of specific adjunctive psychosocial interventions has been proven not only in short- but also long-term follow-up for some treatments. Outcomes vary between studies, with most trials focused on clinical variables like recurrence prevention or symptom reduction and less attention, although gradually expanding, paid to other aspects such as psychosocial functioning. The samples were usually in remission or with mild symptoms when recruited but there were a few studies with acute patients, which resulted in discrepant findings. The efficacy of psychological interventions seems to differ depending on the characteristics of the subjects and the course of the illness. Different approaches, such as functional remediation and mindfulness-based cognitive therapy, have begun to be tested in BD.

LIMITATIONS

Heterogeneity of comparison groups.

CONCLUSIONS

Adjunctive psychological treatments can improve BD outcomes. Although several moderators and mediators have been identified, more research is needed to design shorter but effective interventions tailored to the characteristics of the target population. Ideally, the treatment should be introduced as soon as possible, although it does not mean that more complex patients would not benefit from psychotherapy.

Purpose and effectiveness of psychoeducation in patients with bipolar disorder in a bipolar clinic setting

OBJECTIVE

This article reviews psychological therapies in the treatment of bipolar disorder, in particular psychoeducation, and how the inclusion of four fundamental principles - patient/therapist communication, flow of information, patient involvement and a trusting relationship - can improve patient outcomes.

METHOD

The content of this article is based on the proceedings of a 1-day standalone symposium in November 2011 exploring how to establish a bipolar clinic within the context of existing services in the UK's National Health Service.

RESULTS

Certain psychological interventions have emerged as beneficial add-on treatments to pharmacotherapy in bipolar disorder and are associated with greater stabilisation of symptoms, fewer relapses and longer time to relapse. Psychoeducation is a simple approach to support prevention of future episodes by delivering behavioural training to improve illness insight, early symptom identification and development of coping strategies. Empowering patients to actively participate in their treatment provides independence, counteracts the current disconnect of therapist and patient, and increases awareness and understanding of the challenges of living with and treating bipolar disorder.

CONCLUSION

Psychoeducation enables patients to understand bipolar disorder, get actively involved in therapy planning, and be aware of methods for episode prevention, therefore effectively contributing to improved treatment outcomes and patient quality of life.

The prognostic role of perceived criticism, medication adherence and family knowledge in bipolar disorders

BACKGROUND

In schizophrenia, high levels of critical comments by significant others are associated with early relapse, especially if medication adherence is sub-optimal. Levels of criticism may be influenced by family knowledge about both the disorder and its treatment. No study has explored whether this combination factors influence outcome in adults with bipolar disorders.

METHODS

Medication adherence was assessed in 81 individuals with bipolar disorder of whom 75 rated perceived criticism by an identified 'significant other' as well as their own perceived sensitivity. 33 (of the 75) had a close family member who agreed to completed an assessment of their knowledge and understanding of bipolar disorders. Psychiatric admissions were then recorded prospectively over 12 months.

RESULTS

Perceived criticism and medication adherence were significant predictors of admission. In the patient-family member dyads (n=33), the odds ratio (OR) for admission was 3.3 (95% confidence intervals 1.3-8.6) in individuals with low levels of medication adherence, high perceived criticism, and a family member with poor knowledge and understanding.

LIMITATIONS

The small sub-sample of patient-family member dyads means those findings require replication. Sensitivity to criticism by professional caregivers may not equate to that by relatives.

CONCLUSIONS

Perceived criticism may be a simple but robust clinical predictor of relapse in mood disorders. High levels of perceived criticism, poor understanding of bipolar disorder by a significant other, and sub-optimal treatment adherence are risk factors for hospitalization in adults with bipolar disorders that are potentially modifiable through the use of strategic psychosocial interventions.

La psychoéducation pour les troubles bipolaires : recension des écrits et recommandations pour le système de santé québécois

Le trouble bipolaire est une maladie chronique caractérisée par une récurrence des rechutes thymiques, et par des symptômes résiduels interférant avec le fonctionnement de l’individu. La pharmacothérapie demeure la pierre angulaire du traitement. Malheureusement, la médication a des effets limités sur certains aspects de la maladie, sans compter qu’une grande proportion de patients présente des problèmes d’observance à leur traitement pharmacologique. Cette recension des écrits aborde le rôle de la psychoéducation comme traitement complémentaire dans la prise en charge des patients bipolaires. Les différentes modalités de psychoéducation structurée, dont deux programmes psychoéducatifs manualisés appuyés par des données probantes, sont présentées. Dans une perspective de transfert des connaissances, des recommandations pour l’implantation de la psychoéducation dans le système de santé québécois sont proposées.

