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Objective: To investigate changes in the use of coping styles in response to early symptoms of mania in cognitive-behavioural therapy (CBT), compared with psychoeducation, for bipolar disorder. Method: Data were drawn from a randomized controlled trial comparing CBT and psychoeducation. A subsample of 119 participants completed the Coping Inventory for the Prodromes of Mania and symptom assessments before treatment and 72 weeks later. Results: Both CBT and psychoeducation were associated with similar improvements in symptom burden. Both treatments also produced equivalent improvements in stimulation reduction and problem-directed coping styles, but no statistically significant change on the endorsement of help-seeking behaviours. A treatment interaction showed that a reduction in denial and blame was present only in the CBT treatment condition. Conclusions: CBT and psychoeducation have similar impacts on coping styles for the prodromes of mania. The exception to this is denial and blame, which is positively impacted only by CBT but which does not translate into improved outcome. Given the similar change in coping styles and mood burden, teaching patients about how to cope in adaptive ways with the symptoms of mania may be a shared mechanism of change for CBT and psychoeducation. Clinical trial registration number: NCT00188838.
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482 W La Revue canadienne de psychiatrie, vol 58, no 8, août 2013
CanJPsychiatry 2013;58(8):482–486
Key Words: bipolar disorder,
coping, mania, cognitive-
behavioural therapy,
psychoeducation
Received October 2012,
revised, and accepted March
2013.
Brief Communication
Psychosocial Interventions for Bipolar Disorder and
Coping Style Modication: Similar Clinical Outcomes,
Similar Mechanisms?
Sagar V Parikh, MD, FRCPC
1
; Lisa D Hawke, PhD
2
; Ari Zaretsky, MD, FRCPC
3
;
Serge Beaulieu, MD, FRCPC
4
; Irene Patelis-Siotis, MD, FRCPC
5
;
Glenda MacQueen, MD, FRCPC, PhD
6
; L Trevor Young, MD, FRCPC, PhD
7
;
Lakshmi Yatham, MB, FRCPC
8
; Vytas Velyvis, MA (PhD Candidate)
9
; Claude Bélanger, PhD
10
;
Nancy Poirier, MPs
11
; Jean Enright, RNBN
12
; Pablo Cervantes, MD, FRCPC
13
1
Deputy Psychiatrist-in-Chief, University Health Network, Toronto, Ontario; Professor of Psychiatry, University of Toronto, Toronto, Ontario.
Correspondence: Toronto Western Hospital—Room 9M–324, 399 Bathurst Street, Toronto, ON M5T 2S8; sagar.parikh@uhn.on.ca.
2
Postdoctoral Research Fellow, University of Toronto, Toronto, Ontario; Postdoctoral Research Fellow, University Health Network, Toronto, Ontario.
3
Psychiatrist-in-Chief, Sunnybrook Health Sciences Centre, Toronto, Ontario; Associate Professor of Psychiatry, University of Toronto, Toronto, Ontario.
4
Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec; Medical Chief, Mood, Anxiety and Impulsivity Disorders Program,
Douglas Mental Health University Institute, Montreal, Quebec.
5
Associate Professor, McMaster University, Hamilton, Ontario; Psychiatrist, Mood Disorders Program, St Joseph’s Healthcare, Hamilton, Ontario.
6
Vice Dean, Faculty of Medicine, University of Calgary, Calgary, Alberta.
7
Professor of Psychiatry, University of Toronto, Toronto, Ontario.
8
Professor of Psychiatry, University of British Columbia, Vancouver, British Columbia.
9
Student, York University, Toronto, Ontario; Lecturer, Adler International Learning, Toronto, Ontario.
10
Professor of Psychology, Université du Québec à Montréal, Montreal, Quebec.
11
Psychologist, Douglas Mental Health University Institute, Montreal, Quebec.
12
Case Manager, Clinical-Administrative Professional Coordinator, McGill University Health Centre, Montreal, Quebec.
13
Psychiatrist, McGill University, Montreal, Quebec.
Objective: To investigate changes in the use of coping styles in response to
early symptoms of mania in cognitive-behavioural therapy (CBT), compared with
psychoeducation, for bipolar disorder.
