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Psychotherapy for Bipolar II Disorder: The Role of Interpersonal and Social Rhythm Therapy
Abstract
Although bipolar II disorder is a highly prevalent, chronic illness that is associated with burdensome psychosocial impairment, relatively little is known about the best ways to treat the disorder. Moreover, psychosocial interventions for the management of bipolar II disorder have been largely unexplored, leaving psychologists with few evidence-based recommendations for best treatment practices. In this article, we provide information about interpersonal and social rhythm therapy (IPSRT), an empirically supported treatment for bipolar I disorder that has preliminary evidence supporting its efficacy in bipolar II disorder. After reviewing the phenomenology of bipolar II disorder and differentiating it from bipolar I disorder, we summarize the extant empirical support for using psychotherapy in the management of bipolar II disorder. We explore what is known about the role of psychotherapy in the management of bipolar II disorder as well as lacunae in the evidence base. Next, we introduce IPSRT and discuss how it has been adapted for use as a treatment for individuals suffering from bipolar II disorder. Specific strategies of the treatment are detailed, and preliminary evidence for the efficacy of IPSRT in bipolar II disorder is described. Finally, we present a case vignette demonstrating the use of IPSRT for an individual with bipolar II disorder.
... Notably, poorer health-related quality of life [2] and a higher risk of completed suicides [3] have been observed in patients with BD-II. These concerning features may be because of the significant depressive burden characterizing the condition, including persistent subsyndromal depression, poorer return to baseline psychosocial functioning between episodes [4][5][6], and mixed depressive states that are experienced as highly dysphoric [7]. Despite the best available treatments, depression relapse rates remain high [8,9] and are more frequent in patients with BD-II [10]. ...
... An average of 18 check-ins (SD 10.5; range 3-42) were completed, giving a check-in response rate of 42.9%. The average number of days participants completed check-ins across the study period was 12.4 (SD 5.6; range [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. Time to complete check-in items ranged from 1 to 3 minutes. ...
Background:
Bipolar II disorder (BD-II) is associated with significant burden, disability, and mortality; however, there continues to be a dearth of evidence-based psychological interventions for this condition. Technology-mediated interventions incorporating self-management have untapped potential to help meet this need as an adjunct to usual clinical care.
Objective:
The objective of this pilot study is to assess the feasibility, acceptability, and clinical utility of a novel intervention for BD-II (Tailored Recovery-oriented Intervention for Bipolar II Experiences; TRIBE), in which mindfulness-based psychological content is delivered via an integrated web and smartphone platform. The focus of the study is evaluation of the dynamic use patterns emerging from ecological momentary assessment and intervention to assist the real-world application of mindfulness skills learned from web-delivered modules.
Methods:
An open trial design using pretest and posttest assessments with nested qualitative evaluation was used. Individuals (aged 18-65 years) with a diagnosis of BD-II were recruited worldwide and invited to use a prototype of the TRIBE intervention over a 3-week period. Data were collected via web-based questionnaires and phone interviews at baseline and 3-week follow-up.
Results:
A total of 25 participants completed baseline and follow-up assessments. Adherence rates (daily app use) were 65.6% across the 3-week study, with up to 88% (22/25) of participants using the app synergistically alongside the web-based program. Despite technical challenges with the prototype intervention (from user, hardware, and software standpoints), acceptability was adequate, and most participants rated the intervention positively in terms of concept (companion app with website: 19/25, 76%), content (19/25, 76%), and credibility and utility in supporting their management of bipolar disorder (17/25, 68%). Evaluation using behavioral archetypes identified important use pathways and a provisional model to inform platform refinement. As hypothesized, depression scores significantly decreased after the intervention (Montgomery-Asberg Depression Rating Scale baseline mean 8.60, SD 6.86, vs follow-up mean 6.16, SD 5.11; t24=2.63; P=.01; Cohen d=0.53, 95% CI 0.52-4.36).
Conclusions:
Our findings suggest that TRIBE is feasible and represents an appropriate and acceptable self-management program for patients with BD-II. Preliminary efficacy results are promising and support full development of TRIBE informed by the present behavioral archetype analysis. Modifications suggested by the pilot study include increasing the duration of the intervention and increasing technical support.
... Typically, IPSRT was administered concurrently with pharmacotherapy, but in trials focusing on bipolar II disorder (BDII), it was administered alone. [158][159][160] The studies examined IPSRT both as an acute and a maintenance treatment most commonly for bipolar depression; two articles addressed maintenance efficacy for both manic and depressive relapse. ...
... 25 Indirect evidence (superiority trials that show similar outcomes for two active treatments) suggests that IPSRT is comparable to active treatments such as quetiapine and specialist care for acute bipolar depression. [157][158][159] While receiving support from one RCT, the acute antimanic efficacy of IPSRT requires further evaluation. Overall, these trials indicate that IPSRT is a viable therapy for the acute treatment of bipolar depression and for the prevention of bipolar mood episodes, although more studies are needed to replicate these initial promising findings. ...
Aims:
To systematically review the literature on the efficacy and tolerability of the major chronotherapeutic treatments of bipolar disorders (BD) - bright light therapy (LT), dark therapy (DT), treatments utilizing sleep deprivation (SD), melatonergic agonists (MA), interpersonal social rhythm therapy (IPSRT) and cognitive behavioral therapy adapted for BD (CBTI-BP) - and propose treatment recommendations based on a synthesis of the evidence.
Methods:
PRISMA-based systematic review of the literature.
Results:
The acute antidepressant (AD) efficacy of LT was supported by several open-label studies, 3 randomized controlled trials (RCTs), and 1 pseudorandomized controlled trial. SD showed rapid, acute AD response rates of 43.9%, 59.3% and 59.4% in 8 case series, 11 uncontrolled, studies, and 1 RCT respectively. Adjunctive DT obtained significant, rapid anti-manic results in one RCT and one controlled study. The 7 studies on MA yielded very limited data on acute antidepressant activity, conflicting evidence of both antimanic and maintenance efficacy, and support from two case series of improved sleep in both acute and euthymic states. IPSRT monotherapy for bipolar II depression had acute response rates of 41%, 67% and 67.4% in two open studies and one RCT, respectively; as adjunctive therapy for bipolar depression in one RCT, and efficacy in reducing relapse in 2 RCTs. Among euthymic BD subjects with insomnia, a single RCT found CBTI-BP effective in delaying manic relapse and improving sleep. Chronotherapies were generally safe and well-tolerated.
Conclusions:
The outcome literature on the adjunctive use of chronotherapeutic treatments for BP is variable, with evidence bases that differ in size, study quality, level of evidence, and non-standardized treatment protocols. Evidence-informed practice recommendations are offered.
... IPSRT monotherapy should be considered when individuals prefer, or need, a nonpharmacological modality. IPSRT has been modified for bipolar II disorder (38), with changes that include increased attention to the following: rationale for making changes to social rhythms, identification of mood states, regulation of levels of stimulation, management of grandiosity, addressing emotional dysregulation, and treating comorbid substance use. ...
... Salience of psychotherapies may improve if modified to meet the needs of those with bipolar II disorder. Investigators have specifically attended to this issue when testing IPSRT for patients with bipolar II disorder (38), and those who examined group psychoeducation for patients with bipolar II disorder made similar recommendations for its modification (19,23). We endorse this approach to meet the needs of those with bipolar II disorder. ...
Bipolar II disorder causes significant suffering among patients and their families, some of which may be alleviated by psychotherapy alone or as an adjunct to pharmacotherapy. Psychotherapies may be more effective if modified to meet the specific needs of patients with bipolar II disorder.
... Thus, adjunctive psychosocial interventions are increasingly employed for bipolar disorder. Adjunct psychosocial interventions have been shown to improve outcomes in bipolar disorder because they teach patients strategies to manage their mood instability (Miklowitz, 2008;Swartz et al., 2012b). Evidence supporting the utility of psychotherapy to reduce the risk of relapse (as opposed to relieving acute affective episodes) in people with bipolar disorder has been particularly robust (Miklowitz, 2008). ...
... The remaining psychotherapiesinterpersonal and social rhythm therapy, dialectical behavior therapy, and mindfulnessbased cognitive therapyhave been the focus of fewer randomized, controlled trials. Recent data did not find that IPSRT was superior to control conditions (Inder et al., 2015;Swartz et al., 2012b), but earlier data not reviewed here has suggested that IPSRT may be helpful for bipolar disorder (Frank, 2007;Frank et al., 2005Frank et al., , 2007. ...
Objectives:
Bipolar disorder requires psychiatric medications, but even guideline-concordant treatment fails to bring many patients to remission or keep them euthymic. To address this gap, researchers have developed adjunctive psychotherapies. The purpose of this paper is to critically review the evidence for the efficacy of manualized psychosocial interventions for bipolar disorder.
Methods:
We conducted a search of the literature to examine recent (2007-present), randomized controlled studies of the following psychotherapy interventions for bipolar disorder: psychoeducation (PE), cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), and family therapies such as family focused therapy (FFT).
Results:
All of the psychotherapy interventions appear to be effective in reducing depressive symptoms. Psychoeducation and CBT are associated with increased time to mood episode relapse or recurrence. MBCT has demonstrated a particular effectiveness in improving depressive and anxiety symptoms. Online psychotherapy interventions, programs combining one or more psychotherapy interventions, and targeted interventions centering on particular symptoms have been the focus of recent, randomized controlled studies in bipolar disorder.
Conclusions:
Psychotherapy interventions for the treatment of bipolar disorder have substantial evidence for efficacy. The next challenge will to disseminate these psychotherapies into the community.
... Although phenomenologically distinct, bipolar disorder II (BPII) has proven particularly difficult to differentiate from UD as both are characterized by recurrent episodes of major depression, and DSM-IV defined criteria for depressive episodes are identical across these two disorders (American Psychiatric Association, 1994). As most patients with BP II present for treatment when depressed rather than hypomanic, it is not surprising that it is difficult to differentiate cross-sectionally between BPII and UD (Swartz et al., 2012b). This issue has important clinical implications as treatments for the two disorders differ, and treatments used for UD may exacerbate the course of illness in BP disorders resulting in increased risk of manic switch or cycle acceleration (Bowden, 2005;Newport et al., 2012;Perlis et al., 2010). ...
... Some studies have shown that up to 40% of patients with recurrent depressive episodes may in fact suffer from BPII (Berk and Dodd, 2005). Misdiagnosis may occur because patients do not complain about hypomania as it is experienced as egosyntonic or pleasurable (Swartz et al., 2012b). It may also occur because clinicians do not adequately probe for prior histories of hypomania as reliability of diagnosis can improve up to 16% with strategies that directly target enhanced recall of hypomanic episodes (Benazzi, 2003). ...
Background:
Bipolar disorder II (BPII) and unipolar depression (UD) are both characterized by episodes of major depression (MDE), however DSM-IV criteria for MDE are identical, regardless of diagnosis. As a result, misdiagnosis of BP II and UD is common, leading to inappropriate treatment. Because women are twice as likely as men to experience MDE, differentiating UD from BP II in the context of depression is especially important for women. We examined symptoms and clinical features of MDE in women with UD and BPII to compare presentations of the two disorders in women.
Methods:
We compared characteristics of depressed women meeting DSM-IV criteria for BPII (n=48) or UD (n=48), matched on age.
Results:
Feelings of worthlessness occurred in 98% of participants with UD versus 85% with BPII (p=0.03). Participants with UD experienced either insomnia or hypersomnia, but participants with BPII were more likely to experience both simultaneously (p=0.04). Those with UD were significantly less likely to have >5 prior mood episodes compared to those with BP II (12% versus 61%; p<0.0001) and had a later age of onset (p=0.003).
Limitations:
Small sample size and exclusion criteria (i.e., comorbid substance abuse) may limit generalizability of findings.
Conclusions:
Among a sample of women, number of prior episodes, feelings of worthlessness, age of onset, and sleep patterns distinguished between UD and BP II depressive episodes. A better understanding of differential presentation of BP II versus UD depression in women may help guide clinicians to more accurate diagnoses and, ultimately, better treatment.
... Further, many individuals often experience elevated mood as ego syntonic, and therefore do not consider their hypomanic symptoms as problematic and often fail to seek help [11]. In addition, when hypomanic symptoms occur interspersed within protracted periods of depression that are common in BD II, patients understandably find it difficult to recognize euthymia and therefore regard their hypomanic episodes as 'normal', especially because these symptoms are often enjoyable and seemingly productive and therefore preferable to depression [19]. ...