Efficacy of pharmacotherapy in bipolar disorder: a report by the WPA section on pharmacopsychiatry

The current statement is a systematic review of the available data concerning the efficacy of medication treatment of bipolar disorder (BP). A systematic MEDLINE search was made concerning the treatment of BP (RCTs) with the names of treatment options as keywords. The search was updated on 10 March 2012. The literature suggests that lithium, first and second generation antipsychotics and valproate and carbamazepine are efficacious in the treatment of acute mania. Quetiapine and the olanzapine-fluoxetine combination are also efficacious for treating bipolar depression. Antidepressants should only be used in combination with an antimanic agent, because they can induce switching to mania/hypomania/mixed states/rapid cycling when utilized as monotherapy. Lithium, olanzapine, quetiapine and aripiprazole are efficacious during the maintenance phase. Lamotrigine is efficacious in the prevention of depression, and it remains to be clarified whether it is also efficacious for mania. There is some evidence on the efficacy of psychosocial interventions as an adjunctive treatment to medication. Electroconvulsive therapy is an option for refractory patients. In acute manic patients who are partial responders to lithium/valproate/carbamazepine, adding an antipsychotic is a reasonable choice. The combination with best data in acute bipolar depression is lithium plus lamotrigine. Patients stabilized on combination treatment might do worse if shifted to monotherapy during maintenance, and patients could benefit with add-on treatment with olanzapine, valproate, an antidepressant, or lamotrigine, depending on the index acute phase. A variety of treatment options for BP are available today, but still unmet needs are huge. Combination therapy may improve the treatment outcome but it also carries more side-effect burden. Further research is necessary as well as the development of better guidelines and algorithms for the step-by-step rational treatment.

Effectiveness of six-week psychoeducation program on adherence of patients with bipolar affective disorder

OBJECTIVES

This study examined the effectiveness of a six week psychoeducation program on the adherence of patients with Bipolar Affective Disorder.

METHOD

An experimental study was conducted at a mood disorder outpatient clinic in Zonguldak, Turkiye. Participants were randomly assigned to either intervention (n=35) or control groups (n=36). Both groups were given pre-tests and post-tests to measure their adherence. In the psychoeducation group, the psychoeducation program was provided for 2 h/week for six weeks. In the control group, standard care and information were provided.

RESULTS

After six weeks, the psychoeducation program significantly improved patients' adherence. The treatment adherence rate of the patients in the intervention group increased from 40.0% (14 patients on pre-test), to 86.7% (26 patients on post-test). Meanwhile, the treatment adherence rate of the control group was 38.9% (14 patients) for the pre-test, and 24.2% (8 patients) for the post-test.

CONCLUSION

This controlled trial study demonstrated that a six-week psychoeducation program can be a useful intervention to improve adherence in patients undergoing bipolar affective disorder rehabilitation. More comprehensive mental health outcomes need to be undertaken. Further studies exploring a longer term follow-up are also required.

Effectiveness of interventions to improve medication adherence in bipolar disorder

OBJECTIVE

To identify interventions that improve medication adherence in bipolar disorder.

METHOD

A review of the literature from 2004 to 2011 was conducted using Medline and manual searching.

RESULTS

Eleven studies were identified as meeting inclusion criteria. Five studies demonstrated improved medication adherence. No characteristics of the interventions, clinical characteristics of the groups or methodological factors distinguished those psychosocial interventions that demonstrated improvement from those that did not.

CONCLUSIONS

While only a few interventions improved adherence, most improved clinical outcomes. Issues were also identified about the way in which adherence is defined. It is proposed that incorporating patient preferences into measures of adherence within the context of a disorder-specific psychosocial intervention may provide an approach that demonstrates both improved adherence and improved clinical outcomes. However this requires further research.

Which psychosocial interventions in bipolar depression?