Method: Data were drawn from a randomized controlled trial comparing CBT and
psychoeducation. A subsample of 119 participants completed the Coping Inventory for the
Prodromes of Mania and symptom assessments before treatment and 72 weeks later.
Results: Both CBT and psychoeducation were associated with similar improvements in
symptom burden. Both treatments also produced equivalent improvements in stimulation
reduction and problem-directed coping styles, but no statistically signicant change on the
endorsement of help-seeking behaviours. A treatment interaction showed that a reduction in
denial and blame was present only in the CBT treatment condition.
Conclusions: CBT and psychoeducation have similar impacts on coping styles for the
prodromes of mania. The exception to this is denial and blame, which is positively impacted
only by CBT but which does not translate into improved outcome. Given the similar change
in coping styles and mood burden, teaching patients about how to cope in adaptive
ways with the symptoms of mania may be a shared mechanism of change for CBT and
psychoeducation.
Clinical Trial Registration Number: NCT00188838
W W W
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The Canadian Journal of Psychiatry, Vol 58, No 8, August 2013 W 483
Psychosocial Interventions for Bipolar Disorder and Coping Style Modication: Similar Clinical Outcomes, Similar Mechanisms?
Abbreviations
BD bipolar disorder
CBT cognitive-behavioural therapy
CIPM Coping Inventory for Prodromes of Mania
LIFE Longitudinal Interval Follow-up Evaluation
RCT randomized controlled trial
Clinical Implications
Coping style should be targeted as a mechanism of
change in BD.
Positive impacts on coping styles support the use of
psychoeducation as a cost-effective means of improving
adaptive coping.
Limitations
BD-II is underrepresented.
Self-report measures are dependent on patient insight
and the ability to detect prodromal symptoms.
A
highly recurrent mental illness, BD poses a considerable
burden on affected people. While pharmacotherapy is
the rst line of treatment, treatment success is moderate.
Adjunctive psychosocial interventions have positive
additional impacts.
1
Psychoeducation, CBT, family therapy,
interpersonal psychotherapies, and collaborative care are all
empirically supported psychosocial treatments for BD.
2
The psychosocial interventions for BD share many
common elements, but also some key differences.
3
With
regard to CBT and psychoeducation, both teach patients
about BD, how to recognize prodromes, and what coping
mechanisms to use to manage symptoms.
3,4
However,
CBT adds cognitive and behavioural techniques, such
as cognitive restructuring, behavioural activation, and
activity scheduling, in a personalized, individual treatment.
Psychoeducation, in contrast, is provided in a standardized
group format with a specic focus on education.
As CBT tends to be longer, more tailored to the person, and
more elaborated than psychoeducation in terms of cognitive
and behavioural techniques, it may be hypothesized
to be more effective. However, in an RCT, CBT and
psychoeducation produced equivalent benet.
5
Among 204
patients with BD, there were no statistically signicant
differences in the risk of recurrence of mania or depression
over 72 weeks based on whether participants received 6
weeks of group psychoeducation or 20 weeks of individual
CBT. Completion and dropout rates were comparable
across treatments, but psychoeducation was administered
at a much lower cost. Given the surprising equivalence in
clinical benet, further exploration of treatment similarities
and differences is required to better understand the
mechanisms of action.
Among the shared targets of CBT and psychoeducation is
education about self-monitoring to help patients learn to
detect early warning signs at the behavioural and cognitive
levels and initiate adaptive coping responses. In this line
of research, Wong and Lam
6
investigated common coping
mechanisms in BD and developed the CIPM. Patients were
found to use 4 categories of coping mechanisms: stimulation
reduction, problem-oriented coping, seeking professional
help, and denial or blame.
6,7
Interventions psychosociales pour le trouble bipolaire et la
modication du style d’adaptation : résultats cliniques semblables,
mécanismes semblables?
Objectif : Rechercher les changements d’utilisation des styles d’adaptation en réponse
aux premiers symptômes de manie dans la thérapie cognitivo-comportementale (TCC),
comparativement à la psychoéducation, pour le trouble bipolaire.