... change in role, grief and loss) affects mood and then implement strategies to deal with these by building social skills to assist in problem solving. [19,72]. Current treatment guidelines recommend IPT as an adjunct to pharmacotherapy [27••, 29••], particularly in the acute phase of the disorder [30] and for the long-term prevention of depression [68]. ...
This article provides recommendations for the diagnosis and treatment of mania, which characterizes bipolar I disorder (BD I). Failure to detect mania leads to misdiagnosis and suboptimal treatment. To diagnose mania, clinicians should include a detailed mood history within their assessment of patients presenting with depression, agitation, psychosis or insomnia. With regards to treatment, by synthesizing the findings from recent treatment guidelines, and reviewing relevant literature, this paper has distilled recommendations for both acute and long-term management. Antimanic agents including atypical antipsychotics and traditional mood stabilizers are employed to reduce acute manic symptoms, augmented by benzodiazepines if needed, and in refractory or severe cases with behavioural and/or psychotic disturbance, electroconvulsive therapy may occasionally be necessary. Maintenance/prophylaxis therapy aims to reduce recurrences/relapse, for which the combination of psychological interventions with pharmacotherapy is beneficial as it ensures adherence and monitoring of tolerability.
... To achieve a stable condition, patients with BD need to take treatment in the form of drugs and therapy regularly. Otherwise, over time it will get worse [49]. More than 20% of BD patients (mostly without treatment) end their lives by suicide [50]. ...
Mood swings in patients with bipolar disorder (BD) are difficult to control and can lead to self-harm and suicide. The interaction between the therapist and BD will determine the success of therapy. The interaction model between the therapist and BD begins by reviewing the models that were previously developed using the Systematic Literature Review and Bibliometric methods. The limit of articles used was sourced from the Science Direct, Google Scholar, and Dimensions databases from 2009 to 2022. The results obtained were 67 articles out of a total of 382 articles, which were then re-selected. The results of the selection of the last articles reviewed were 52 articles. Using VOSviewer version 1.6.16, a visualization of the relationship between the quotes “model”, “therapy”, “emotions”, and “bipolar disorder” can be seen. This study also discusses the types of therapy that can be used by BD, as well as treatment innovations and the mathematical model of the therapy itself. The results of this study are expected to help further researchers to develop an interaction model between therapists and BD to improve the quality of life of BD.
... As rest-activity changes can be robust in precipitating mood episodes, and are possible early indicators of impending episodes and of the beneficial effects of treatments, interventions targeted at regulating rest-activity patterns and those that integrate actigraphy over time may be especially effective in treatment and prevention strategies. Interpersonal and Social Rhythm Therapy (IPSRT), which has an SRT component designed to help individuals regularize their rest-activity pattern, is one of the few psychotherapies shown in clinical trials to be effective in treating BD (135)(136)(137)(138)(139)(140)(141)(142). The rhythm regularization of IPSRT has been shown to reduce risk of recurrence over 2 years (143) with changes in regularity of daily routines mediating symptomatic outcomes, supporting rhythm regulation as a treatment target with potential for sustained benefits and prognosis improvements. ...
Background
Disruptions in rest and activity patterns are core features of bipolar disorder (BD). However, previous methods have been limited in fully characterizing the patterns. There is still a need to capture dysfunction in daily activity as well as rest patterns in order to more holistically understand the nature of 24-h rhythms in BD. Recent developments in the standardization, processing, and analyses of wearable digital actigraphy devices are advancing longitudinal investigation of rest-activity patterns in real time. The current systematic review aimed to summarize the literature on actigraphy measures of rest-activity patterns in BD to inform the future use of this technology.
Methods
A comprehensive systematic review using PRISMA guidelines was conducted through PubMed, MEDLINE, PsycINFO, and EMBASE databases, for papers published up to February 2021. Relevant articles utilizing actigraphy measures were extracted and summarized. These papers contributed to three research areas addressed, pertaining to the nature of rest-activity patterns in BD, and the effects of therapeutic interventions on these patterns.
Results
Seventy articles were included. BD was associated with longer sleep onset latency and duration, particularly during depressive episodes and with predictive value for worsening of future manic symptoms. Lower overall daily activity was also associated with BD, especially during depressive episodes, while more variable activity patterns within a day were seen in mania. A small number of studies linked these disruptions with differential patterns of brain functioning and cognitive impairments, as well as more adverse outcomes including increased suicide risk. The stabilizing effect of therapeutic options, including pharmacotherapies and chronotherapies, on activity patterns was supported.
Conclusion
The use of actigraphy provides valuable information about rest-activity patterns in BD. Although results suggest that variability in rhythms over time may be a specific feature of BD, definitive conclusions are limited by the small number of studies assessing longitudinal changes over days. Thus, there is an urgent need to extend this work to examine patterns of rhythmicity and regularity in BD. Actigraphy research holds great promise to identify a much-needed specific phenotypic marker for BD that will aid in the development of improved detection, treatment, and prevention options.
... Like schizophrenia spectrum disorders, bipolar disorders were once viewed as best treated with pharmacotherapy, and, against the backdrop of disappointingly low remission and recovery rates, the need for novel adjunctive modalities was clear (15). IPSRT was originally developed by Frank and colleagues (16) as an adaptation of interpersonal psychotherapy (IPT) (17) for bipolar I disorder (18) and has since been adapted for bipolar II disorder (19) and adolescents with bipolar spectrum disorders (20). IPSRT rests on an instability model that defines three interconnected pathways to affective recurrences: social rhythm disruption, stressful life events, and medication nonadherence (16,18). ...
People with schizophrenia spectrum disorders frequently experience depression, yet depressive symptoms are often unaddressed. The authors propose that interpersonal and social rhythm therapy (IPSRT) may be effective for individuals with these disorders who experience depression. IPSRT is a manualized, evidence-based treatment for bipolar disorders. It combines the core elements of interpersonal psychotherapy for unipolar depression with social rhythm therapy to target disrupted social rhythms. The authors highlight evidence for the potential utility of IPSRT to treat patients with schizophrenia spectrum disorders and present a case example. IPSRT is one promising therapy that could fill a treatment gap for people with schizophrenia spectrum disorders by addressing depressive symptoms. Future work should build on this rationale and case example to design and implement a randomized controlled trial of IPSRT for treatment of schizophrenia spectrum disorders and evaluate needed modifications.
... In addition, it has been shown that 40% of bipolar patients are usually first diagnosed with MDD (Ghaemi et al., 2001), and latency from illness onset to diagnosis and appropriate treatment for BD patients averages 5-10 years (Baldessarini et al., 2007). These are important findings since patients with BD are much more likely to present to clinicians when they are depressed in outpatient settings (Hirschfeld et al., 2005;Swartz et al., 2012). Moreover, these findings also suggest that the current diagnostic system, which is based only on subjective clinical judgments, lacks the required sensitivity and specificity to differentiate patients with bipolar depression from unipolar depression. ...
Objective
This study used machine learning techniques combined with peripheral biomarker measurements to build signatures to help differentiating (1) patients with bipolar depression from patients with unipolar depression, and (2) patients with bipolar depression or unipolar depression from healthy controls.
Methods
We assessed serum levels of interleukin-2, interleukin-4, interleukin-6, interleukin-10, tumor necrosis factor-α, interferon-γ, interleukin-17A, brain-derived neurotrophic factor, lipid peroxidation and oxidative protein damage in 54 outpatients with bipolar depression, 54 outpatients with unipolar depression and 54 healthy controls, matched by sex and age. Depressive symptoms were assessed using the Hamilton Depression Rating Scale. Variable selection was performed with recursive feature elimination with a linear support vector machine kernel, and the leave-one-out cross-validation method was used to test and validate our model.
Results
Bipolar vs unipolar depression classification achieved an area under the receiver operating characteristics (ROC) curve (AUC) of 0.69, with 0.62 sensitivity and 0.66 specificity using three selected biomarkers (interleukin-4, thiobarbituric acid reactive substances and interleukin-10). For the comparison of bipolar depression vs healthy controls, the model retained five variables (interleukin-6, interleukin-4, thiobarbituric acid reactive substances, carbonyl and interleukin-17A), with an AUC of 0.70, 0.62 sensitivity and 0.7 specificity. Finally, unipolar depression vs healthy controls comparison retained seven variables (interleukin-6, Carbonyl, brain-derived neurotrophic factor, interleukin-10, interleukin-17A, interleukin-4 and tumor necrosis factor-α), with an AUC of 0.74, a sensitivity of 0.68 and 0.70 specificity.
Conclusion
Our findings show the potential of machine learning models to aid in clinical practice, leading to more objective assessment. Future studies will examine the possibility of combining peripheral blood biomarker data with other biological data to develop more accurate signatures.
... In IPSRT, the clinician helps an individual link mood and life events, identify and manage symptoms, mourn the loss of the healthy self ( i.e., who the person would have been without bipolar disorder), resolve a primary problem area (e.g., role transitions, role disputes, interpersonal sensitivities, or grief ), maintain regular daily rhythms, and predict and troubleshoot potential precipitants of rhythm dysregulation (e.g., interpersonal triggers). IPSRT typically is administered individually but can be provided in a group format (63), and the therapy has been modified for bipolar disorder type II (64). Changes include increased attention to the rationale for making changes to social rhythms; identification of mood states; regulation of levels of stimulation; and management of grandiosity, emotional dysregulation, and comorbid substance use. ...
Bipolar disorder is a recurrent psychiatric disorder marked by waxing and waning affective symptoms and impairment in functioning. Some of the morbidity and mortality associated with the illness may be reduced with evidence-based psychotherapies (EBPs) along with pharmacotherapy. To enhance clinicians' understanding of which therapy modalities have evidence supporting their use, the authors conducted a systematic literature review to identify randomized controlled trials (RCTs) of psychotherapy for adults with bipolar disorder. A strong evidence base exists for psychoeducation, cognitive-behavioral therapy, family-focused therapy, interpersonal and social rhythm therapy, and peer-support programs. Promising modalities include functional remediation, mindfulness-based cognitive therapy, illness management and recovery, and technology-assisted strategies. RCTs demonstrate a consistent advantage of these psychotherapies plus pharmacotherapy, compared with the use of pharmacotherapy alone. Adjunctive EBPs hasten time to remission, delay time to recurrence, and improve functional outcomes. EBPs play an important role in helping individuals develop skills needed to manage the persistent and lifelong psychosocial, neurocognitive, vocational, and interpersonal consequences of bipolar disorder. Continued efforts to improve the effectiveness of EBPs for adults with bipolar disorder are warranted.
... Among the first manualized psychotherapies to be developed for this patient population, it was tested in stepped care, with adolescents, and in group format. [29][30][31][169][170][171] Substance use disorders reemerged as a target, with several studies for patients with comorbid depression or dysthymia and alcohol abuse or dependence. 172,173 Most IPT studies found that, like other psychotherapies, IPT was not sufficient as a monotherapy treatment for patients with dysthymia/ persistent depressive disorder and substance use disorders; IPT was efficacious, however, for relapse prevention of alcohol misuse in depressed female prisoners. ...
Background:
Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders.
Methods:
English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research.
Results:
IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment.
Conclusion:
Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.
... It could be conjectured that social rhythm therapy, via its chronotherapeutic effect, may also be procognitive in adults with mood disorders. 60 Several modalities of neuromodulation are established or are currently undergoing investigation (e.g., electroconvulsive therapy [ECT], rTMS, transcranial direct-current stimulation, deep brain stimulation, magnetic seizure therapy, vagus nerve stimulation). [61][62][63] Anterograde amnesia due to ECT is well known and established. ...
Learning objectives:
After participating in this activity, learners should be better able to:• Characterize cognitive dysfunction in patients with major depressive disorder.• Evaluate approaches to treating cognitive dysfunction in patients with major depressive disorder.
Abstract:
Cognitive dysfunction is a core psychopathological domain in major depressive disorder (MDD) and is no longer considered to be a pseudo-specific phenomenon. Cognitive dysfunction in MDD is a principal determinant of patient-reported outcomes, which, hitherto, have been insufficiently targeted with existing multimodal treatments for MDD. The neural structures and substructures subserving cognitive function in MDD overlap with, yet are discrete from, those subserving emotion processing and affect regulation. Several modifiable factors influence the presence and extent of cognitive dysfunction in MDD, including clinical features (e.g., episode frequency and illness duration), comorbidity (e.g., obesity and diabetes), and iatrogenic artefact. Screening and measurement tools that comport with the clinical ecosystem are available to detect and measure cognitive function in MDD. Notwithstanding the availability of select antidepressants capable of exerting procognitive effects, most have not been sufficiently studied or rigorously evaluated. Promising pharmacological avenues, as well as psychosocial, behavioral, chronotherapeutic, and complementary alternative approaches, are currently being investigated.