This review of psychosocial interventions in bipolar disorders demonstrates that some therapies, when combined with medication, are more efficacious at preventing or delaying depressive relapse, and can be more effective than medication alone in reducing time to recovery from an acute bipolar depressive episode. However, apparent benefits diminish over time, suggesting that maintenance or « booster » therapy sessions may be needed. Given the scarcity of trained therapists, further studies are needed to determine which bipolar depressed patients should be targeted and to establish more clearly the potential cost and benefits of such interventions.

Refractoriness in bipolar disorder: definitions and evidence-based treatment

Defining refractoriness in bipolar disorder is complex and should concern and include either every phase and pole or the disorder as a whole. The data on the treatment of refractory bipolar patients are sparse. Combination and add-on studies suggest that in acutely manic patients partial responders to lithium, valproate, or carbamazepine, a good strategy would be to add haloperidol, risperidone, olanzapine, quetiapine, or aripiprazole. Adding oxcarbazepine to lithium is also a choice. There are no reliable data concerning the treatment of refractory bipolar depressives and also there is no compelling data for the maintenance treatment of refractory patients. It seems that patients stabilized on combination treatment might do worse if shifted from combination. Conclusively there are only limited and sometimes confusing data on the treatment of refractory bipolar patients. Further focused research is necessary on this group of patients.

Keeping therapies simple: psychoeducation in the prevention of relapse in affective disorders

Psychological interventions for mood disorders can be divided into 'skilled' and 'simple'. Psychoeducation belongs to the latter group: a simple and illness-focused therapy with prophylactic efficacy in all major mood disorders. Successful implementation of psychoeducation requires a proper setting, including open-door policy, team effort and empowerment of the therapeutic alliance.

REVIEW: Patient, treatment, and systems-level factors in bipolar disorder nonadherence: A summary of the literature

This is a review of adherence determinants in bipolar disorder based on published prospective studies. Patient, treatment, and systems-level adherence determinants are summarized. The review concludes with recommendations on approaches that may minimize nonadherence. MEDLINE, PsychINFO, and the Cochrane Database were searched using key terms of adherence, compliance, or persistence, combined with terms of bipolar disorder, bipolar depression, or mania. Publications were filtered for randomized clinical trials (RCTs). Due to low yields of RCTs, we additionally included prospective nonrandomized clinical and epidemiologic studies, and prospective studies of severe mental illness that had a focus on adherence as an outcome and reported data separately for bipolar disorder. A targeted review of the broader bipolar literature provided background for concluding remarks. Twenty-two publications were identified describing RCTs with a specific population of bipolar disorder and a measure of adherence. Additional prospective nonrandomized studies were also identified. Studies identified three major categories of factors important to adherence: patient, treatment, and systems-associated factors. Patient factors include selected demographic features, symptom severity and phase of illness, presence of past suicide attempts, psychiatric comorbidity, illness and treatment duration, and relationship with providers. Treatment factors include type and intensity of pharmacotherapy and psychotherapy. Systems-level factors include differential levels of care access and costs. There is an overall lack of RCTs, and few prospective studies, on patient and systems-related determinants of adherence. Treatment-related determinants of adherence have the most evidence to date; however, would benefit from larger studies with diverse populations. Careful assessment of treatment adherence (including partial adherence) should be included in all prospective bipolar treatment studies, and studies should be conducted to prospectively evaluate interventions to minimize nonadherence.

Effects of recurrence on the cognitive performance of patients with bipolar I disorder: implications for relapse prevention and treatment adherence

OBJECTIVE

To determine if the repeated occurrence of manic episodes in bipolar I disorder (BD-I) patients is associated with reduced cognitive performance, which could in turn imply a worsening in the disorder's evolution.

METHOD

Cognitive performance in euthymic patients was assessed using attention, memory, and executive function tests on 24 BD-I patients who had experienced only 1 manic episode, on 27 BD-I patients with 2 manic episodes, on 47 BD-I patients with 3 or more manic episodes, and on 66 healthy control subjects.

RESULTS

In BD-I patients, number of manic episodes was positively associated with poorer performance on neurocognitive tests, an association that was not accounted for by depression, disease chronicity, onset, or medication. Significant differences in attention and executive function were found between patients and controls and in those patients who had had just 1 manic episode compared to those who had 3 or more.