Méthode : Les données ont été tirées d’un essai randomisé contrôlé comparant la TCC avec
la psychoéducation. Un sous-échantillon de 119 participants a rempli l’inventaire d’adaptation
aux prodromes de manie et les évaluations de symptômes avant le traitement, et
72 semaines plus tard.
Résultats : La TCC et la psychoéducation étaient associées à des améliorations semblables
du fardeau des symptômes. Les deux traitements produisaient aussi des améliorations
équivalentes de la réduction de stimulation et des styles d’adaptation axée sur les problèmes,
mais aucun changement statistiquement signicatif de l’acceptation de comportements de
recherche d’aide. Une interaction des traitements a montré qu’une réduction du déni et du
blâme n’était présente que dans le traitement par TCC.
Conclusions : La TCC et la psychoéducation ont des effets semblables sur les styles
d’adaptation pour les prodromes de la manie. Font exception le déni et le blâme, qui ne
répondent positivement qu’à la TCC, ce qui ne se traduit pas par un meilleur résultat.
Étant donné le changement semblable des styles d’adaptation et du fardeau de l’humeur,
enseigner aux patients comment adopter des moyens de s’adapter aux symptômes de manie
peut être un mécanisme de changement partagé par la TCC et la psychoéducation.
Numéro d’enregistrement de l’essai clinique : NCT00188838
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484 W La Revue canadienne de psychiatrie, vol 58, no 8, août 2013
Brief Communication
While pretest analyses from the RCT comparing CBT and
psychoeducation supported the psychometric properties
of the CIPM and described the coping styles used prior to
treatment,
7
treatment impacts on coping styles have not
been examined. Given the similar attention to coping in
psychoeducation and CBT, similar levels of learning may
take place. Our report is a subanalysis of the data from the
CBT, compared with psychoeducation, study investigating
changes in the use of coping mechanisms among patients
receiving either CBT or psychoeducation.
5
Method
Participants
A subgroup of 119 participants is included in our
study, encompassing all participants who completed
the assessment of coping styles at the end of the study.
Participants included in the analyses did not differ on
sociodemographic characteristics, manic or depressive
symptoms, or baseline coping style, compared with those
who were not included. The average age was 42.3 years
(SD 9.7). Participants had a diagnosis of BD-I (73.1%)
or BD-II (26.9%), conrmed with the Structured Clinical
Interview for the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition.
8
There was no difference
between BD-I and BD-II on symptoms, sociodemographic
characteristics, or baseline coping styles, with the exception
of seeking professional help, which was more common in
BD-I, as expected, owing to a prole of full manic episodes
requiring hospitalization.
Procedure
A detailed description of the study is provided elsewhere.
5
Participants were randomized to individual CBT or group
psychoeducation for BD. Psychoeducation consisted of
6 didactic 90-minute sessions drawn from a published
manual.
9
Topics included illness recognition, treatment
approaches, and coping strategies, culminating in the
creation of personal action plans for depression and mania.
CBT consisted of 20 individual 50-minute sessions from a
published manual.
10
Content included psychoeducation on
BD, goal-setting, early warning sign identication, a relapse
action plan, and additional strategies, such as activity
scheduling, behavioural self-monitoring, stimulus control,
and cognitive restructuring. Our study was approved by
the institutional ethics board at each participating medical
centre, and written informed consent was obtained from all
participants.
Measures
We used the following validated assessment tools: LIFE
scale scores for mania or hypomania and depression
11
and
the CIPM. The LIFE is a semistructured interview and
weekly retrospective rating system for depressive and
manic or hypomanic symptoms. It uses a 6-point scale
ranging from no symptoms (low score) to severe syndromal
symptoms (high score). The CIPM
6
is a 23-item, self-report
scale that assesses 4 types of coping responses to prodromes
of mania, including stimulation reduction, problem-directed
coping, seeking professional help, and denial or blame.
Respondents rate the frequency with which they use each
coping strategy on a scale of 1 (never) to 4 (all the time).
The CIPM has been validated among patients with BD.