... Two small studies failed to demonstrate specific benefits of IPSRT compared to control conditions. 99,100 Other open studies have shown some pre-post benefits in very small sam- ples. [101][102][103] Again, since many psychosocial treatments for bipolar dis- order share common core elements that may be psychoeducational, it is possible that the relapse prevention aspects of psychoeducation may also result from IPSRT interventions, mediated by the same ther- apeutic processes. ...
The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.
... In recent years, psychosocial approaches (e.g., cognitive-behavioral therapy, family therapy, and interpersonal and social rhythm therapies) have gained importance in understanding the course of the bipolar disorder (BPD) and psychosocial treatments are considered as important adjuncts to biological treatment for achieving functional recovery and decreasing the relapse risk of bipolar patients (1). These treatments may help patients to recognize their cycling-affective states and to develop skills to manage psychosocial difficulties associated with the illness (2). ...
Introduction:
To identify dysfunctional attitudes seen in bipolar disorder (BPD) is important for the cognitive theories of BPD and corresponding psychosocial interventions. Cognitions are seen as vulnerability factors in the development and maintenance of BPD. The present study aims to contribute to the cognitive literature on BPD by examining depressive and hypomanic attitudes and their contribution to the prediction of BPD diagnosis as well as by exploring the relationship between dysfunctional cognitions and clinical features (types of episodes experienced, duration of illness, and duration of remission).
Methods:
One hundred and eighteen remitted bipolar patients and 103 healthy controls completed the Mood Disorder Questionnaire (MDQ), Turkish Brief-Hypomanic Interpretations and Positive Predictions Inventory (HAPPI), and Dysfunctional Attitudes Scale.
Results:
The bipolar group had significantly higher depressive and hypomanic attitudes than the control group. No significant differences were found regarding the types of episodes experienced and duration of illness. However, both types of attitudes decreased as the duration of remission increased. They were also found to contribute to the prediction of bipolar diagnosis together with the screening of the MDQ.
Conclusion:
The results pointed out that dysfunctional cognitions may be utilized as possible indicators for the risk of relapse in clinical groups and vulnerability for BPD among other populations.
... Adjunctive psychotherapy can thus be very beneficial as it targets areas that medications do not address, such as teaching individuals about the illness, providing skills to control their mood fluctuations, coping with stressful life events, improving social rhythms, sleep patterns, and interpersonal skills (Miklowitz, 2008a;Swartz et al., 2012). In a review of 18 randomized trials of psychotherapy, adjunctive psychosocial treatments were associated with a 30 to 40% reduction in relapse rates over the course of 12 to 30 months, as well as greater functional improvements compared to those taking medications alone (Miklowitz, 2008a). ...
This study examines characteristics of individuals with bipolar disorder who sought psychotherapy versus those who did not.
Bipolar CHOICE was an 11-site comparative effectiveness study of lithium versus quetiapine in symptomatic outpatients (N = 482) with bipolar disorder. At baseline, participants' psychotherapy use within the past 3 months, mood, functioning, and overall health were assessed. Logistic regressions were used to test whether psychotherapy users and non-users differed on various demographic and clinical variables at baseline. Mixed-effects regression was used to determine whether psychotherapy groups differed on response to treatment over the 6-month study. Kaplan-Meier plots and log-rank tests were employed to test whether there were any differences in time to recovery (CGI-BP ≤ 2 for at least 8 weeks) between the groups.
Thirty one percent of participants reported using psychotherapy services. Psychotherapy users reported greater medication side effect burden than non-users and were more likely to have moderate to high suicide risk and at least one anxiety disorder. Participants not utilizing medications or psychotherapy had greater mania symptom severity, were younger, and less educated than medication only users. Medication only users were more likely to be married than the other participants.
These data suggest that a minority of individuals with bipolar disorder attend psychotherapy services, and those that do have greater illness burden.
© The Royal Australian and New Zealand College of Psychiatrists 2015.
... Frank, Swartz, and colleagues created IPSRT for this patient population, based on the findings that radical changes in daily routines precede circadian rhythm instability, which can lead to affective episodes (40,41). IPSRT utilizes the Social Rhythm Metric (SRM), a behavioral tool (42) developed to help stabilize circadian and social rhythms during manic or depressive phases of bipolar illness and to provide patients with skills that will help prevent the onset of future episodes (43,44). The SRM tracks five distinct activities: the times they get out of bed; have first contact with another person; start meaningful activity such as work, school, housework or volunteering; have dinner; and go to bed. ...
Abstract: Interpersonal psychotherapy (IPT) is a time-limited psychotherapy that focuses on relationship stressors and ways to adaptively engage with social supports. Since the first controlled IPT depression study 40 years ago, new applications of the model have emerged, informed by research and public health needs. Evidence for its effectiveness has led to its inclusion in expert consensus treatment guidelines for the treatment of depression, eating disorders, and bipolar disorder. This paper provides a clinical synthesis of IPT, reviewing adaptations that include: IPT-A, for use with adolescents with depression; interpersonal social rhythm therapy (IPSRT), for patients with bipolar disorder; IPT, for patients with eating disorders; and IPT, for patients with depression in culturally diverse settings. With its clear clinical guidelines, therapist- and patient-friendly approach, and data supporting its effectiveness, IPT is easily integrated into mental health care to help patients with mood or eating disorders and interpersonal problems.
... Frank, Swartz, and colleagues created IPSRT for this patient population, based on the findings that radical changes in daily routines precede circadian rhythm instability, which can lead to affective episodes (40,41). IPSRT utilizes the Social Rhythm Metric (SRM), a behavioral tool (42) developed to help stabilize circadian and social rhythms during manic or depressive phases of bipolar illness and to provide patients with skills that will help prevent the onset of future episodes (43,44). The SRM tracks five distinct activities: the times they get out of bed; have first contact with another person; start meaningful activity such as work, school, housework or volunteering; have dinner; and go to bed. ...
A quick-reference, multi-media guide with DVD and captioned demonstrations of therapeutic techniques to using Interpersonal Psychotherapy (IPT) to treat depression.
... Psychological literature today is replete with articles about bipolar disorder, including its etiology, treatment, and the biochemical imbalances requiring correction (e.g., Kurtz and Gerraty, 2009; Lönnqvist et al., 2009; Swartz et al., 2012). Yet discussion on how stigma and other societal processes affect people labeled with bipolar disorder has been minimal (Proudfoot et al., 2009). ...
The initial reactions to a bipolar disorder diagnosis of research participants in a small, qualitative study consisted of astonishment, dread of being "mad," and extremely negative associations. All had prior mental health diagnoses, including episodes of severe depression (all but one) and alcoholism (one). All participants reported mental health histories prediagnosis and most had spent years contending with mental health labels, medications, symptoms, and hospitalizations. In addition, most participants were highly educated health professionals, quite familiar with the behaviors that the medical system considered to comprise bipolar disorder. Their negative associations to the initial bipolar disorder diagnosis, therefore, appeared inconsistent with their mental health histories and professional knowledge. This article contextualizes these initial reactions of shock and distress and proposes interpretations of these findings from societal and psychodynamic group relations perspectives. The participants' initial negative reactions are conceptualized as involving the terror of being transported from the group of "normal" people into the group of "mad" or "crazy" people, i.e., people with mental illnesses, who may constitute a societal "denigrated other."
Bipolar disorder is a common psychiatric dysfunction characterized by recurrent episodes of mania and depression. The dynamics of the mood of a bipolar person can be seen from the fluctuations in mood change. This study uses the Van Der Pol equation approach to the mood mathematical model of a bipolar type II person. The mathematical model for the mood is in the form of a nonlinear differential equation. By analyzing stability through linierization, a stable solution is obtained towards x = 0 and towards the limit cycle. Furthermore, the existence of the limit cycle is tested using Lienard's theorem. When looking for the amplitude of the limit cycle analytically using the Average Method, the results of this study obtained several interpretations, namely that the solution to the limit cycle with normal amplitude in bipolar with treatment must be greater than dysregulation minus the levels of mood stabilizer nerve cells in the body so that the mood reaches normal levels. Another interpretation is that the greater the abnormality in sleep patterns, the faster the mood swings occur. By knowing the stability of the mathematical model of mood, it is hoped that the appropriate therapy for bipolar disorder can be determined.
Background
Rhythms And You (RAY) is an online intervention for bipolar disorders (BD) based on Interpersonal and Social Rhythm Therapy. We examined RAY's feasibility and acceptability for individuals with BD recruited from primary care. Because online interventions may be more effective when paired with human support, we evaluated RAY with and without weekly brief (∼5 minutes) calls from clinical helpers (CH).
Methods
Participants (n=47) meeting criteria for BD I, II or other specified BD, presenting for primary care, were randomly assigned to RAY, RAY-CH, or Adjunctive Reading Material (ARM) control. RAY consisted of 12 weekly online modules. ARM consisted of 12 weekly emails. Participants were assessed at baseline, 4, 8, and 12 weeks.
Results
RAY showed high completion rates and Client Satisfaction Questionnaire scores (36/47, 77% and 25.1±5.5, respectively; no group differences). Effect sizes for RAY- CH ranged from small [Internal State Scale-Activation Subscale (ISS-ACT); d=0.3] to large [SF-12 Mental Health Composite Score (SF-12 MHC); d=1.3]. ARM also showed moderate effects (ISS-ACT d=0.7; Quick Inventory of Depressive Symptoms, d=0.8). SF-12 MHC scores showed a time*group interaction (F=2.38, df=6,32, p=0.05) favoring RAY-CH. Number of logins trended toward significant association with improved social rhythm regularity (F=4.09, df=1, 17, p=0.06).
Limitations
Sample size is small, limiting conclusions that can be drawn.
Conclusions
Remote delivery of RAY for individuals with BD is feasible and acceptable. More time spent engaged in RAY was associated with greater improvement in social rhythm regularity. Preliminary evidence suggests adding brief human support to RAY may yield better outcomes.
Circadian rhythms have been related to psychiatric diseases and regulation of dopaminergic transmission, especially in substance abusers. The relationship between them remained enigmatic and no data on the role of clock genes on cannabis dependence have been documented. We aimed at exploring the role of clock gene genotypes as potential predisposing factor to cannabis addiction, using a high throughput mass spectrometry methodology that enables the large-scale analysis of the known relevant polymorphisms of the clock genes. We have conducted a case-control study on 177 Caucasians categorizing between cannabis-addicted subjects and casual consumers based on structured interviews recorded socio-demographic data, AUDIT, Fagerström test, MINI, and medical examinations. Alcohol, opiates, and stimulants’ consumption was as exclusion criteria. We report an association between several Single Nucleotide Polymorphism (SNP)s in main circadian genes SNPs, especially the gene locus HES7/PER1 on chromosome 17 and cannabis consumption as well as the development of neuropsychiatric and social disorders. This SNP’s signature that may represent a meaningful risk factor in the development of cannabis dependence and its severity requires to be deeply explored in a prospective study.
This article describes the development and pilot of a recovery-focused group intervention for individuals who experience extreme mood states delivered within secondary care NHS services.
Purpose
To conduct a thematic synthesis to evaluate qualitative studies exploring individuals’ experiences of psychological‐based interventions for bipolar disorder (BD).
Method
A systematic search of relevant databases (Web of Science, PsycINFO, MEDLINE, CINAHL) was conducted using predefined search terms related to ‘Bipolar’ ‘Qualitative method’, ‘Psychological‐based interventions’ and ‘Adults’. Studies meeting the inclusion criteria were selected and were then evaluated using established quality appraisal criteria. A thematic synthesis was used to synthesize the findings.
Results
From the thematic synthesis, nine analytical themes were derived from the 10 identified research studies. These were helpful and unhelpful aspects of the intervention, increased knowledge of BD, mood recognition, control of moods, change of perspective, mood stability, empowerment, improved relationships and lifestyle changes.
Conclusions
Findings from the review suggest there were characteristics of psychological‐based interventions that individuals with BD valued and which helped facilitate areas of positive change, such as feeling empowered and in control of their moods and other aspects of their lives. However, there were also elements that individuals did not find as helpful and therefore reflects the challenge of a one‐size‐fits‐all model or plan of interventions, compared to a wider recognition of the individuals as being the agent of their recovery. Future qualitative research is needed to explore individual experiences across a range of psychological interventions, in order to further understand the therapeutic processes, which may facilitate recovery.
