Therapy plus medication better than medication alone in bipolar disorder

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A review of 39 randomised clinical trials by scientists from University of California – Los Angeles Health Sciences and their colleagues from other institutions has found that combining the use medication with psycho-educational therapy is more effective at preventing a recurrence of illness in people with bipolar disorder than medication alone.

For the paper, researchers analysed studies that included adult and adolescent patients currently receiving medication for bipolar disorder who were randomly assigned to either an active family, individual or group therapy, or "usual care," meaning medication with routine monitoring and support from a psychiatrist.

Dr David Miklowitz, the study's lead author, and a distinguished professor of psychiatry at the Jane and Terry Semel Institute for Neuroscience and Human Behaviour at UCLA, said the studies reviewed followed patients for at least a year, measured rates of recurrence of bipolar disorder, depression and mania symptoms, and included study attrition or dropout rates.

The findings were:
Psycho-education with guided practice of illness management skills (for example, how to keep regular sleep and wake cycles) in a family or group format was more effective in reducing recurrences of mania and depressive symptoms than the same strategies in an individual therapy format.

Cognitive behavioural therapy, family therapy and interpersonal therapy were better at stabilising depressive symptoms than other forms of treatment.

Rates of dropout were lower in patients who received family-oriented therapies.

Of the findings, Miklowitz said they point to the importance of having a support system.
"Not everyone may agree with me, but I think the family environment is very important in terms of whether somebody stays well," he said. "There's nothing like having a person who knows how to recognise when you're getting ill and can say, 'you're starting to look depressed or you're starting to get ramped up.' That person can remind their loved one to take their medications or stay on a regular sleep-wake cycle or contact the psychiatrist for a medication evaluation."

Miklowitz said the same is true for a patient who may not have close relatives but does have support through group therapy.

"If you're in group therapy, other members of that group may be able to help you recognize that you're experiencing symptoms," he said. "People tend to pair off. It's a little bit like the AA model of having a sponsor."

Importance: Several psychotherapy protocols have been evaluated as adjuncts to pharmacotherapy for patients with bipolar disorder, but little is known about their comparative effectiveness.
Objective: To use systematic review and network meta-analysis to compare the association of using manualized psychotherapies and therapy components with reducing recurrences and stabilizing symptoms in patients with bipolar disorder.
Data Sources: Major bibliographic databases (MEDLINE, PsychInfo, and Cochrane Library of Systematic Reviews) and trial registries were searched from inception to June 1, 2019, for randomized clinical trials of psychotherapy for bipolar disorder.
Study Selection: Of 3255 abstracts, 39 randomized clinical trials were identified that compared pharmacotherapy plus manualized psychotherapy (cognitive behavioral therapy, family or conjoint therapy, interpersonal therapy, or psychoeducational therapy) with pharmacotherapy plus a control intervention (eg, supportive therapy or treatment as usual) for patients with bipolar disorder.
Data Extraction and Synthesis: Binary outcomes (recurrence and study retention) were compared across treatments using odds ratios (ORs). For depression or mania severity scores, data were pooled and compared across treatments using standardized mean differences (SMDs) (Hedges-adjusted g using weighted pooled SDs). In component network meta-analyses, the incremental effectiveness of 13 specific therapy components was examined.
Main Outcomes and Measures: The primary outcome was illness recurrence. Secondary outcomes were depressive and manic symptoms at 12 months and acceptability of treatment (study retention).
Results: A total of 39 randomized clinical trials with 3863 participants (2247 of 3693 [60.8%] with data on sex were female; mean [SD] age, 36.5 [8.2] years) were identified. Across 20 two-group trials that provided usable information, manualized treatments were associated with lower recurrence rates than control treatments (OR, 0.56; 95% CI, 0.43-0.74). Psychoeducation with guided practice of illness management skills in a family or group format was associated with reducing recurrences vs the same strategies in an individual format (OR, 0.12; 95% CI, 0.02-0.94). Cognitive behavioral therapy (SMD, −0.32; 95% CI, −0.64 to −0.01) and, with less certainty, family or conjoint therapy (SMD, −0.46; 95% CI, −1.01 to 0.08) and interpersonal therapy (SMD, –0.46; 95% CI, −1.07 to 0.15) were associated with stabilizing depressive symptoms compared with treatment as usual. Higher study retention was associated with family or conjoint therapy (OR, 0.46; 95% CI, 0.26-0.82) and brief psychoeducation (OR, 0.44; 95% CI, 0.23-0.85) compared with standard psychoeducation.
Conclusions and Relevance: This study suggests that outpatients with bipolar disorder may benefit from skills-based psychosocial interventions combined with pharmacotherapy. Conclusions are tempered by heterogeneity in populations, treatment duration, and follow-up.

David J Miklowitz, Orestis Efthimiou, Toshi A Furukawa, Jan Scott, Ross McLaren, John R Geddes, Andrea Cipriani


University of California – Los Angeles Health Sciences material


JAMA Psychiatry abstract

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