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Adjunctive psychotherapy benefits outpatients with bipolar disorder

JAMA Psychiatry
Reuters Health - 22/10/2020 - People with bipolar disorder benefit from certain forms of psychotherapy, particularly skills-based interventions, combined with medication, a systematic review and meta-analysis suggests.

Researchers examined data from 39 randomized clinical trials with a total of 3,863 participants with bipolar disorder who received pharmacotherapy along with usual care or in combination with interventions such as cognitive behavioral therapy, family or conjoint therapy, interpersonal therapy, or psychoeducational therapy. The primary endpoint was illness recurrence, while secondary outcomes included depressive and manic symptoms at 12 months.

Across 20 two-group trials, individuals who received manualized treatments were less likely to experience recurrence (odds ratio 0.56) than control patients who didn't receive psychotherapy.

In addition, patients who received psychoeducation with guided practice for illness management in group or family formats had lower recurrence rates (OR 0.12) than those who received individual psychoeducation. Participants were also less likely to drop out of studies when they received family or group psychoeducation (OR 0.46) or went through brief psychoeducation (OR 0.44) than with standard psychoeducation.

"Bipolar patients benefit from learning strategies for managing depressive or manic episodes, marked by changes in mood, thinking, sleep, and behavior - they need to be able to recognize when they're starting to develop early warning signs of new mood episodes," said lead study author David Miklowitz, a professor of psychiatry and biobehavioral sciences at the David Geffen School of Medicine at the University of California, Los Angeles.

These patients also benefit when their family members or close friends learn to recognize when these early warning signs of recurrence are happening, Miklowitz said by email.

"A family needs a relapse prevention plan - a list of strategies for the patient, relatives, and the patient's doctors to follow if he or she is cycling into an episode," Miklowitz said. "Also, families need to be able to provide a protective health environment for the bipolar person by communicating clearly, keeping conflict to a minimum, and helping him/her regulate sleep/wake cycles."

The study also found that compared with standard treatment only, adjunctive cognitive behavioral therapy (standard mean difference -0.32), interpersonal therapy (SMD -0.46), and family or group therapy (SMD -0.46) were associated with stabilizing symptoms.

One limitation of the analysis is that researchers lacked data to examine the effect of different interventions based on illness severity, the study team notes in JAMA Psychiatry. It wouldn't be ethical or feasible, for example to include patients with severe bipolar disorder.

Even so, the results offer some insight into which elements of psychotherapy interventions might be most effective, said Danella Hafeman, an assistant professor of psychiatry at the University of Pittsburgh Medical Center who coauthored an editorial accompanying the study.

"It seems that psychoeducation is most effective for reducing recurrence, cognitive restructuring is among the most helpful strategies for treating depression, and maintaining regular daily rhythms is effective for addressing mania," Hafeman, who wasn't involved in the study, said by email. "These ideas are consistent with previous literature and important clinically, in terms of evidence-based approaches that can be used to address particular aspects of illness."

By Lisa Rapaport

SOURCE: https://bit.ly/34jnZT6 and https://bit.ly/37yx0di JAMA Psychiatry, online October 14, 2020.

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