Practitioner points
• Psychological‐based interventions for BD need to consider facilitating and measuring empowerment in individuals, rather than focusing just on mood stability.
• Clinicians with expertise and knowledge in BD should provide timely information to individuals and their families to help increase their understanding of the diagnosis.
Objective:
Bipolar II disorder (BP-II) is associated with marked morbidity and mortality. Quetiapine, the treatment with greatest evidence for efficacy in BP-II depression, is associated with metabolic burden. Psychotherapy, a treatment with few side effects, has not been systematically evaluated in BP-II. This study compared psychotherapy plus placebo to psychotherapy plus pharmacotherapy as treatments for BP-II depression.
Methods:
From 2010 to 2015, unmedicated adults (n = 92) with DSM-IV-TR BP-II depression were randomly assigned to weekly sessions of Interpersonal and Social Rhythm Therapy (IPSRT) plus placebo or IPSRT plus quetiapine and followed for 20 weeks.
Results:
For primary outcomes, IPSRT + quetiapine yielded significantly faster improvement on 17-item Hamilton Depression Rating Scale (F₁,₁₁₅.₄ = 3.924, P = .048) and greater improvement on Young Mania Rating Scale (F₅₈.₅ = 4.242, P = .044) scores. Both groups, however, improved significantly over time with comparable response rates (≥ 50% reduction in depression scores): 67.4% (62/92) in the entire sample, with no between-group differences. Those randomly assigned to their preferred treatment were 4.5 times more likely to respond (OR = 4.48, 95% CI = 1.20-16.77, P = .026). IPSRT + quetiapine assignment was associated with significantly higher body mass index over time (F₆₇.₉₆ = 6.671, P = .012) and rates of dry mouth (79% v. 58%; χ² = 4.0, P = .046) and a trend toward more complaints of oversedation (100% vs 92%; χ² = 3.4, P = .063).
Conclusions:
IPSRT plus quetiapine resulted in greater symptomatic improvement but also more side effects than IPSRT alone. A subset of participants improved with IPSRT alone, although absence of an inactive comparator limits interpretation of this finding. Receipt of preferred treatment was associated with better outcomes. Harms, benefits, and preferences should be considered when recommending treatments for BP-II depression.
Trial registration:
ClinicalTrials.gov identifier: NCT01133821.
Psychological interventions are critical in the treatment of bipolar disorders, especially for older adults, who face psychosocial challenges, cognitive difficulties, high rates of medical comorbidity, disability, and increased rates of suicide. This chapter focuses on outpatient psychological treatments for older adults with bipolar disorders, including psychotherapeutic, psychosocial, skills training, psychoeducational, and family support interventions. Critical clinical issues, such as disability, cognitive impairment, emotion regulation, social and family support, and suicidality, are discussed. This chapter describes a case study and highlights a list of helpful clinical “pearls.”
Background:
There are substantial gaps in understanding near-term precursors of suicidal ideation in bipolar II disorder. We evaluated whether repeated patient-reported mood and energy ratings predicted subsequent near-term increases in suicide ideation.
Methods:
Secondary data were used from 86 depressed adults with bipolar II disorder enrolled in one of 3 clinical trials evaluating Interpersonal and Social Rhythm Therapy and/or pharmacotherapy as treatments for depression. Twenty weeks of daily mood and energy ratings and weekly Hamilton Depression Rating Scale (HDRS) were obtained. Penalized regression was used to model trajectories of daily mood and energy ratings in the 3 week window prior to HDRS Suicide Item ratings.
Results:
Participants completed an average of 68.6 (sd=52) days of mood and energy ratings. Aggregated across the sample, 22% of the 1675 HDRS Suicide Item ratings were non-zero, indicating presence of at least some suicidal thoughts. A cross-validated model with longitudinal ratings of energy and depressed mood within the three weeks prior to HDRS ratings resulted in an AUC of 0.91 for HDRS Suicide item >2, accounting for twice the variation when compared to baseline HDRS ratings. Energy, both at low and high levels, was an earlier predictor than mood.
Limitations:
Data derived from a heterogeneous treated sample may not generalize to naturalistic samples. Identified suicidal behavior was absent from the sample so it could not be predicted.
Conclusions:
Prediction models coupled with intensively gathered longitudinal data may shed light on the dynamic course of near-term risk factors for suicidal ideation in bipolar II disorder.
Ziel der vorliegenden Dissertation war die Entwicklung einer computeradaptierten Version der Social-Rhythm-Metric(SRM). Die SRM erfasst 17 "zeitgebende" Aktivtäten wie Mahlzeiten, Arbeitszeiten oder Schlafgewohnheiten und bildet so den sozialen Rhythmus eines Menschen ab. Sie ist integraler Bestandteil der Interpersonal and Social Rhythm Therapie, die speziell für bipolare Patienten entwickelt wurde und deren Wirksamkeit in verschiedenen Studien belegt werden konnte. Neben der Klärung von Schwierigkeiten im interpersonellen Bereich hat diese die Stabilisierung des sozialen Rhythmus mithilfe der SRM zum Ziel, wodurch man sich eine präventive Wirkung gegen affektive Episoden erhofft. Limitiert wurde der Einsatz der SRM dadurch, dass sie bislang nur als Papierverfahren verfügbar war, was sie in Praxis und Forschung aufgrund des hohen Zeitaufwandes bei der Datenverarbeitung wenig praktikabel machte. An der Entwicklung der computerisierten Version waren von Beginn an sechs bipolar erkrankte Freiwillige beteiligt. Ergebnis ist ein flexibles, individuell variierbares Modul, mit dessen Gestaltung die mitwirkenden Probanden zufrieden waren. Die Möglichkeit, die erhobenen Daten jederzeit per Internet abzurufen und das Modul den individuellen Bedürfnissen anzupassen, schätzten die Probanden sehr. Mit der vorliegenden Arbeit konnte gezeigt werden, dass die computerisierte Version der SRM praktisch anwendbar ist. Durch den automatisierten Ablauf der in der Papierversion arbeitsintensiven Schritte der Datenverarbeitung konnte eine deutliche Zeit- und damit Kostenersparnis erreicht werden.
Die Wirksamkeit stimmungsstabilisierender Medikation in der phasenprophylaktischen Behandlung bei bipolaren Störungen ist belegt. Dennoch leiden Patienten vielfach unter Rezidiven und Residualsymptomen, die Medikamenten-Adhärenz ist oftmals nicht ausreichend, ein chronischer Krankheitsverlauf mit zunehmendem Verlust des psychosozialen Funktionsniveaus tritt häufig ein. In einem multimodalen Behandlungsansatz haben psycho- und soziotherapeutische Interventionen verstärkt an Bedeutung gewonnen. Als evidenzbasierte Verfahren stehen die psychoedukative Therapie, das Intensive Clinical Management (ICM), die Interpersonelle und Soziale Rhythmustherapie (IPSRT), die Kognitive Verhaltenstherapie (KVT), die Familienfokussierte Therapie (FFT) sowie die psychodynamisch orientierte Psychotherapie zur Verfügung. Die aktuellen S3-Leitlinien zur Behandlung bipolarer Störungen empfehlen interaktive Gruppenpsychoedukation, KVT und FFT für die Phasenprophylaxe. Zur Unterstützung der Rezidivprophylaxe manischer und depressiver Episoden ist Psychoedukation indiziert. Zur Rückfallverhinderung nach depressiven Episoden werden KVT und FFT empfohlen. Zukünftige Fragestellungen sind differentialdiagnostische Zuordnungen von Patientensubgruppen zu den unterschiedlichen Verfahren und zugrundeliegende Wirkmechanismen. Inhalte, aktuelle Entwicklungen und empirische Befunde zu den verschiedenen psycho- und soziotherapeutischen Interventionen werden in diesem Review aufgezeigt.
To assess the efficacy of six tools utilized in primary care for the screening of bipolar affective disorder (BPAD). BPAD has historically been underdiagnosed or misdiagnosed followed by inappropriate treatment leading to detrimental relapses, suicide, and increased risks for comorbidities.
An electronic search was conducted to identify articles in the following databases: MEDLINE, CINAHL, Cochrane Library, ERIC, National Guideline Clearinghouse, PsycINFO, Psychology and Behavioral Sciences collection, and PsycARTICLES. Other information was also collected from the NIH, CDC, Healthy People 2020, the Black Dog Institute, and the Center for Quality Assessment and Improvement for Mental Health.
Evidence indicates that primary care providers are often the first and sometimes sole provider, which signifies the importance of early detection and screening of BPAD in primary care. By implementing the use of appropriate screening tools and following recommended treatment and intervention guidelines, the prevention of relapse is increased, and comorbidities are more frequently diagnosed leading to an overall improved quality of life.
Primary care practitioners play a vital role in appropriately screening for BPAD and implementing the recommended treatments to increase prevention of relapse and promote a healthier and more socially successful quality of life.
©2015 American Association of Nurse Practitioners.
Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder.
To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression.
Randomized controlled trial.
Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention.
Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks.
Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months.
All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies.
Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder.
clinicaltrials.gov Identifier: NCT00012558.
There is limited information on the prevalence and correlates of bipolar spectrum disorder in international population-based studies using common methods.
To describe the prevalence, impact, patterns of comorbidity, and patterns of service utilization for bipolar spectrum disorder (BPS) in the World Health Organization World Mental Health Survey Initiative.
Cross-sectional, face-to-face, household surveys of 61,392 community adults in 11 countries in the Americas, Europe, and Asia assessed with the World Mental Health version of the World Health Organization Composite International Diagnostic Interview, version 3.0, a fully structured, lay-administered psychiatric diagnostic interview.
Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) disorders, severity, and treatment.
The aggregate lifetime prevalences were 0.6% for bipolar type I disorder (BP-I), 0.4% for BP-II, 1.4% for subthreshold BP, and 2.4% for BPS. Twelve-month prevalences were 0.4% for BP-I, 0.3% for BP-II, 0.8% for subthreshold BP, and 1.5% for BPS. Severity of both manic and depressive symptoms as well as suicidal behavior increased monotonically from subthreshold BP to BP-I. By contrast, role impairment was similar across BP subtypes. Symptom severity was greater for depressive episodes than manic episodes, with approximately 74.0% of respondents with depression and 50.9% of respondents with mania reporting severe role impairment. Three-quarters of those with BPS met criteria for at least 1 other disorder, with anxiety disorders (particularly panic attacks) being the most common comorbid condition. Less than half of those with lifetime BPS received mental health treatment, particularly in low-income countries, where only 25.2% reported contact with the mental health system.
Despite cross-site variation in the prevalence rates of BPS, the severity, impact, and patterns of comorbidity were remarkably similar internationally. The uniform increases in clinical correlates, suicidal behavior, and comorbidity across each diagnostic category provide evidence for the validity of the concept of BPS. Treatment needs for BPS are often unmet, particularly in low-income countries.
Bipolar disorder is complex and can be difficult to diagnose. It is often misdiagnosed as recurrent major depressive disorder.
We had three main aims. To estimate the proportion of primary care patients with a working diagnosis of unipolar depression who satisfy DSM-IV criteria for bipolar disorder. To test two screening instruments for bipolar disorder (the Hypomania Checklist (HCL-32) and Bipolar Spectrum Diagnostic Scale (BSDS)) within a primary care sample. To assess whether individuals with major depressive disorder with subthreshold manic symptoms differ from those individuals with major depressive disorder but with no or little history of manic symptoms in terms of clinical course, psychosocial functioning and quality of life.
Two-phase screening study in primary care.
Three estimates of the prevalence of undiagnosed bipolar disorder were obtained: 21.6%, 9.6% and 3.3%. The HCL-32 and BSDS questionnaires had quite low positive predictive values (50.0 and 30.1% respectively). Participants with major depressive disorder and with a history of subthreshold manic symptoms differed from those participants with no or little history of manic symptoms on several clinical features and on measures of both psychosocial functioning and quality of life.
Between 3.3 and 21.6% of primary care patients with unipolar depression may have an undiagnosed bipolar disorder. The HCL-32 and BSDS screening questionnaires may be more useful for detecting broader definitions of bipolar disorder than DSM-IV-defined bipolar disorder. Subdiagnostic features of bipolar disorder are relatively common in primary care patients with unipolar depression and are associated with a more morbid course of illness. Future classifications of recurrent depression should include dimensional measures of bipolar symptoms.
There is growing clinical and epidemiologic evidence that major mood disorders form a spectrum from major depressive disorder to pure mania. The authors examined the prevalence and clinical correlates of major depressive disorder with subthreshold bipolarity compared with pure major depressive disorder in the National Comorbidity Survey Replication (NCS-R).
