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.

Psychosocial interventions for bipolar disorder and coping style modification: similar clinical outcomes, similar mechanisms?

OBJECTIVE: To investigate changes in the use of coping styles in response to early symptoms of mania in cognitive-behavioural therapy (CBT), compared with psychoeducation, for bipolar disorder. METHOD: Data were drawn from a randomized controlled trial comparing CBT and psychoeducation. A subsample of 119 participants completed the Coping Inventory for the Prodromes of Mania and symptom assessments before treatment and 72 weeks later. RESULTS: Both CBT and psychoeducation were associated with similar improvements in symptom burden. Both treatments also produced equivalent improvements in stimulation reduction and problem-directed coping styles, but no statistically significant change on the endorsement of help-seeking behaviours. A treatment interaction showed that a reduction in denial and blame was present only in the CBT treatment condition. CONCLUSIONS: CBT and psychoeducation have similar impacts on coping styles for the prodromes of mania. The exception to this is denial and blame, which is positively impacted only by CBT but which does not translate into improved outcome. Given the similar change in coping styles and mood burden, teaching patients about how to cope in adaptive ways with the symptoms of mania may be a shared mechanism of change for CBT and psychoeducation. CLINICAL TRIAL REGISTRATION NUMBER: NCT00188838.

Objectif : Rechercher les changements d'utilisation des styles d'adaptation en réponse aux premiers symptômes de manie dans la thérapie cognitivo-comportementale (TCC), comparativement à la psychoéducation, pour le trouble bipolaire. Méthode : Les données ont été tirées d'un essai randomisé contrôlé comparant la TCC avec la psychoéducation. Un sous-échantillon de 119 participants a rempli l'inventaire d'adaptation aux prodromes de manie et les évaluations de symptômes avant le traitement, et 72 semaines plus tard. Résultats : La TCC et la psychoéducation étaient associées à des améliorations semblables du fardeau des symptômes. Les deux traitements produisaient aussi des améliorations équivalentes de la réduction de stimulation et des styles d'adaptation axée sur les problèmes, mais aucun changement statistiquement significatif de l'acceptation de comportements de recherche d'aide. Une interaction des traitements a montré qu'une réduction du déni et du blâme n'était présente que dans le traitement par TCC. Conclusions : La TCC et la psychoéducation ont des effets semblables sur les styles d'adaptation pour les prodromes de la manie. Font exception le déni et le blâme, qui ne répondent positivement qu'à la TCC, ce qui ne se traduit pas par un meilleur résultat. Étant donné le changement semblable des styles d'adaptation et du fardeau de l'humeur, enseigner aux patients comment adopter des moyens de s'adapter aux symptômes de manie peut être un mécanisme de changement partagé par la TCC et la psychoéducation. Numéro d'enregistrement de l'essai clinique : NCT00188838.

Association of psychotherapy with disability benefit claim closure among patients disabled due to depression.

BACKGROUND: Depression is the most frequent reason for receiving disability benefits in North America, and treatment with psychotherapy is often funded by private insurers. No studies have explored the association between the provision of psychotherapy for depression and time to claim closure. METHODS: Using administrative data from a Canadian disability insurer, we evaluated the association between the provision of psychotherapy and short-term disability (STD) and long-term disability (LTD) claim closure by performing Cox proportional hazards regression. RESULTS: We analyzed 10,508 STD and 10,338 LTD claims for depression. In our adjusted analyses, receipt of psychotherapy was associated with longer time to STD closure (HR [99% CI] = 0.81 [0.68 to 0.97]) and faster LTD claim closure (1.42 [1.33 to 1.52]). In both STD and LTD, older age (0.90 [0.88 to 0.92] and 0.83 [0.80 to 0.85]), per decade), a primary diagnosis of recurrent depression versus non-recurrent major depression (0.78 [0.69 to 0.87] and 0.80 [0.72 to 0.89]), a psychological secondary diagnosis (0.90 [0.84 to 0.97] and 0.66 [0.61 to 0.71]), or a non-psychological secondary diagnosis (0.81 [0.73 to 0.90] and 0.77 [0.71 to 0.83]) versus no secondary diagnosis, and an administrative services only policy ([0.94 [0.88 to 1.00] and 0.87 [0.75 to 0.996]) or refund policy (0.86 [0.80 to 0.92] and 0.73 [0.68 to 0.78]) compared to non-refund policy claims were independently associated with longer time to claim closure [corrected]. CONCLUSIONS: We found, paradoxically, that receipt of psychotherapy was independently associated with longer time to STD claim closure and faster LTD claim closure in patients with depression. We also found multiple factors that were predictive of time to both STD and LTD claim closure. Our study has limitations, and well-designed prospective studies are needed to establish the effect of psychotherapy on disabling depression.

Effectiveness of cognitive behavioral therapy for depression in patients receiving disability benefits: a systematic review and individual patient data meta-analysis.