CONCLUSION

The number of manic episodes predicted poor cognitive performance, suggesting that the recurrence of mania may have a long-term neuropsychological impact. Prospective follow-up studies need to be completed to explore this effect further as better treatment adherence may have a protective effect on neurocognitive function.

Enhancing medication adherence in patients with bipolar disorder

OBJECTIVES

Medication adherence contributes to the efficacy-effectiveness gap of treatment in patients with bipolar disorder. This paper aims to examine the challenges involved in improving medication adherence in bipolar disorder, and to extract some suggestions for future directions from the core psychosocial studies that have targeted adherence as a primary or secondary outcome.

METHODS

A search was conducted for articles that focused on medication adherence in bipolar disorder, with emphasis on publications from 1996 to 2008 using Medline, Web of Science, CINAHL PLUS, and PsychINFO. The following key words were used: adherence, compliance, alliance, adherence assessment, adherence measurement, risk factors, psychosocial interventions, and psycho-education.

RESULTS

There are a number of challenges to understanding non-adherence including the difficulty in defining and measuring it and the various risk factors that need to be considered when aiming to enhance adherence. Nevertheless, the importance of addressing adherence is evidenced by the connection between adherence problems and poor outcome. Despite these challenges, a number of small psychosocial studies targeting adherence as a primary outcome point to the potential usefulness of psycho-education aimed at improving knowledge, attitudes, and adherence behavior, but more large scale randomized controlled trials are needed in this area. Evidence of improved outcomes from larger randomized controlled trials of psychosocial interventions that target medication adherence as a secondary outcome suggests that tackling other factors besides medication adherence may also be an advantage. While some of these larger studies demonstrate an improvement in medication adherence, the translation of these interventions into real life settings may not always be practical. A person centered approach that considers risk factors for non-adherence and barriers to other health behaviors may assist with the development of more targeted briefer interventions. Integral to improving medication adherence is the delivery of psycho-education, and attention needs to be paid to the implementation, and timing of psycho-education. Progress in the understanding of how medicines work may add to the credibility of psycho-education in the future.

CONCLUSIONS

Enhancement of treatment adherence in bipolar patients is a necessary and promising management component as an adjunct to pharmacotherapy. The current literature on psychosocial interventions that target medication adherence in bipolar disorder points to the possibility of refining the concept of non-adherence and adapting psycho-education to the needs of certain subgroups of people with bipolar disorder. Large scale randomized controlled trials of briefer or more condensed interventions are needed that can inform clinical practice.

Adherence according to Mary Poppins: strategies to make the medicine go down

PURPOSE

This article reviews the prevalence, risk factors, and burden of nonadherence in mood and psychotic disorders, and presents evidence-based, disease-specific strategies shown to improve adherence.

CONCLUSION

A comprehensive approach based on the goal of remission, designed around the patient's individual needs, facilitates adherence, leads to improved quality of life, and reduces disease burden.

PRACTICE IMPLICATIONS

Adherence in mood and psychotic disorders can be improved when providers take time to build trusting relationships; identify risk factors; anticipate nonadherence; individualize treatment; and educate patients, families, and other healthcare providers.

A critical update on psychological interventions for bipolar disorders

Although pharmacotherapy is the mainstay of treatment for bipolar disorder, the combination of evidence-based psychological interventions and drug treatment enhances overall effectiveness, mostly by further protecting patients from relapse/recurrence. In recent years, well-designed controlled studies have added weight to evidence favoring specific psychotherapy modalities for bipolar disorders. However, critical issues that may limit the benefits of psychotherapy in day-to-day clinical practice have emerged. In this article, we critically examine the effectiveness of psychosocial approaches to bipolar illness by reviewing the literature, which has been substantially enriched during the past 5 years. Recent studies further support the fact that psychoeducation and cognitive-behavioral therapy are effective in bipolar disorder, especially the early stages. Family interventions based on a psychoeducational model are also effective. Intensive psychotherapies may be more effective than short, managed care-based ones. Group psychoeducation seems to have long-lasting effects and to be cost-effective. Future studies should focus on neurobiological markers of response to psychotherapy and tailor interventions to specific subtypes.