The NCS-R is a nationally representative face-to-face household survey of the U.S. population conducted between February 2001, and April 2003. Lifetime history of mood disorders, symptoms, and clinical indicators of severity were collected using version 3.0 of the World Health Organization's Composite International Diagnostic Interview.
Nearly 40% of study participants with a history of major depressive disorder had a history of subthreshold hypo-mania. This subgroup had a younger age at onset, more episodes of depression, and higher rates of comorbidity than those without a history of hypomania and lower levels of clinical severity than those with bipolar II disorder.
These findings demonstrate heterogeneity in major depressive disorder and support the validity of inclusion of subthreshold mania in the diagnostic classification. The broadening of criteria for bipolar disorder would have important implications for research and clinical practice.
Psychosocial interventions have the potential to enhance relapse prevention in bipolar disorder.
To evaluate a manualised group-based intervention for people with bipolar disorder in a naturalistic setting.
Eighty-four participants were randomised to receive the group-based intervention (a 12-week programme plus three booster sessions) or treatment as usual, and followed up with monthly telephone interviews (for 9 months post-intervention) and face-to-face interviews (at baseline, 3 months and 12 months).
Participants who received the group-based intervention were significantly less likely to have a relapse of any type and spent less time unwell. There was a reduced rate of relapse in the treatment group for pooled relapses of any type (hazard ratio 0.43, 95% CI 0.20-0.95; t(343) = -2.09, P = 0.04).
This study suggests that the group-based intervention reduces relapse risk in bipolar disorder.
Recent studies demonstrate the poor psychosocial outcomes associated with bipolar disorder. Occupational functioning, a key indicator of psychosocial disability, is often severely affected by the disorder. The authors describe the effect of acute treatment with interpersonal and social rhythm therapy on occupational functioning over a period of approximately 2.5 years.
Patients with bipolar I disorder were randomly assigned to receive either acute and maintenance interpersonal and social rhythm therapy, acute and maintenance intensive clinical management, acute interpersonal and social rhythm therapy and maintenance intensive clinical management, or acute intensive clinical management and maintenance interpersonal and social rhythm therapy, all with appropriate pharmacotherapy. Occupational functioning was measured with the UCLA Social Attainment Scale at baseline, at the end of acute treatment, and after 1 and 2 years of maintenance treatment.
The main effect of treatment did not reach conventional levels of statistical significance; however, the authors observed a significant time by initial treatment interaction. Participants initially assigned to interpersonal and social rhythm therapy showed more rapid improvement in occupational functioning than those initially assigned to intensive clinical management, primarily accounted for by greater improvement in occupational functioning during the acute treatment phase. At the end of 2 years of maintenance treatment, there were no differences between the treatment groups. A gender effect was also observed, with women who initially received interpersonal and social rhythm therapy showing more marked and rapid improvement. There was no effect of maintenance treatment assignment on occupational functioning outcomes.
In this study, interpersonal and social rhythm therapy, with its emphasis on amelioration of interpersonal and role functioning, improved occupational functioning significantly more rapidly than did a psychoeducational and supportive approach with no such emphasis on functional capacities.
Psychosocial research in bipolar disorder (BD) has not yet assessed the relative benefits of a short course of psychoeducation (PE), compared with a longer course of cognitive-behavioural therapy (CBT) containing psychoeducational principles. This pilot study evaluated the efficacy and added benefit of adding a course of CBT to a standard course of brief PE, as maintenance therapy for BD.
Seventy-nine consenting adult men and women with BD on stable medication regimens, who were in full or partial remission from an index episode (BD I = 52; BD II = 27), were randomized to receive either 7 sessions of individual PE, or 7 sessions of PE followed by 13 additional individual sessions of CBT. Weekly mood and medication adherence was rated using the National Institute of Mental Health's Life Chart Method, while psychosocial functioning and mental health use were assessed monthly.
Forty-six participants completed the entire study. Participants who received CBT in addition to PE experienced 50% fewer days of depressed mood over the course of one year. Participants who received PE alone had more antidepressant increases compared with those who received CBT. There were no group differences in hospitalization rates, medication adherence, psychosocial functioning, or mental health use.
Pilot data from this real-world study suggest that even after medication treatment has been optimized, a longer course of adjunctive CBT may offer some additional benefits over a shorter course of PE alone for the maintenance treatment of BD. Larger randomized controlled trials with equal treatment lengths are indicated.
This is the first prospective longitudinal study, to our knowledge, of the natural history of the weekly symptomatic status of bipolar II disorder (BP-II).
Weekly affective symptom status ratings for 86 patients with BP-II were based on interviews conducted at 6- or 12-month intervals during a mean of 13.4 years of prospective follow-up. Percentage of weeks at each symptom severity level and the number of shifts in symptom status and polarity were examined. Predictors of chronicity for BP-II were evaluated using new chronicity measures. Chronicity was also analyzed in relation to the percentage of follow-up weeks with different types of somatic treatment.
Patients with BP-II were symptomatic 53.9% of all follow-up weeks: depressive symptoms (50.3% of weeks) dominated the course over hypomanic (1.3% of weeks) and cycling/mixed (2.3% of weeks) symptoms. Subsyndromal, minor depressive, and hypomanic symptoms combined were 3 times more common than major depressive symptoms. Longer intake episodes, a family history of affective disorders, and poor previous social functioning predicted greater chronicity. Prescribed somatic treatment did not correlate significantly with symptom chronicity. Patients with BP-II of brief (2-6 days) vs longer (> or =7 days) hypomanias were not significantly different on any measure.
The longitudinal symptomatic course of BP-II is chronic and is dominated by depressive rather than hypomanic or cycling/mixed symptoms. Symptom severity fluctuates frequently within the same patient over time, involving primarily symptoms of minor and subsyndromal severity. Longitudinally, BP-II is expressed as a dimensional illness involving the full severity range of depressive and hypomanic symptoms. Hypomania of long or short duration in BP-II seems to be part of the same disease process.
A large body of research has now accumulated concerning quality of life (QoL) for patients with major depressive disorder, both in terms of describing levels of well-being and in terms of assessing the impact of treatment interventions. However, there is little information concerning QoL for patients with bipolar disorder (BD), and there is relatively little published evidence concerning the effectiveness of psychological interventions for BD. We aimed to assess the impact of a time-limited psychoeducation (PE) group therapy upon perceived QoL among patients with BD.
Participants were patients (n = 57) with BD type I or II who were clinically described as euthymic or mildly symptomatic. Treatment intervention was a standardized, 8-week group PE course delivered in a mood disorders program in British Columbia, Canada. Using retrospective chart review and the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), we assessed QoL at baseline and at 8 weeks.
Mean baseline Q-LES-Q scores were 56%, representing moderate impairment in QoL. Group PE was associated with a 5-point increase in Q-LES-Q scores (where higher scores indicate better QoL). Examination of the questionnaire's subscales revealed that 2 domains (that is, physical functioning and general satisfaction) increased significantly following PE, with the remaining domains showing nonsignificant trends toward improved functioning. Multivariate analysis indicated that only one factor (having had a recent episode of depression) significantly predicted pre- and posttreatment Q-LES-Q scores.
Patients with BD continue to show impaired QoL even when clinically euthymic. Although preliminary, our results show that group PE is associated with improved QoL in this population, both in terms of general satisfaction and in relation to levels of physical functioning. The use of PE as an adjunct to pharmacotherapy in BD should be further studied with particular emphasis on characterizing the effects of treatment intervention on perceived QoL.
Randomized trials indicate that psychosocial interventions effective adjuncts to pharmacotherapy in bipolar disorder (1,2). A one-year naturalistic-prospective design was used to examine the association between psychotherapy use and the symptomatic and functional outcomes of patients with bipolar disorder.
Patients with bipolar disorder in a depressed phase (N=248) were drawn from the first 1,000 enrollees (November 1999 to April 2002) in the Systematic Treatment Enhancement Program (STEP-BD), a study of patients with bipolar disorder receiving best-practice pharmacotherapy. Patients were seen clinics and interviewed every three months over one year regarding of psychotherapy services, symptoms, and role functioning. Mixed-effects regression models were used to examine whether the amount of psychotherapy the patients received during each three-month interval was associated with symptomatic or psychosocial functioning during the same or a subsequent three-month interval.
During the study year, percent of the patients had at least one psychotherapy session. Among patients who began an interval with severe depressive symptoms or low functioning, having more frequent sessions of psychotherapy was associated with less severe mood symptoms and better functioning in the same or a subsequent study interval. In contrast, among patients who began interval with less severe depressive symptoms or higher functioning, fewer psychotherapy sessions were associated with less severe depressive symptoms and greater functioning in the same or a subsequent interval.
Intensive psychotherapy may be most applicable to severely ill patients with bipolar disorder, whereas briefer treatments may be adequate for less severely ill patients.
The aim of the present study was to compare health-related quality of life (HRQoL) measures in euthymic patients with bipolar I and II disorder. We included as comparison samples a group of subjects with recurrent major depression (RMD) and a group of non-psychiatrically ill individuals.
HRQoL was assessed using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) in 253 subjects recruited in 5 Italian centers: 90 patients with bipolar I disorder, 52 patients with bipolar II disorder, 61 subjects with RMD, and 50 healthy comparison individuals. All subjects were evaluated with the Structured Clinical Interview for DSM-IV; psychiatric patients had to be in a euthymic state for at least 2 months prior to the inclusion in the study, as confirmed by a Hamilton Rating Scale for Depression total score < 8 and a Young Mania Rating Scale total score < 6. Data were drawn from a study that was performed from May 2003 to December 2004.
When we compared the bipolar and RMD groups with the control group of non-psychiatrically ill individuals and controlled for differences in mean actual age, both bipolar subgroups and subjects with RMD had lower SF-36 mean scores on several subscales; differences in mean SF-36 scores were also detected between bipolar subtypes: bipolar II patients showed HRQoL that was poorer than that of bipolar I patients, even after controlling for age, age at onset, and length of illness, and equal to that of RMD subjects.
Our study provides evidence that bipolar type II is associated with poorer HRQoL compared to type I even during sustained periods of euthymia and excluding residual symptoms. Interventions targeting rehabilitation and/or functional enhancement may be helpful to improve HRQoL, especially among patients with bipolar II disorder.
Die Zeit antagonistischer Wissenschaftskulturen scheint vorüber: Begriffe, Modelle und Objekte wandern zwischen den Geistes-, Sozial- und Technowissenschaften. Dabei entstehen neue und intensive Verflechtungen. So werden ehemals kritische Konzepte des vermeintlich Nicht-Technischen in den Technowissenschaften aufgegriffen, während biokybernetische Denkfiguren auch die Geisteswissenschaften durchziehen. Dieser Band verfolgt solche Übersetzungsversuche und fragt, ob sich eine kreative interdisziplinäre Wissenskultur oder eine restriktive, formale Kultur der ›Interdisziplinierung‹ auf der Grundlage einer neuen Technorationalität herausbildet.
• Results of biological and psychosocial studies of depression completed in the last decade have stimulated the need for new hypotheses that synthesize these findings in a unified etiologic theory. The importance of disruption of biological rhythms on the one hand, and psychosocial losses on the other, in the causation of depressive episodes suggest one possible unifying hypothesis. The concept of loss of "social zeitgebers," ie, persons, social demands, or tasks that set the biological clock, may provide the link between biological and psychosocial theories of etiology. We suggest that a disruption of social rhythms, which may result in instability in biological rhythms, could be responsible for triggering the onset of a major depressive episode in vulnerable individuals.
this chapter will describe Interpersonal Psychotherapy (IPT) for depression, including the theoretical and empirical bases, efficacy studies, and derivative forms, and will also make recommendations for its use in clinical practice
Interpersonal Psychotherapy (IPT) is based on the observation that major depression—regardless of symptom patterns, severity, presumed biological or genetic vulnerability, or the patients' personality traits—usually occurs in an interpersonal context, often an interpersonal loss or dispute / IPT is a brief, weekly psychotherapy that is usually conducted for 12 to 16 weeks, although it has been used for longer periods of time with less frequency as maintenance treatment for recovered depressed patients with major depression / the focus is on improving the quality of the depressed patients' current interpersonal functioning and the problems associated with the onset of depression (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The role of antidepressants in the acute treatment of bipolar depression remains a contentious issue. A previous meta-analysis of randomized controlled trials (RCTs) concluded that antidepressants were effective and safe for bipolar depression. Several trials published since then suggest that antidepressants may not be as beneficial as previously concluded. The current systematic review and meta-analyses reexamine the efficacy and safety of antidepressant use for the acute treatment of bipolar depression.