6,7
Table 1 Sociodemographic and baseline clinical characteristics by treatment
group
Characteristic
CBT PE P
Age, years, mean (SD)
41.9 (10.1) 42.7 (9.4) 0.67
Sex, female, n (%)
38 (65.5) 32 (52.5) 0.15
Employment status, employed full- or
part-time, n (%)
30 (51.7) 25 (41.0) 0.24
Civil status, n (%)
Married or common law
23 (39.7) 29 (48.3) 0.60
Divorced, separated, or widowed
15 (25.9) 12 (20.0)
Single
20 (34.5) 19 (31.7)
BD subtype, n (%)
BD-I
40 (69.0) 47 (77.0) 0.32
BD-II
18 (31.0) 14 (23.0)
HDRS depression, mean (SD)
6.5 (4.5) 6.9 (5.0) 0.68
CARS-M mania, mean (SD)
1.7 (2.7) 2.0 (3.5) 0.65
GAF functioning, mean (SD)
63.6 (11.0) 66.52 (11.2) 0.16
Percentages may not sum to 100%, owing to missing data.
CARS-M = Clinician-Administered Rating Scale for Mania; GAF = Global Assessment of
Functioning; HDRS = Hamilton Depression Rating Scale; PE = psychoeducation
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The Canadian Journal of Psychiatry, Vol 58, No 8, August 2013 W 485
Psychosocial Interventions for Bipolar Disorder and Coping Style Modication: Similar Clinical Outcomes, Similar Mechanisms?
Results
There were no signicant differences between the CBT and
psychoeducation groups based on sociodemographic or
clinical characteristics (Table 1). As in the main outcome
study,
5
this sample replicates the equivalence in weekly
symptom levels in CBT and psychoeducation groups.
Average weekly symptom scores for the rst 20 weeks
of the study were compared with averages for the last 20
weeks of the follow-up period. A signicant time effect
shows a decline in manic symptoms (F = 11.389, df = 1/117,
P = 0.001), with no treatment interaction (F = 0.444,
df = 1/117, P = 0.51). A similar time effect is observed for
depressive symptoms (F = 14.042, df = 1/117, P < 0.001),
with no group interaction (F = 1.659, df = 1/117, P = 0.20).
There was no interaction between treatment groups for
the quantity of pharmacotherapy based on the Intensity of
Somatotherapy Index score (F = 0.982, df = 1/117, P = 0.32).
Endorsement of coping styles before and after treatment
is presented in Figure 1. Signicant time effects show that
the use of stimulation reduction increased signicantly
in both CBT and psychoeducation conditions (F = 19.48,
df = 1/113, P < 0.001), with no treatment interaction
(F = 0.009, df = 1/113, P = 0.93). A similar result was
found for Problem-Directed Coping, with a signicant time
effect (F = 28.20, df = 1/110, P < 0.001), but no interaction
(F = 0.625, df = 1/110, P = 0.43). There was no change
over time in either treatment in the endorsement of seeking
professional help (F = 0.014, df = 1/86, P = 0.91), and
there was no treatment interaction (F = 0.751, df = 1/86,
P = 0.39). A different prole was found for denial or blame:
although the time effect showed a signicant decline
(F = 9.13, df = 1/107, P = 0.003), a signicant interaction
showed that this decline was due to the CBT condition (F =
7.01, df = 1/107, P = 0.009).
Discussion
After either CBT or psychoeducation, patients with BD
increased their use of stimulation reduction and problem-
directed coping styles in response to prodromal manic
symptoms. There was no change in the disposition to seek
professional help, which is not surprising given that all
subjects had a physician and had enrolled in a clinical trial
Figure 1 Changes in the endorsement of coping style (CIPM) and symptom burden (LIFE) before and after
treatment, by treatment condition
2.8
Stimulation reduction
CBT
2.8
Problem-directed coping
CBT
PE
Time:
P
< 0.001
Time: P < 0.001
2.0
2.2
2.4
2.6
2.8
CBT
PE
2.0
2.2
2.4
2.6
2.8
CBT
PE
Time: P < 0.001
Time H Group: P = 0.93
Time: P < 0.001
Time H Group: P = 0.42
1.6
1.8
2.0
2
.