The Bipolar Interactive Psychoeducation (BIPED) study: trial design and protocol

BACKGROUND

Bipolar disorders affect between 3-5% of the population and are associated with considerable lifelong impairment. Since much of the morbidity associated with bipolar disorder is caused by recurrent depressive symptoms, which are often only poorly responsive to antidepressants, there is a need to develop alternative, non-pharmacological interventions. Psychoeducational interventions have emerged as promising long-term therapeutic options for bipolar disorder.

METHODS/DESIGN

The study is an exploratory, individually randomised controlled trial. The intervention known as 'Beating Bipolar' is a psychoeducational programme which is delivered via a novel web-based system. We will recruit 100 patients with a diagnosis of DSM-IV bipolar disorder (including type I and type II) currently in clinical remission. The primary outcome is quality of life. This will be compared for those patients who have participated in the psychoeducational programme with those who received treatment as usual. Quality of life will be assessed immediately following the intervention as well as 10 months after randomisation. Secondary outcomes include current depressive and manic symptoms, number of episodes of depression and mania/hypomania experienced during the follow-up period, global functioning, functional impairment and insight. An assessment of costs and a process evaluation will also be conducted which will explore the feasibility and acceptability of the intervention as well as potential barriers to effectiveness.

DISCUSSION

Bipolar disorder is common, under-recognised and often poorly managed. It is a chronic, life-long, relapsing condition which has an enormous impact on the individual and the economy. This trial will be the first to explore the effectiveness of a novel web-based psychoeducational intervention for patients with bipolar disorder which has potential to be easily rolled out to patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN81375447.

Preventing mania: a preliminary examination of the GOALS Program

There is strong evidence of a relationship between goal dysregulation and mania. Building on these findings, we examined the feasibility of developing a mania prevention treatment program designed to improve goal regulation skills for those with bipolar disorder. Here, we describe the process of developing a manual, delivering the intervention to a series of cases, and then conducting a small open uncontrolled trial. All participants met diagnostic criteria for bipolar I disorder based on the Structured Clinical Interview for DSM-IV and were not currently experiencing episodes of depression or mania. Ten participants (8 female, mean age = 46.7 years) were enrolled in the GOALS program and completed an average of 13.2 weekly sessions. Participants were administered the Bech-Rafaelson Mania Scale (BRMS) and the Modified Hamilton Rating Scale for Depression at baseline and termination. Some participants completed self-report scales including the Altman Self-Rating Mania Scale, the Beck Depression Inventory, and the Willingly Approached Set of Statistically Unrealistic Pursuits at baseline and termination. In addition, participants were administered a consumer satisfaction questionnaire at termination. At termination, all 10 participants found the program highly relevant and helpful. Most importantly, even though levels of mania were low initially, mean levels of manic symptoms on the BRMS decreased significantly from baseline to termination, and all 10 participants were within a healthy range (BRMS <7) at termination. Although the lack of control group or follow-up data limits this study, preliminary evidence suggests that it is feasible to identify treatment targets by drawing from the basic research literature in bipolar disorder. Findings await replication and more careful testing within a randomized controlled trial.

Psychosocial treatments for bipolar disorder: cost-effectiveness, mediating mechanisms, and future directions

OBJECTIVES

Randomized trials of adjunctive psychotherapy for bipolar disorder are reviewed, in tandem with discussion of cost-effectiveness, mediating mechanisms, and moderators of effects.

METHODS

Systematic searches of the MEDLINE and PSYCHLIT databases yielded 19 randomized controlled trials of individual family and group therapies. Outcome variables included time to recovery, relapse or recurrence, symptom severity, medication adherence, and psychosocial functioning.

RESULTS

Meta-analyses consistently show that disorder-specific psychotherapies [cognitive-behavioral therapy (CBT), interpersonal, family, and group] augment mood stabilizers in reducing rates of relapse (OR = 0.57; 95% CI: 0.39-0.82) over 1-2 years. Specific mediating mechanisms include, but are not limited to, increasing medication adherence, teaching self-monitoring and early intervention with emergent episodes, and enhancing interpersonal functioning and family communication. All therapies have strengths and weaknesses. One group psychoeducation trial, demonstrated effect sizes for recurrence that are at least equivalent to individual therapies, but findings await replication. Family interventions have been successfully administered in both single and multi-family formats, but no studies report the comparative cost-effectiveness of these formats. The best-studied psychotherapy modality, CBT, can have beneficial effects on depression, but findings are inconsistent across studies and vary with sample characteristics and comparison treatments.