EMBASE, MEDLINE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials databases were searched for double-blind RCTs published from 2003 to 2009 using the following diagnostic medical subject heading (MESH) terms: bipolar disorder, bipolar depression, bipolar I disorder, bipolar II disorder, bipolar III disorder, bipolar mania, cyclothymia, manic depressive psychosis, mixed mania and depression, and rapid cycling and bipolar disorder. Databases of trial registries were also searched for unpublished RCTs. These searches were supplemented by hand searches of relevant articles and review articles.
Trials that compared acute (< 16 wk) antidepressant treatment with either an active drug or a placebo comparator in adult bipolar patients, depressive phase were eligible for inclusion. Main outcome measures were clinical response, remission, and affective switch.
Six RCTs (N = 1,034) were identified since publication in 2004 of the first meta-analysis that assessed antidepressant use in the acute treatment of bipolar depression. These studies were combined with earlier studies for a total of 15 studies containing 2,373 patients. Antidepressants were not statistically superior to placebo or other current standard treatment for bipolar depression. Antidepressants were not associated with an increased risk of switch. Studies that employed more sensitive criteria to define switch did report elevated switch rates for antidepressants.
Although antidepressants were found to be safe for the acute treatment of bipolar depression, their lack of efficacy may limit their clinical utility. Further high-quality studies are required to address the existing limitations in the literature.
The present open study investigates the feasibility of Mindfulness-based cognitive therapy (MBCT) in groups solely composed of bipolar patients of various subtypes. MBCT has been mostly evaluated with remitted unipolar depressed patients and little is known about this treatment in bipolar disorder.
Bipolar outpatients (type I, II and NOS) were included and evaluated for depressive and hypomanic symptoms, as well as mindfulness skills before and after MBCT. Patients' expectations before the program, perceived benefit after completion and frequency of mindfulness practice were also recorded.
Of 23 included patients, 15 attended at least four MBCT sessions. Most participants reported having durably, moderately to very much benefited from the program, although mindfulness practice decreased over time. Whereas no significant increase of mindfulness skills was detected during the trial, change of mindfulness skills was significantly associated with change of depressive symptoms between pre- and post-MBCT assessments.
MBCT is feasible and well perceived among bipolar patients. Larger and randomized controlled studies are required to further evaluate its efficacy, in particular regarding depressive and (hypo)manic relapse prevention. The mediating role of mindfulness on clinical outcome needs further examination and efforts should be provided to enhance the persistence of meditation practice with time.
The prevalence of suicide attempts (SA) in bipolar II disorder (BPII), particularly in comparison to the prevalence in bipolar I disorder (BPI), is an understudied and controversial issue with mixed results. To date, there has been no comprehensive review of the published prevalence data for attempted suicide in BPII.
We conducted a literature review and meta-analysis of published reports that specified the proportion of individuals with BPII in their presentation of SA data. Systematic searching yielded 24 reports providing rates of SA in BPII and 21 reports including rates of SA in both BPI and BPII. We estimated the prevalence of SA in BPII by combining data across reports of similar designs. To compare rates of SA in BPII and BPI, we calculated a pooled odds ratio (OR) and 95% confidence interval (CI) with random-effect meta-analytic techniques with retrospective data from 15 reports that detailed rates of SA in both BPI and BPII.
Among the 24 reports with any BPII data, 32.4% (356/1099) of individuals retrospectively reported a lifetime history of SA, 19.8% (93/469) prospectively reported attempted suicide, and 20.5% (55/268) of index attempters were diagnosed with BPII. In 15 retrospective studies suitable for meta-analysis, the prevalence of attempted suicide in BPII and BPI was not significantly different: 32.4% and 36.3%, respectively (OR = 1.21, 95% CI: 0.98-1.48, p = 0.07).
The contribution of BPII to suicidal behavior is considerable. Our findings suggest that there is no significant effect of bipolar subtype on rate of SA. Our findings are particularly alarming in concert with other evidence, including (i) the well-documented predictive role of SA for completed suicide and (ii) the evidence suggesting that individuals with BPII use significantly more violent and lethal methods than do individuals with BPI. To reduce suicide-related morbidity and mortality, routine clinical care for BPII must include ongoing risk assessment and interventions targeted at risk factors.
We developed models of Specialized Care for Bipolar Disorder (SCBD) and a psychosocial treatment [Enhanced Clinical Intervention (ECI)] that is delivered in combination with SCBD. We investigated whether SCBD and ECI + SCBD are able to improve outcomes and reduce health disparities for young and elderly individuals, African Americans, and rural residents with bipolar disorder.
Subjects were 463 individuals with bipolar disorder, type I, II, or not otherwise specified, or schizoaffective disorder, bipolar type, randomly assigned to SCBD or ECI + SCBD and followed longitudinally for a period of one to three years at four clinical sites.
Both treatment groups significantly improved over time, with no significant differences based on age, race, or place of residence, except for significantly greater improvement among elderly versus adult subjects. Improvement in quality of life was greater in the ECI + SCBD group. Of the 299 participants who were symptomatic at study entry, 213 achieved recovery within 24 months, during which 86 of the 213 subjects developed a new episode. No significant difference was found for race, place of residence, or age between the participants who experienced a recurrence and those who did not. However, the adolescent patients were less likely than the adult and elderly patients to experience a recurrence.
This study demonstrated the effectiveness of SCBD and the additional benefit of ECI independent of age, race, or place of residence. It also demonstrated that new mood episodes are frequent in individuals with bipolar disorder who achieve recovery and are likely to occur in spite of specialized, guideline-based treatments.
Various adjunctive psychotherapies assist in decreasing relapse and improving outcomes for people with bipolar disorder (BD). Psychoeducation programs involving patient-only or caregiver-only groups have demonstrated some efficacy. We tested in recently remitted BD if a combined group based psychoeducation program involving patient-companion dyads decreased relapse.
58 recently remitted BD out-patients were randomised to receive either treatment as usual (TAU, n=31) or 12 x 90 minute psychoeducation sessions delivered weekly in a group program to the patient and companion (SIMSEP, n=27). After 12 weeks SIMSEP patients reverted to TAU and all patients were followed until week 60 or relapse. The primary outcome measure was relapse requiring hospital or intensive community intervention.
45 patients completed the study. 29 patients remained well at week 60 (SIMSEP n=17, TAU n=12), whilst 16 had relapsed (SIMSEP n=3, TAU n=13). The SIMSEP group were less likely to relapse (Fisher's exact test p=0.013; OR=0.16; 95% CI 0.04-0.70) and had an 11 week longer time to relapse compared to the TAU group (chi-square (1)=8.48, p<0.01). At study completion SIMSEP compared to TAU patients had lower Young Mania Rating Scale scores (Mann-Whitney U=255, p<0.01).
The study was limited by a small sample size.
A brief group psychoeducation program with recently remitted BD patients and their companions resulted in a decreased relapse rate, longer time to relapse, decreased manic symptoms and improved medication adherence suggesting utility in the adjunctive psychotherapeutic treatment of BD.
We conducted a proof of concept study to determine the feasibility of using an individual psychotherapy, Interpersonal and Social Rhythm Therapy (IPSRT), as monotherapy for the acute treatment of bipolar II depression.
Unmedicated individuals (n = 17) meeting DSM-IV criteria for bipolar II disorder and currently depressed received weekly psychotherapy (IPSRT) for 12 weeks. After 12 weeks of acute treatment, individuals received an additional 8 weeks of follow-up treatment consisting of continued weekly IPSRT with supplementary lamotrogine for IPSRT non-responders.
By week 12, 41% (n = 7) of the sample responded to IPSRT monotherapy (defined as > or =50% reduction in depression scores without an increase in mania scores), 41% (n = 7) dropped out of or were removed from the study, and 18% (n = 3) did not respond to treatment. By week 20, 53% (n = 9) had achieved a response and 29% (n = 5) achieved a full remission of symptoms.
Interpersonal and Social Rhythm Therapy appears to be a promising intervention for a subset of individuals with bipolar II depression. A randomized controlled trial is needed to systematically evaluate the efficacy of IPSRT as an acute monotherapy for bipolar II depression.
A review of clinical experience with 163 patients with primary affective disorder indicates that patients with a history characterized by recurrent depression interspersed with periods of hypomania (bipolar II) may have clinical courses that are distinguishable from bipolar I (depression with histories of mania) or unipolar patients. A prior history of suicide attempt and suicide after discharge from the research unit were most frequent among bipolar II patients. The family histories of bipolar I and bipolar II patients revealed similarly increased morbid risks for bipolar illness, whereas no bipolar illness was found in the first-degree relatives of unipolar patients. The suggestion that patients classified as bipolar II be separately considered in future studies of affective disorder is discussed.
The Social Rhythm Metric (SRM) is an instrument designed to quantify an individual's daily social rhythms. Social rhythms are important both as a way of structuring the day cognitively and as time cues (or zeitgebers) that drive the biological clock (circadian system). The development of the SRM and its pilot testing in 50 healthy control subjects is described, along with measurements of reliability and validity. The potential of the SRM for integrating psychosocial and biological research and its clinical applicability are discussed.
Results of biological and psychosocial studies of depression completed in the last decade have stimulated the need for new hypotheses that synthesize these findings in a unified etiologic theory. The importance of disruption of biological rhythms on the one hand, and psychosocial losses on the other, in the causation of depressive episodes suggest one possible unifying hypothesis. The concept of loss of "social zeitgebers," ie, persons, social demands, or tasks that set the biological clock, may provide the link between biological and psychosocial theories of etiology. We suggest that a disruption of social rhythms, which may result in instability in biological rhythms, could be responsible for triggering the onset of a major depressive episode in vulnerable individuals.
Patients with primary major depression (N = 372) were followed for 2 years to determine the prognostic importance of past manic or hypomanic episodes. While bipolar I and bipolar II patients were more likely to relapse and bipolar I patients were more likely to attempt suicide, these patients resembled nonbipolar depressed patients in likelihood of recovery and psychosocial impairment in various areas. Compared to nonbipolar patients, those with bipolar I depression were much more likely to develop mania, while bipolar II patients were more likely to develop hypomania. Cycling during the index episode predicted a relatively low likelihood of recovery for bipolar I patients but had no apparent prognostic significance for patients with bipolar II illness.
Evaluated the efficacy of a preventive compliance intervention based on cognitive therapy principles with 11 male and 17 female 24–60 yr old newly admitted lithium outpatients. Half of the Ss received standard medication clinic care; the rest also received the compliance intervention. Global medical regimen adherence at postintervention and at 3- and 6-mo follow-up assessments was assessed by self- and informant reports, physicians' ratings, chart notations, and serum lithium blood levels. Results show that the intervention significantly enhanced compliance at both postintervention and 6-mo follow-up assessment. In addition, intervention Ss significantly less often terminated lithium against medical advice, were hospitalized during the course of the study, or had noncompliance-precipitated episodes. (17 ref)
The association between stressful life events and onset of bipolar episodes is unclear. The association between bipolar episode onset and types of life events that disrupt social routines, and potentially sleep, has not yet been investigated.
Thirty-nine bipolar patients with primarily manic (n = 20) or depressed (n = 19) index episodes were interviewed with the Bedford College Life Event and Difficulty Schedule to determine the presence of severe events during 8-week pre-onset and control periods. All life events were also rated for degree of social rhythm disruption (SRD).
More bipolar subjects experienced at least 1 SRD event and severe event in the pre-onset vs control periods. When subjects were divided into those with manic or depressive onsets, the only significant pre-onset vs control difference was for manic patients with SRD events. Additionally, the proportion of subjects with a pre-onset SRD event was greater for manic than for depressed patients.
We found evidence that life events characterized by SRDs routines are associated with the onset of manic, but not depressive, episodes. Severe events seem to be related to onset of bipolar episodes, although it remains unclear whether severe events relate differentially to depressive and manic onsets.
The authors' goal was to investigate the awareness of illness and subjective cognitive complaints of patients with either bipolar I disorder or bipolar II disorder during a phase of clinical stabilization.
They used a structured clinical interview, the Frankfurt Complaints Questionnaire, to determine subjective cognitive complaints, and the Scale of Unawareness of Mental Disorder to assess 57 consecutively enrolled patients with bipolar I or bipolar II disorder.
Patients with bipolar II disorder had significantly less insight and a higher level of subjective complaints of stimulus overload than patients with bipolar I disorder.
These results suggest that a severe deficit in self-awareness may constitute a distinguishing psychopathological characteristic of patients with bipolar II disorder. Further studies are required to determine if there are associated neuropsychological dysfunctions.
