Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention - a systematic review.

OBJECTIVES: Despite some encouraging outcomes and shared components of psychological therapies specific to bipolar disorders, not all studies found conclusively that the addition of a psychosocial intervention to pharmacological interventions improves outcomes. There was some tentative evidence from post hoc analyses that patients with more than 12 previous episodes did not benefit from psychoeducation or cognitive therapy. This paper presents a systematic review and meta-analysis which examines the overall efficacy of bipolar disorder-specific psychological therapies and the impact of the number of previous episodes on the efficacy of psychological therapies in relapse prevention. METHODS: Systematic literature searches of electronic databases and reference lists of existing reviews were carried out. The number of participants experiencing relapse in randomized, controlled studies was combined in a meta-analysis to determine the overall treatment effect in relapse prevention. Metaregression modeling was used to examine whether the number of previous episodes confounded the number of relapses experienced by participants by the end of treatment. RESULTS: Meta-analysis of relapse calculated an overall relative risk of 0.74 [95% confidence interval (CI): 0.64-0.85] with some heterogeneity present (I(2) = 43.3%). Metaregression of six studies showed no relationship between number of episodes and number of relapses by endpoint. CONCLUSION: Psychological therapy specifically designed for bipolar disorder is effective in preventing or delaying relapses in bipolar disorders, and there is no clear evidence that the number of previous episodes moderated the effect.

Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years.

OBJECTIVE: In a previous randomized controlled study, the authors reported significant beneficial effects of cognitive therapy for relapse prevention in bipolar disorder patients up to 1 year. This study reports additional 18-month follow-up data and presents an overview of the effect of therapy over 30 months. METHOD: Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent relapses were randomly assigned into a cognitive therapy plus medication group or a control condition of medication only. Independent raters, who were blind to patient group status, assessed patients at 6-month intervals. RESULTS: Over 30 months, the cognitive therapy group had significantly better outcome in terms of time to relapse. However, the effect of relapse prevention was mainly in the first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to 189) in bipolar episodes out of a total of 900 for the whole 30 months and 54 fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the last 18 months. Multivariate analyses of variance showed that over the last 18 months, the cognitive therapy group exhibited significantly better mood ratings, social functioning, coping with bipolar prodromes, and dysfunctional goal attainment cognition. CONCLUSIONS: Patients in the cognitive therapy group had significantly fewer days in bipolar episodes after the effect of medication compliance was controlled. However, the results showed that cognitive therapy had no significant effect in relapse reduction over the last 18 months of the study period. Further studies should explore the effect of booster sessions or maintenance therapy.

A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year.

BACKGROUND: Despite the use of mood stabilizers, a significant proportion of patients with bipolar affective disorder experience frequent relapses. A pilot study of cognitive therapy (CT) specifically designed to prevent relapses for bipolar affective disorder showed encouraging results when used in conjunction with mood stabilizers. This article reports the outcome of a randomized controlled study of CT to help prevent relapses and promote social functioning. METHODS: We randomized 103 patients with bipolar 1 disorder according to the DSM-IV, who experienced frequent relapses despite the prescription of commonly used mood stabilizers, into a CT group or control group. Both the control and CT groups received mood stabilizers and regular psychiatric follow-up. In addition, the CT group received an average of 14 sessions of CT during the first 6 months and 2 booster sessions in the second 6 months. RESULTS: During the 12-month period, the CT group had significantly fewer bipolar episodes, days in a bipolar episode, and number of admissions for this type of episode. The CT group also had significantly higher social functioning. During these 12 months, the CT group showed less mood symptoms on the monthly mood questionnaires. Furthermore, there was significantly less fluctuation in manic symptoms in the CT group. The CT group also coped better with manic prodromes at 12 months. CONCLUSION: Our findings support the conclusion that CT specifically designed for relapse prevention in bipolar affective disorder is a useful tool in conjunction with mood stabilizers.

Ruminative and mindful self-focused processing modes and their impact on problem solving in dysphoric individuals.

A mindful experiential rather than an analytical ruminative mode of information processing is beneficial in depression. However studies have not taken into account people's trait mindfulness or trait rumination. This study aimed to examine the effects of state and trait analytical rumination and experiential mindfulness on affect and social problem solving (SPS). Participants filled in the trait mindfulness and trait rumination questionnaires. After mood induction, dysphoric participants with and without a history of depression were assessed for SPS and affect before and after induction of mindful (experiential) or ruminative (analytic) processing modes. Results showed trait mindfulness was negatively correlated with the BDI and trait rumination was positively correlated with the BDI. There was no significant difference between groups after the induced experiential mindful or analytical ruminative processing modes. However, participants who scored high on trait rumination showed significant improvement in SPS after induced mindfulness processing. No such effect was found on trait mindfulness. These findings suggest a useful way to prevent high trait ruminators from developing depressive symptoms or depression. Experiential mindful processing may help reduce the risk of developing depressive symptoms by increasing social problem solving ability in those with low mood and high levels of trait rumination.

Cost-effectiveness of relapse-prevention cognitive therapy for bipolar disorder: 30-month study.

BACKGROUND: We have reported the advantageous clinical outcome of adding cognitive therapy to medication in the prevention of relapse of bipolar disorder. AIMS: This 30-month study compares the cost-effectiveness of cognitive therapy with standard care. METHOD: We randomly allocated 103 individuals with bipolar 1 disorder to standard treatment and cognitive therapy plus standard treatment. Service use and costs were measured at 3-month intervals and cost-effectiveness was assessed using the net-benefit approach. RESULTS: The group receiving cognitive therapy had significantly better clinical outcomes. The extra costs were offset by reduced service use elsewhere. The probability of cognitive therapy being cost-effective was high and robust to different therapy prices. CONCLUSIONS: Combination of cognitive therapy and mood stabilizers was superior to mood stabilizers alone in terms of clinical outcome and cost-effectiveness for those with frequent relapses of bipolar disorder.