CONCLUSIONS

Adjunctive psychotherapies can be cost-effective when weighed against observed reductions in recurrence, hospitalization and functional impairments. Future trials need to (i) clarify which populations are most likely to benefit from which strategies; (ii) identify putative mechanisms of action; (iii) systematically evaluate costs, benefits, and generalizability; and (iv) record adverse effects. The application of psychosocial interventions to young-onset populations deserves further study.

Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial

BACKGROUND

The long-term efficacy of psychological interventions for bipolar disorders has not been tested.

AIMS

This study assessed the efficacy of group psychoeducation to prevent recurrences and to reduce time spent ill for people with bipolar disorders.

METHOD

A randomised controlled trial with masked outcome assessment comparing group psychoeducation and non-structured group intervention during 5-year follow-up. One hundred and twenty people with bipolar disorders were included in the study and 99 completed 5-year follow-up. Time to any recurrence, number of recurrences, total number of days spent ill, frequency and length of hospitalisations were the main outcome measures.

RESULTS

At the 5-year follow-up, time to any recurrence was longer for the psychoeducation group (log rank=9.953, P<0.002). The psychoeducation group had fewer recurrences (3.86 v. 8.37, F=23.6, P<0.0001) of any type and they spent less time acutely ill (154 v. 586 days, F=31.66, P=0.0001). The median number of days of hospitalisation per hospitalised participant was also lower for the psychoeducation group (45 v. 30, F=4.26, P=0.047).

CONCLUSIONS

Six-month group psychoeducation has long-lasting prophylactic effects in individuals with bipolar disorders. Group psychoeducation is the first psychological intervention showing such a long-term maintained efficacy in people with bipolar disorders.

Enhanced relapse prevention for bipolar disorder: a qualitative investigation of value perceived for service users and care coordinators

Background

Enhanced relapse prevention (ERP) is a psychological intervention delivered by mental health professionals to help individuals with bipolar disorder (BD) recognise and manage early warning signs for mania and depression. ERP has an emerging evidence base and is recommended as good practice for mental health professionals. However, without highly perceived value to both those receiving (services users) or delivering it (health professionals), implementation will not occur. The aim of this study is to determine what values of ERP are perceived by service users (SUs) and mental health professionals (care coordinators, CCs) providing community case management.

Methods

A nested qualitative study design was employed as part of a randomised controlled trial of ERP. Semi-structured interviews were conducted with a purposive sub-sample of 21 CCs and 21 SUs, and an iterative approach used to develop a framework of conceptual categories that was applied systematically to the data.

Results

The process of implementing and receiving ERP was valued by both SUs and CCs for three similar sets of reasons: improved understanding of BD (where a knowledge deficit of BD was perceived), enhanced working relationships, and improved ways of managing the condition. There were some differences in the implications these had for both CCs and SUs who also held some reservations.

Conclusion

CCs and SUs perceive similar value in early warning signs interventions to prevent relapse, and these have particular benefits to them. If this perceived value is maintained, CCs and SUs in routine practice may use ERP long-term.

Psychotherapeutic intervention and suicide risk reduction in bipolar disorder: a review of the evidence

BACKGROUND

25-50% of bipolar patients attempt suicide at least once in their lifetime and completed suicide in this population is about 1% annually, about 60 times the rate of the general population. Psychotherapy may be an effective adjunctive option in preventing suicide in bipolar patients. It has been suggested that interpersonal, cognitive and behavioural techniques may be effective in controlling mood shifts, increasing compliance with pharmacotherapy, and maintaining morale in the face of therapeutic adversity and incomplete response. The aim of our study was to systematically review the literature concerning the efficacy of psychosocial interventions in reducing the risk for attempting or committing suicide.