For major depression and schizophrenia, gender differences have been reported in symptom expression and course of illness. Gender differences in bipolar disorder are becoming increasingly apparent, but have been less studied. Research data on these differences will help determine whether gender is important in influencing illness variables such as course, symptom expression, and likelihood of comorbidity.
Charts of 131 patients (63 women and 68 men) with a DSM-IV diagnosis of bipolar disorder admitted to the University of California Los Angeles Mood Disorders Program over a 3-year period were reviewed to gather data on demographic variables and course of illness and to assess differences in the illness across genders.
No significant gender differences were found in the rate of bipolar I or bipolar II diagnoses, although women were overrepresented in the latter category. Also, no significant gender differences emerged in age at onset, number of depressive or manic episodes, and number of hospitalizations for depression. Women, however, had been hospitalized significantly more often than men for mania. Further, whereas bipolar men were significantly more likely than bipolar women to have a comorbid substance use disorder, women with bipolar disorder had 4 times the rate of alcohol use disorders and 7 times the rate of other substance use disorders than reported in women from community-derived samples.
For bipolar disorder, course of illness variables such as age at onset and number of affective episodes of each polarity do not seem to differ across genders. Women, however, may be more likely than men to be hospitalized for manic episodes. While both men and women with the illness have high rates of comorbidity with alcohol and other substance use disorders, women with bipolar disorder are at a particularly high risk for comorbidity with these conditions.
The authors' goal was to pilot test a newly developed manual-based group psychotherapy, called Integrated Group Therapy (IGT), for patients with bipolar disorder and substance dependence.
In this open trial, patients with DSM-IV bipolar disorder and substance dependence (N = 45) were recruited in sequential blocks to receive either group therapy (N = 21) or 6 monthly assessments, but no experimental treatment (N = 24).
When compared with patients who did not receive group therapy, patients who received IGT had significantly better outcomes on the Addiction Severity Index drug composite score (p < .03), percentage of months abstinent (p < .01), and likelihood of achieving 2 (p < .002) or 3 (p < .004) consecutive abstinent months.
IGT is a promising treatment for patients with bipolar disorder and substance dependence, who have traditionally had poor outcomes. It is unclear, however, how much of the improvement among the group therapy patients is attributable to the specific content of the treatment. A study comparing this treatment with another active psychotherapy treatment is warranted.
To determine if bipolar disorder is accurately diagnosed in clinical practice and to assess the effects of antidepressants on the course of bipolar illness.
Charts of outpatients with affective disorder diagnoses seen in an outpatient clinic during 1 year (N = 85 with bipolar or unipolar disorders) were reviewed. Past diagnostic and treatment information was obtained by patient report and systematic psychiatric history. Bipolar diagnosis was based on DSM-IV criteria using a SCID-based interview.
Bipolar disorder was found to be misdiagnosed as unipolar depression in 37% of patients who first see a mental health professional after their first manic/hypomanic episode. Antidepressants were used earlier and more frequently than mood stabilizers, and 23% of this unselected sample experienced a new or worsening rapid-cycling course attributable to antidepressant use.
These results suggest that bipolar disorder tends be misdiagnosed as unipolar major depressive disorder and that antidepressants seem to be associated with a worsened course of bipolar illness. However, this naturalistic trial was uncontrolled, and more controlled research is required to confirm or refute these findings.
Until recently it was believed that no more than 1% of the general population has bipolar disorder. Emerging transatlantic data are beginning to provide converging evidence for a higher prevalence of up to at least 5%. Manic states, even those with mood-incongruent features, as well as mixed (dysphoric) mania, are now formally included in both ICD-10 and DSM-IV. Mixed states occur in an average of 40% of bipolar patients over a lifetime; current evidence supports a broader definition of mixed states consisting of full-blown mania with two or more concomitant depressive symptoms. The largest increase in prevalence rates, however, is accounted for by 'softer' clinical expressions of bipolarity situated between the extremes of full-blown bipolar disorder where the person has at least one manic episode (bipolar I) and strictly defined unipolar major depressive disorder without personal or family history for excited periods. Bipolar II is the prototype for these intermediary conditions with major depressions and history of spontaneous hypomanic episodes; current evidence indicates that most hypomanias pursue a recurrent course and that their usual duration is 1-3 days, falling below the arbitrary 4-day cutoff required in DSM-IV. Depressions with antidepressant-associated hypomania (sometimes referred to as bipolar III) also appear, on the basis of extensive international research neglected by both ICD-10 and DSM-IV, to belong to the clinical spectrum of bipolar disorders. Broadly defined, the bipolar spectrum in studies conducted during the last decade accounts for 30-55% of all major depressions. Rapid-cycling, defined as alternation of depressive and excited (at least four per year), more often arise from a bipolar II than a bipolar I baseline; such cycling does not in the main appear to be a distinct clinical subtype - but rather a transient complication in 20% in the long-term course of bipolar disorder. Major depressions superimposed on cyclothymic oscillations represent a more severe variant of bipolar II, often mistaken for borderline or other personality disorders in the dramatic cluster. Moreover, atypical depressive features with reversed vegetative signs, anxiety states, as well as alcohol and substance abuse comorbidity, is common in these and other bipolar patients. The proper recognition of the entire clinical spectrum of bipolarity behind such 'masks' has important implications for psychiatric research and practice. Conditions which require further investigation include: (1) major depressive episodes where hyperthymic traits - lifelong hypomanic features without discrete hypomanic episodes - dominate the intermorbid or premorbid phases; and (2) depressive mixed states consisting of few hypomanic symptoms (i.e., racing thoughts, sexual arousal) during full-blown major depressive episodes - included in Kraepelin's schema of mixed states, but excluded by DSM-IV. These do not exhaust all potential diagnostic entities for possible inclusion in the clinical spectrum of bipolar disorders: the present review did not consider cyclic, seasonal, irritable-dysphoric or otherwise impulse-ridden, intermittently explosive or agitated psychiatric conditions for which the bipolar connection is less established. The concept of bipolar spectrum as used herein denotes overlapping clinical expressions, without necessarily implying underlying genetic homogeneity. In the course of the illness of the same patient, one often observes the varied manifestations described above - whether they be formal diagnostic categories or those which have remained outside the official nosology. Some form of life charting of illness with colored graphic representation of episodes, stressors, and treatments received can be used to document the uniquely varied course characteristic of each patient, thereby greatly enhancing clinical evaluation.
Uncertainties exist about whether depressive episodes differ phenomenologically in unipolar and bipolar II patients. The aim of the present study was to better define the clinical picture and course of bipolar II depression. Three hundred and ninety-nine consecutive outpatients, presenting for treatment of unipolar and bipolar II depression, were interviewed with the Structured Clinical Interview for DSM-IV, the Montgomery-Asberg Depression Rating Scale and the Global Assessment of Functioning Scale. Bipolar II depression had significantly lower age at onset, more recurrences and more patients with DSM-IV atypical features. Gender, duration of illness, psychosis, chronicity, severity, axis I comorbidity, melancholic features, individual atypical symptoms and other symptoms of depression were not significantly different. The presence of DSM-IV atypical features predicted bipolar II diagnosis with 63% probability.
The efficacy and effectiveness of cognitive therapy (CT) is well established for unipolar disorders, but little is known about its utility in bipolar disorders. This study aimed to explore the feasibility and efficacy of using CT as an adjunct to usual psychiatric treatment in this patient population.
Subjects referred by general adult psychiatrists were assessed by and independent rater and then randomly allocated to immediate CT (N = 21) or 6-month waiting-list control, which was then followed by CT (N = 21). Observer and self-ratings of symptoms and functioning were undertaken immediately prior to CT, after a 6-month course of CT and a further 6-months later. Data on relapse and hospitalization rates in the 18 months before and after commencing CT were also collected.
At 6-month follow-up, subjects allocated to CT showed statistically significantly greater improvements in symptoms and functioning as measured on the Beck Depression Inventory, the Internal State Scale, and the Global Assessment of Functioning than those in the waiting-list control group. In the 29 patients who eventually received CT, relapse rates in the 1 8 months after commencing CT showed a 60 % reduction in comparison with the 18 months prior to commencing CT. Seventy per cent of subjects who commenced therapy viewed CT as highly acceptable.
Although the results of this study are encouraging, the use of CT in subjects with bipolar disorders is more complex than in unipolar disorders and requires a high level of therapist expertise. The therapy may prove to be particularly useful in the treatment of bipolar depression.
Bipolar disorder (BD) is a common disorder that results in significant psychosocial impairment, including diminished quality of life and functioning, despite aggressive pharmacotherapy. Psychosocial interventions that target functional factors could be beneficial for this population, and we hypothesized that the addition of group cognitive behavioral therapy (CBT) to maintenance pharmacotherapy would improve functioning and quality of life.
Patients diagnosed (by SCID) with bipolar disorder attending an outpatient clinic of a mood disorders program participated in the study. All patients were on maintenance mood stabilizers, and were required to have controlled symptoms before entering the study. Mood symptoms were assessed with the Hamilton Depression Rating scale and Young Mania scale at baseline and 14 weeks. Objective and subjective functioning was rated at the same interval using the Global Assessment of Functioning scale and the Medical Outcomes Survey SF-36. Treatment was provided via a specific manual based on CBT principles that could be applied to this population.
Forty nine patients participated in this open trial, and 38 patients completed treatment. Objective and subjective indices of impairment showed improvement after 14 weeks. Both GAF and MOS scores increased significantly by the end of treatment.
This study was an open trial, and lack of control groups limits the interpretation of results. Because the study concerned effectiveness, the results do not clarify whether the improvement represents the normal course of illness or whether it is the result of the CBT intervention.
The addition of group CBT to standard pharmacological treatment was acceptable to patients, and nearly 80% of patients complied with treatment. Despite the fact that mood symptoms were controlled at entry into the study, psychosocial functioning increased significantly at the end of treatment. Adjunctive CBT should be further investigated in this population.
Symptomatological differences between bipolar II (n = 251) and unipolar (n = 306) depressed outpatients, interviewed with the Structured Clinical Interview for DSM-IV, were studied by Montgomery Asberg Depression Rating Scale factor analysis. Different factors were found in bipolar II [factor 1 (apparent sadness, reported sadness), factor 2 (reduced sleep, reduced appetite), factor 3 (concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal thoughts)], and in unipolar [factor 1 (apparent sadness, reported sadness, inability to feel, suicidal thoughts), factor 2 (concentration difficulties, lassitude, inability to feel, pessimistic thoughts), factor 3 (inner tension, reduced sleep)]. Different factor structure (between bipolar II and unipolar depression) supports previous findings that response to antidepressants and biology may be different in bipolar II and unipolar depression.
A brief diary instrument to quantify daily lifestyle regularity (SRM-5) is developed and compared with a much longer version of the instrument (SRM-17) described and used previously. Three studies are described. In Study 1, SRM-17 scores (2 weeks) were collected from a total of 293 healthy control subjects (both genders) aged between 19 and 92 years. Five items (1) Get out of bed, (2) First contact with another person, (3) Start work, housework or volunteer activities, (4) Have dinner, and (5) Go to bed were then selected from the 17 items and SRM-5 scores calculated as if these five items were the only ones collected. Comparisons were made with SRM-17 scores from the same subject-weeks, looking at correlations between the two SRM measures, and the effects of age and gender on lifestyle regularity as measured by the two instruments. In Study 2 this process was repeated in a group of 27 subjects who were in remission from unipolar depression after treatment with psychotherapy and who completed SRM-17 for at least 20 successive weeks. SRM-5 and SRM-17 scores were then correlated within an individual using time as the random variable, allowing an indication of how successful SRM-5 was in tracking changes in lifestyle regularity (within an individual) over time. In Study 3 an SRM-5 diary instrument was administered to 101 healthy control subjects (both genders, aged 20-59 years) for two successive weeks to obtain normative measures and to test for correlations with age and morningness. Measures of lifestyle regularity from SRM-5 correlated quite well (about 0.8) with those from SRM-17 both between subjects, and within-subjects over time. As a detector of irregularity as defined by SRM-17, the SRM-5 instrument showed acceptable values of kappa (0.69), sensitivity (74%) and specificity (95%). There were, however, differences in mean level, with SRM-5 scores being about 0.9 units [about one standard deviation (SD)] above SRM-17 scores from the same subject-weeks. SRM-5 scores also deviated more from a Gaussian distribution than did SRM-17 ones. In a study with a sample size of 101, the new SRM-5 instrument yielded scores with a mean of 4.11 and an SD of 1.13. Correlations between lifestyle regularity and age, and between lifestyle regularity and morningness appeared similar whether 5-item or 17-item SRM measures were used. When a gender difference in lifestyle regularity appeared, it was detected by both SRM-5 and SRM-17 measures.