OBJECTIVES: To systematically summarize the randomized trial evidence regarding the relative effectiveness of cognitive behavioural therapy (CBT) in patients with depression in receipt of disability benefits in comparison to those not receiving disability benefits. DATA SOURCES: All relevant RCTs from a database of randomized controlled and comparative studies examining the effects of psychotherapy for adult depression (http://www.evidencebasedpsychotherapies.org), electronic databases (MEDLINE, EMBASE, PSYCINFO, AMED, CINAHL and CENTRAL) to June 2011, and bibliographies of all relevant articles. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTION: Adult patients with major depression, randomly assigned to CBT versus minimal/no treatment or care-as-usual. STUDY APPRAISAL AND SYNTHESIS METHODS: Three teams of reviewers, independently and in duplicate, completed title and abstract screening, full text review and data extraction. We performed an individual patient data meta-analysis to summarize data. RESULTS: Of 92 eligible trials, 70 provided author contact information; of these 56 (80%) were successfully contacted to establish if they captured receipt of benefits as a baseline characteristic; 8 recorded benefit status, and 3 enrolled some patients in receipt of benefits, of which 2 provided individual patient data. Including both patients receiving and not receiving disability benefits, 2 trials (227 patients) suggested a possible reduction in depression with CBT, as measured by the Beck Depression Inventory, mean difference [MD] (95% confidence interval [CI]) = -2.61 (-5.28, 0.07), p = 0.06; minimally important difference of 5. The effect appeared larger, though not significantly, in those in receipt of benefits (34 patients) versus not receiving benefits (193 patients); MD (95% CI) = -4.46 (-12.21, 3.30), p = 0.26. CONCLUSIONS: Our data does not support the hypothesis that CBT has smaller effects in depressed patients receiving disability benefits versus other patients. Given that the confidence interval is wide, a decreased effect is still possible, though if the difference exists, it is likely to be small.

A randomized controlled trial of psychoeducation or cognitive-behavioral therapy in bipolar disorder: a Canadian Network for Mood and Anxiety treatments (CANMAT) study [CME].

OBJECTIVE: Bipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder. METHOD: This single-blind randomized controlled trial was conducted between June 2002 and September 2006. A total of 204 participants (ages 18-64 years) with DSM-IV bipolar disorder type I or II participated from 4 Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of cognitive-behavioral therapy or 6 sessions of group psychoeducation. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week. RESULTS: Both treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Eight percent of subjects dropped out prior to receiving psychoeducation, while 64% were treatment completers; rates were similar for cognitive-behavioral therapy (6% and 66%, respectively). Psychoeducation cost $180 per subject compared to cognitive-behavioral therapy at $1,200 per subject. CONCLUSIONS: Despite longer treatment duration and individualized treatment, cognitive-behavioral therapy did not show a significantly greater clinical benefit compared to group psychoeducation. Psychoeducation is less expensive to provide and requires less clinician training to deliver, suggesting its comparative attractiveness. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00188838.

Changes in self-schema structure in cognitive therapy for major depressive disorder: a randomized clinical trial.

Negative cognitive structure (particularly for interpersonal content) has been shown in some research to persist past a current episode of depression and potentially to be a stable marker of vulnerability for depression (D. J. A. Dozois, 2007; D. J. A. Dozois & K. S. Dobson, 2001a). Given that cognitive therapy (CT) is highly effective for treating the acute phase of a depressive episode and that this treatment also reduces the risk of relapse and recurrence, it is possible that CT may alter these stable cognitive structures. In the current study, patients were randomly assigned to CT+ pharmacotherapy (n = 21) or to pharmacotherapy alone (n = 21). Both groups evidenced significant and similar reductions in level of depression (as measured with the Beck Depression Inventory-II and the Hamilton Rating Scale for Depression), as well as automatic thoughts and dysfunctional attitudes. However, group differences were found on cognitive organization in favor of individuals who received the combination of CT+ pharmacotherapy. The implications of these results for understanding mechanisms of change in therapy and the prophylactic nature of CT are discussed.

Psychological intervention for premenstrual syndrome: a meta-analysis of randomized controlled trials.

BACKGROUND: We conducted a systematic review and meta-analysis to determine the efficacy of psychological interventions for premenstrual syndrome. METHODS: We systematically searched and selected studies that enrolled women with premenstrual syndrome in which investigators randomly assigned them to a psychological intervention or to a control intervention. Trials were included irrespective of their outcomes and, when possible, we conducted meta-analyses. RESULTS: Nine randomized trials, of which 5 tested cognitive behavioural therapy, contributed data to the meta-analyses. Low quality evidence (design and implementation weaknesses of the studies, possible reporting bias) suggests that cognitive behavioural therapy significantly reduces both anxiety (effect size [ES] = -0.58; 95% confidence interval [CI] = -1.15 to -0.01; number needed to treat [NNT] = 5), and depression (ES = -0.55; 95% CI = -1.05 to -0.05; NNT = 5), and also suggests a possible beneficial effect on behavioural changes (ES = -0.70; 95% CI = -1.29 to -0.10; NNT = 4) and interference of symptoms on daily living (ES = -0.78; 95% CI = -1.53 to -0.03; NNT = 4). Results provide much more limited support for monitoring as a form of therapy and suggest the ineffectiveness of education. CONCLUSIONS: Low quality evidence from randomized trials suggests that cognitive behavioural therapy may have important beneficial effects in managing symptoms associated with premenstrual syndrome.