METHODS

We searched MEDLINE with the combination of the key words 'psychotherapy' or 'psychoeducation' or 'cognitive therapy' or 'behavio(u)ral therapy', 'cognitive-behavio(u)ral' or 'family therapy' or 'social rhythm' or 'rhythm' with 'suicide' and 'bipolar', limited to English language papers published between 1990 and January 2008. Papers were selected based on the criterium that they provided definite data on the role of psychotherapy in suicide prevention, and specifically in bipolar disorder.

RESULTS

Our search returned 481 references, of which 17 were selected based on the above criteria. The selected papers were classified according to the area of suicide prevention they were dealing with as 1. Psychosocial and demographic factors, 2. Psychological profile and 3. Efficacy of psychotherapies.

DISCUSSION

Our paper summarizes specific features and correlates of suicide in bipolar patients and possible targets of psychosocial intervention in the prevention of suicide in bipolar patients. Although studies researching the effect of psychosocial interventions on suicidal behaviour are virtually non-existent, hard data concerning the effectiveness of psychosocial interventions in bipolar disorder are emerging, but still suffer from methodological drawbacks.

Adjunctive psychotherapy for bipolar disorder: state of the evidence

OBJECTIVE

Psychotherapy has long been recommended as adjunctive to pharmacotherapy for bipolar disorder, but it is unclear which interventions are effective for which patients, over what intervals, and for what domains of outcome. This article reviews randomized trials of adjunctive psychotherapy for bipolar disorder.

METHOD

Eighteen trials of individual and group psychoeducation, systematic care, family therapy, interpersonal therapy, and cognitive-behavioral therapy are described. Relevant outcome variables include time to recovery, recurrence, duration of episodes, symptom severity, and psychosocial functioning.

RESULTS

The effects of the treatment modalities varied according to the clinical condition of patients at the time of random assignment and the polarity of symptoms at follow-up. Family therapy, interpersonal therapy, and systematic care appeared to be most effective in preventing recurrences when initiated after an acute episode, whereas cognitive-behavioral therapy and group psychoeducation appeared to be most effective when initiated during a period of recovery. Individual psychoeducational and systematic care programs were more effective for manic than depressive symptoms, whereas family therapy and cognitive-behavioral therapy were more effective for depressive than manic symptoms.

CONCLUSIONS

Adjunctive psychotherapy enhances the symptomatic and functional outcomes of bipolar disorder over 2-year periods. The various modalities differ in content, structure, and associated mediating mechanisms. Treatments that emphasize medication adherence and early recognition of mood symptoms have stronger effects on mania, whereas treatments that emphasize cognitive and interpersonal coping strategies have stronger effects on depression. The placement of psychotherapy within chronic care algorithms and its role as a preventative agent in the early stages of the disorder deserve investigation.

Tendencies Toward Mania and Tendencies Toward Depression Have Distinct Motivational, Affective, and Cognitive Correlates

Debate has emerged in the literature on mania, with some evidence suggesting that tendencies toward mania relate to negative emotional and cognitive styles, and other evidence suggesting that tendencies toward mania relate to positive emotional and cognitive styles. An initial study examined how tendencies toward mania (as measured by the Hypomanic Personality Scale) and tendencies toward depression (as measured by the Inventory to Diagnose Depression-Lifetime version) were related to diverse measures pertaining to incentive and threat motivations, negative and positive emotionality, and cognitive responses to emotion, among 238 undergraduates. Tendencies toward mania related to a self-reported pattern of reacting intensely to positive stimuli, both cognitively and emotionally, as well as lower sensitivity to threatening stimuli and less restraint over impulses. In contrast, tendencies toward depression related to a pattern of reacting more strongly to negative stimuli emotionally and cognitively, as well as deficits in the ability to savor positive affect. This pattern was re-confirmed in a second sample of 394 undergraduates, who completed many of the same measures plus a measure of current mood symptoms. This second sample confirmed that the pattern was not mood-state dependent. Implications for future research and clinical work are discussed, including an intriguing conceptual parallel in the distinct sets of correlates of depressive versus manic tendencies.