The present analyses were designed to compare the clinical characteristics and long-term episode course of Bipolar-I and Bipolar-II patients in order to help clarify the relationship between these disorders and to test the bipolar spectrum hypothesis.
The patient sample consisted of 135 definite RDC Bipolar-I (BP-I) and 71 definite RDC Bipolar-II patients who entered the NIMH Collaborative Depression Study (CDS) between 1978 and 1981; and were followed systematically for up to 20 years. Groups were compared on demographic and clinical characteristics at intake, and lifetime comorbidity of anxiety and substance use disorders. Subsets of patients were compared on the number and type of affective episodes and the duration of inter-episode well intervals observed during a 10-year period following their resolution of the intake affective episode.
BP-I and BP-II had similar demographic characteristics and ages of onset of their first affective episode. Both disorders had more lifetime comorbid substance abuse disorders than the general population. BP-II had a significantly higher lifetime prevalence of anxiety disorders in general, and social and simple phobias in particular, compared to BP-I. Intake episodes of BP-I were significantly more acutely severe. BP-II patietns had a substantially more chronic course, with significantly more major and minor depressive episodes and shorter inter-episode well intervals. BP-II patients were prescribed somatic treatment a substantially lower percentage of time during and between affective episodes.
BP-I patients with severe manic course are less likely to be retained in long-term follow-up, whereas the reverse might be true for BP-II patients who are significantly more prone to depression (i.e., patients with less inclination to depression and with good prognosis may have dropped out in greater proportions); this could increase the gap in long term course characteristics between the two samples. The greater chronicity of BP-II may be due, in part, to the fact that the patients were prescribed somatic treatments substantially less often both during and between affective episodes.
The variety in severity of the affective episodes shows that bipolar disorders, similar to unipolar disorders, are expressed longitudinally during their course as a dimensional illness. The similarities of the clinical phenotypes of BP-I and BP-II, suggest that BP-I and BP-II are likely to exist in a disease spectrum. They are, however, sufficiently distinct in terms of long-term course (i.e., BP-I with more severe episodes, and BP-II more chronic with a predominantly depressive course), that they are best classified as two separate subtypes in the official classification systems.
In recent years, much progress has been made in the diagnosis and treatment of schizophrenia and depression. Bipolar disorder, however, remains frequently misunderstood, leading to inconsistent diagnosis and treatment. Why is the case? What is to be done about it?
We critically review studies in the nosology of bipolar disorder and the effects of antidepressant agents.
Bipolar disorder is underdiagnosed and frequently misdiagnosed as unipolar major depressive disorder. Antidepressants are probably overused and mood stabilisers underused. Reasons for underdiagnosis include patients' impaired insight into mania, failure to involve family members in the diagnostic process, and inadequate understanding by clinicians of manic symptoms. We propose using a mnemonic to aid in diagnosis, obtaining family report, and utilising careful clinical interviewing techniques given the limitations of patients' self-report. We recommend aggressive use of mood stabilisers, and less emphasis on antidepressants.
The state of diagnosis and treatment in bipolar disorder is suboptimal. More diagnostic attention to manic criteria is necessary and the current pattern of use of antidepressant use in bipolar disorder needs to change.
Studies on individual psychotherapy indicate that some interventions may reduce the number of recurrences in bipolar patients. However, there has been a lack of structured, well-designed, blinded, controlled studies demonstrating the efficacy of group psychoeducation to prevent recurrences in patients with bipolar I and II disorder.
One hundred twenty bipolar I and II outpatients in remission (Young Mania Rating Scale score <6, Hamilton Depression Rating Scale-17 score <8) for at least 6 months prior to inclusion in the study, who were receiving standard pharmacologic treatment, were included in a controlled trial. Subjects were matched for age and sex and randomized to receive, in addition to standard psychiatric care, 21 sessions of group psychoeducation or 21 sessions of nonstructured group meetings. Subjects were assessed monthly during the 21-week treatment period and throughout the 2-year follow-up.
Group psychoeducation significantly reduced the number of relapsed patients and the number of recurrences per patient, and increased the time to depressive, manic, hypomanic, and mixed recurrences. The number and length of hospitalizations per patient were also lower in patients who received psychoeducation.
Group psychoeducation is an efficacious intervention to prevent recurrence in pharmacologically treated patients with bipolar I and II disorder.
Inconsistent clinical differences were reported in bipolar II versus unipolar depression. Age difference may be a confounding factor. Study aims were to describe the clinical and family history features of bipolar II versus unipolar depression, and to control for the possible confounding effect of age on clinical features.
Consecutive 126 unipolar and 187 bipolar II major depressive episode (MDE) outpatients were interviewed with the Structured Clinical Interview for DSM-IV. Variables studied were gender, age, age of onset, MDE recurrences, axis I comorbidity, MDE severity, psychotic, melancholic, and atypical features, depression chronicity, melancholic, atypical, and hypomanic symptoms, depressive mixed state-DMX3 (MDE+three or more concurrent hypomanic symptoms), and mood disorders family history. The effect of age on clinical differences was controlled by logistic regression (by adding age as an independent variable after each independent variable).
Bipolar II had significantly lower age, lower age of onset, more recurrences, more atypical features, more DMX3, more family history of bipolar II and MDE. Almost all the clinical differences found significant in the first analysis resulted still significant when controlled for age.
Single interviewer, non-blind, cross-sectional assessment, bipolar II diagnosis based on history.
Results confirmed previous findings, and showed that bipolar II-unipolar MDE clinical differences were not related to age.
The 16-item Quick Inventory of Depressive Symptomatology (QIDS), a new measure of depressive symptom severity derived from the 30-item Inventory of Depressive Symptomatology (IDS), is available in both self-report (QIDS-SR(16)) and clinician-rated (QIDS-C(16)) formats. This report evaluates and compares the psychometric properties of the QIDS-SR(16) in relation to the IDS-SR(30) and the 24-item Hamilton Rating Scale for Depression (HAM-D(24)) in 596 adult outpatients treated for chronic nonpsychotic, major depressive disorder. Internal consistency was high for the QIDS-SR(16) (Cronbach's alpha =.86), the IDS-SR(30) (Cronbach's alpha =.92), and the HAM-D(24) (Cronbach's alpha =.88). QIDS-SR(16) total scores were highly correlated with IDS-SR(30) (.96) and HAM-D(24) (.86) total scores. Item-total correlations revealed that several similar items were highly correlated with both QIDS-SR(16) and IDS-SR(30) total scores. Roughly 1.3 times the QIDS-SR(16) total score is predictive of the HAM-D(17) (17-item version of the HAM-D) total score. The QIDS-SR(16) was as sensitive to symptom change as the IDS-SR(30) and HAM-D(24), indicating high concurrent validity for all three scales. The QIDS-SR(16) has highly acceptable psychometric properties, which supports the usefulness of this brief rating of depressive symptom severity in both clinical and research settings.
Bipolar disorder is a highly recurrent and chronic psychiatric condition that shortens life expectancy, causes functional impairment and disruption to social, work and family life. Several forms of bipolar disorder are recognised, including both bipolar I and bipolar II disorder. Bipolar I is characterised by recurrent episodes of depression and mania whereas bipolar II disorder is characterised by recurrent depression and hypomania, a milder form of mania. There has been debate concerning the definition of hypomania since at least the 1970s. The main areas of argument focus on the minimum duration of hypomania, its stem criteria and the number of symptoms required for diagnosis. Arriving at the correct definition of hypomania is a key diagnostic issue. There is increasing evidence for the existence of a broad spectrum of bipolar disorders, and data demonstrating the clinical validity of modifying some of the criteria for hypomania are reviewed here.
The boundary between borderline personality disorder (BPD) and bipolar disorder (BD) is a controversial subject. Clinically, it can be difficult to diagnose patients who present with both affective instability and impulsivity. This paper reviews concepts and challenges related to the overlap of these disorders.
A Medline search was conducted, using the key words borderline personality disorder, bipolar disorder, affective disorder, and personality disorder. Reference lists from articles generated were also used. Publications from the last 20 years were considered.
Studies demonstrate a greater cooccurrence between these 2 disorders than between BPD and other Axis I disorders or between BD and other Axis II disorders. Some authors suggest that many patients diagnosed with BPD are better described as having BD, that the bipolar classification is too narrow, or that BPD should be considered a variant of affective disorders. Others present evidence supporting BPD as a valid construct. Hypotheses about the relation between the 2 disorders and suggestions for clinical practice are offered.
There appears to be sufficient evidence to consider BPD to be a valid diagnosis. Both disorders apply to heterogeneous populations, and their characteristics require further clarification. In diagnostically challenging situations, careful consideration of a patient's longitudinal history is essential. Future research will be important to ensure that our diagnostic classifications reflect clinically useful entities.
Despite the availability of efficacious medications and psychotherapies, care of bipolar disorder in everyday practice is often deficient. This trial evaluated the effectiveness of a multi-component care management program in a population-based sample of people with bipolar disorder.
Four hundred and forty-one patients treated for bipolar disorder during the prior year were randomly assigned to continued usual care or usual care plus a systematic care management program including: initial assessment and care planning, monthly telephone monitoring including brief symptom assessment and medication monitoring, feedback to and coordination with the mental health treatment team, and a structured group psychoeducational program--all provided by a nurse care manager. Blinded quarterly assessments generated week-by-week ratings of severity of depression and mania symptoms using the Longitudinal Interval Follow-Up Evaluation.
Participants assigned to the intervention group had significantly lower mean mania ratings averaged across the 12-month follow-up period (Z= 2.44, p=0.015) and approximately one-third less time in hypomanic or manic episode (2.59 weeks v. 1.69 weeks). Mean depression ratings across the entire follow-up period did not differ significantly between the two groups, but the intervention group showed a greater decline in depression ratings over time (Z statistic for group-by-time interaction = 1.98, p = 0.048).
A systematic care program for bipolar disorder significantly reduces risk of mania over 12 months. Preliminary results suggest a growing effect on depression over time, but longer follow-up will be needed.
Numerous studies have pointed to the failure of prophylaxis with pharmacotherapy alone in the treatment of bipolar I disorder. Recent investigations have demonstrated benefits from the addition of psychoeducation or psychotherapy to pharmacotherapy in this population.
To compare 2 psychosocial interventions: interpersonal and social rhythm therapy (IPSRT) and an intensive clinical management (ICM) approach in the treatment of bipolar I disorder.
Randomized controlled trial involving 4 treatment strategies: acute and maintenance IPSRT (IPSRT/IPSRT), acute and maintenance ICM (ICM/ICM), acute IPSRT followed by maintenance ICM (IPSRT/ICM), or acute ICM followed by maintenance IPSRT (ICM/IPSRT). The preventive maintenance phase lasted 2 years.
Research clinic in a university medical center.
One hundred seventy-five acutely ill individuals with bipolar I disorder recruited from inpatient and outpatient settings, clinical referral, public presentations about bipolar disorder, and other public information activities.
Interpersonal and social rhythm therapy, an adaptation of Klerman and Weissman's interpersonal psychotherapy to which a social rhythm regulation component has been added, and ICM.
Time to stabilization in the acute phase and time to recurrence in the maintenance phase.
We observed no difference between the treatment strategies in time to stabilization. After controlling for covariates of survival time, we found that participants assigned to IPSRT in the acute treatment phase survived longer without a new affective episode (P = .01), irrespective of maintenance treatment assignment. Participants in the IPSRT group had higher regularity of social rhythms at the end of acute treatment (P<.001). Ability to increase regularity of social rhythms during acute treatment was associated with reduced likelihood of recurrence during the maintenance phase (P = .05).
Interpersonal and social rhythm therapy appears to add to the clinical armamentarium for the management of bipolar I disorder, particularly with respect to prophylaxis of new episodes.
Bipolar disorder is both prevalent and disabling. Surveys suggest that patients with bipolar disorder are often misdiagnosed on initial presentation, most often with major depressive disorder. These patients may receive ineffective treatment, which, in some cases, actually worsens outcome, either by inducing manic or mixed states or by increasing mood cycling. Major contributors to misdiagnosis include incomplete history and lack of patient insight as well as presence of psychiatric comorbidity, such as anxiety or substance use disorders. Careful screening for current and past symptoms of mania or hypomania, as well as close clinical follow-up, can help to reduce misdiagnosis.