2
Intake 18 months
1.6
1.8
2.0
2
.
2
Intake 18 months
2.8
Denial or blame
CBT
2.8
Seek professional help
Intake 18 months
Intake 18 months
P
=
0.91
Tim
e:
P
= 0
.
003
2.2
2.4
2.6
2.8
CBT
PE
2.2
2.4
2.6
2.8
CBT
PE
Time: P = 0.91
Time H Group: P = 0.39
Time: P = 0.003
Time H Group: P = 0.009
1.6
1.8
2.0
2.2
Intake 18 months
1.6
1.8
2.0
2.2
Intake 18 months
1.6
Intake 18 months
1.6
Intake 18 months
Figure1.Changesintheendorsementofcopingstyle(CIPM)andsymptomburden(LIFE)beforeandaftertreatment,bytreatment
condition.Errorbarsrepresentthestandarderrorofthemean.
condition
.
Error
bars
represent
the
standard
error
of
the
mean
.
2.8
Stimulation reduction
CBT
2.8
Problem-directed coping
CBT
PE
Time:
P
< 0.001
Time: P < 0.001
2.0
2.2
2.4
2.6
2.8
CBT
PE
2.0
2.2
2.4
2.6
2.8
CBT
PE
Time: P < 0.001
Time H Group: P = 0.93
Time: P < 0.001
Time H Group: P = 0.42
1.6
1.8
2.0
2
.
2
Intake 18 months
1.6
1.8
2.0
2
.
2
Intake 18 months
2.8
Denial or blame
CBT
2.8
Seek professional help
Intake 18 months
Intake 18 months
Time:
P
=
0.91
Tim
e:
P
= 0
.
003
2.2
2.4
2.6
2.8
CBT
PE
2.2
2.4
2.6
2.8
CBT
PE
Time: P = 0.91
Time H Group: P = 0.39
Time: P = 0.003
Time H Group: P = 0.009
1.6
1.8
2.0
2.2
Intake 18 months
1.6
1.8
2.0
2.2
Intake 18 months
1.6
Intake 18 months
1.6
Intake 18 months
Figure1.Changesintheendorsementofcopingstyle(CIPM)andsymptomburden(LIFE)beforeandaftertreatment,bytreatment
condition.Errorbarsrepresentthestandarderrorofthemean.
condition
.
Error
bars
represent
the
standard
error
of
the
mean
.
2.8
Stimulation reduction
CBT
2.8
Problem-directed coping
CBT
PE
Time:
P
< 0.001
Time: P < 0.001
2.0
2.2
2.4
2.6
2.8
CBT
PE
2.0
2.2
2.4
2.6
2.8
CBT
PE
Time: P < 0.001
Time H Group: P = 0.93
Time: P < 0.001
Time H Group: P = 0.42
1.6
1.8
2.0
2
.
2
Intake 18 months
1.6
1.8
2.0
2
.
2
Intake 18 months
2.8
Denial or blame
CBT
2.8
Seek professional help
Intake 18 months
Intake 18 months
Time:
P
=
0.91
Tim
e:
P
= 0
.
003
2.2
2.4
2.6
2.8
CBT
PE
2.2
2.4
2.6
2.8
CBT
PE
Time: P = 0.91
Time H Group: P = 0.39
Time: P = 0.003
Time H Group: P = 0.009
1.6
1.8
2.0
2.2
Intake 18 months
1.6
1.8
2.0
2.2
Intake 18 months
1.6
Intake 18 months
1.6
Intake 18 months
Figure1.Changesintheendorsementofcopingstyle(CIPM)andsymptomburden(LIFE)beforeandaftertreatment,bytreatment
condition.Errorbarsrepresentthestandarderrorofthemean.
condition
.
Error
bars
represent
the
standard
error
of
the
mean
.
Error bars represent the standard error of the mean.
PE = psychoeducation
2.8
Stimulation reduction
CBT
2.8
Problem-directed coping
CBT
PE
Time:
P
< 0.001
Time: P < 0.001
2.0
2.2
2.4
2.6
2.8
CBT
PE
2.0
2.2
2.4
2.6
2.8
CBT
PE
Time: P < 0.001
Time H Group: P = 0.93
Time: P < 0.001
Time H Group: P = 0.42
1.6
1.8
2.0
2
.