The contemporary face of bipolar illness: complex diagnostic and therapeutic challenges

Manic depression, or bipolar disorder, is a multifaceted illness with an inevitably complex treatment. The current article summarizes the current status of our knowledge and practice concerning its diagnosis and treatment. While the prototypic clinical picture concerns the "classic" bipolar disorder, today mixed episodes with incomplete recovery and significant psychosocial impairment are more frequent. The clinical picture of these mixed episodes is variable, eludes contemporary classification systems, and possibly includes a constellation of mental syndromes currently classified elsewhere. Treatment includes the careful combination of lithium, antiepileptics, atypical antipsychotics, and antidepressants, but not all of the agents in these broad categories are effective for the treatment of bipolar disorder.

Development of the treatment attitudes questionnaire in bipolar disorder

Despite the success of pharmacotherapy in the management of bipolar disorder, as many as one-half of those in treatment discontinue their medication over time. Currently, no self-report measure is available that predicts treatment engagement in bipolar disorder. The goal of the current study was to develop a measure of awareness of symptoms and attitudes toward treatment among those with bipolar disorder. Sixty-six participants diagnosed with bipolar I disorder on the SCID completed the Treatment Attitudes Questionnaire (TAQ) and were then followed for up to 2 years to assess symptom levels. Medication data were available for 37 participants. Analyses of the TAQ were conducted to examine reliability, predictors of subscales, and how well scores predicted medication and symptom levels over time. Results indicate that previous episodes of depression, but not episodes of mania, correlated with increased scores on the Insight and the Enjoyment of Mania subscales. Scores on the Nonbiological Attributions subscale predicted lower levels of lithium as well as increased depressive symptoms over time. Although the current study includes limited measurement of treatment engagement and a small sample size, this easily administered scale may help treatment planning for those with bipolar disorder.

Improving treatment adherence in bipolar disorder: a review of current psychosocial treatment efficacy and recommendations for future treatment development

Treatment adherence is a frequent problem in bipolar disorder, with research showing that more than 60% of bipolar patients are at least partially nonadherent to medications. Treatment nonadherence is consistently predictive of a number of negative outcomes in bipolar samples, and the discontinuation of mood stabilizers places these patients at high risk for relapse. Several types of adjunctive treatment (family, psychoeducational, cognitive-behavioral) have been investigated for improving symptoms and functioning in bipolar patients with some success. To date, less attention has been paid to developing treatments specifically to promote treatment adherence to and engagement with pharmacological as well as behavioral treatments in patients with bipolar disorder. First, we review the effects of adjunctive interventions specifically on treatment adherence outcomes in 14 published clinical trials. Based on this empirical knowledge base, we present a preliminary description of the treatment strategies that appear most promising for improving adherence. The article also provides research recommendations for developing more effective interventions for the purpose of improving bipolar treatment adherence. Finally, special treatment considerations, including the potential impact of comorbid substance abuse and bipolar depression, are discussed.

Psychosocial interventions as adjunctive therapy for bipolar disorder

Evidence suggests that adjunctive psychosocial interventions in bipolar disorder are clinically beneficial and cost effective when used in conjunction with pharmacotherapy. Appropriate adjunctive psychosocial interventions in bipolar disorder have been found to be associated with improved treatment adherence, greater stability, fewer hospitalizations, fewer days hospitalized, less need for crisis interventions, decreased relapse risk, and fewer acute episodes. Specific types of therapy that have shown efficacy include bipolar-specific cognitive-behavioral therapy, family-focused therapy, interpersonal and social rhythm therapy, and systematic care management. A positive impact on medication adherence is a major goal of these adjunctive treatments. Studies show variable efficacy depending on patient characteristics, phase of illness, and presence of comorbid conditions so that therapies should be selected and administered on an individualized basis that takes into account each specific patient's current presentation and treatment history. For example, psychosocial interventions have been found to be more effective in patients with depressive than manic symptoms and during maintenance treatment. Given findings showing benefits of psychosocial interventions in the treatment of bipolar disorder, the STAndards for BipoLar Excellence (STABLE) project has developed and tested a performance measure to evaluate the use of this critical treatment component.

Lithium in mood disorders: increasing evidence base, declining use?

Use of lithium for the treatment of bipolar disorder may be declining even as knowledge of the efficacy and side-effects of lithium has increased. Recent meta-analyses confirm the benefits of maintenance lithium treatment and show that it reduces suicide and suicidality. Psychiatrists should continue to utilise this efficacious treatment for bipolar disorder.