2
Intake 18 months
1.6
1.8
2.0
2
.
2
Intake 18 months
2.8
Denial or blame
CBT
2.8
Seek professional help
Intake 18 months
Intake 18 months
Time:
P
=
0.91
Tim
e:
P
= 0
.
003
2.2
2.4
2.6
2.8
CBT
PE
2.2
2.4
2.6
2.8
CBT
PE
Time: P = 0.91
Time H Group: P = 0.39
Time: P = 0.003
Time H Group: P = 0.009
1.6
1.8
2.0
2.2
Intake 18 months
1.6
1.8
2.0
2.2
Intake 18 months
1.6
Intake 18 months
1.6
Intake 18 months
Figure1.Changesintheendorsementofcopingstyle(CIPM)andsymptomburden(LIFE)beforeandaftertreatment,bytreatment
condition.Errorbarsrepresentthestandarderrorofthemean.
condition
.
Error
bars
represent
the
standard
error
of
the
mean
.
www.LaRCP.ca
486 W La Revue canadienne de psychiatrie, vol 58, no 8, août 2013
Brief Communication
involving professional help to enhance coping. In contrast,
only patients undergoing CBT reduced their use of blame
or denial to explain their manic symptoms. These results
can be interpreted in the context of the similarities and
differences between CBT and psychoeducation treatment
approaches.
All psychosocial interventions for BD include instruction in
coping with the disorder.
3
Both CBT and psychoeducation
teach patients to identify prodromes and enact response
behaviours to prevent relapse.
8,9
Target behaviours include
reducing stimulation, contacting health care providers, and
problem solving using cost-benet analysis. Cognitive
restructuring, that is, identifying and challenging
dysfunctional beliefs, is specic to CBT
3
and would
be expected to reduce blame and denial of illness. The
treatment interaction for denial or blame conrms that
CBT was administered as intended and that CBT reduces
cognitive distortions, although this did not translate into
improved clinical outcomes.
While psychosocial interventions for BD have demonstrated
impacts on relapse prevention and symptom reduction, it is
important to begin identifying the shared and differential
mechanisms of change.
1
The cognitive dysfunction often
accompanying BD may compromise adaptive coping,
leading to further relapses and progressively worse
cognitive impairment.
12
This illustrates the importance of
explicitly teaching patients symptom identication and
adaptive coping, as reected in the common focus across
interventions. Early detection has been suggested as a
possible therapeutic ingredient for mania,
1
while early
symptom detection and problem solving skills training
have been suggested as key benets of family-focused
psychotherapy.
13
Based on these ndings, improved coping
may be among the shared mechanisms of change across
treatments.
Study limitations include recruitment primarily from
academic medical centres and an underrepresentation of
BD-II, limiting generalizability. Another limitation is the
self-report assessment of coping; adding observer-rated
assessments may provide more objective measures of
the behavioural manifestations of coping, independent of
insight and ability to detect prodromes.
In summary, our study demonstrated that both CBT
and psychoeducation have signicant impacts on manic
prodrome coping styles. As with the full trial comparing
psychoeducation to CBT in BD, no differences in relapse
rates or time to relapse were seen between treatments.
However, both interventions helped patients learn to reduce
stimulation and use problem-directed coping strategies.
Given the equivalent change in these coping styles and
mood burden, coping style modication may be a shared
mechanism of action of CBT and psychoeducation.
Acknowledgements
Our paper was presented at the 2011 Annual Meeting of the
Canadian Psychiatric Association, where it was awarded
the R O Jones Award for best research paper, second place.
Our study was supported by grants from the Canadian
Institutes for Health Research (MCT 55404) and the Stanley
Medical Research Institute (01–153).
Neither funding body had any input into the design or
conduct of the study; collection, management, analysis,
or interpretation of the data; or preparation, review, or
approval of the manuscript.
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... Kallestad et al. (2016) found that 10 weekly sessions of group PE followed by eight booster-sessions over the next 2 years were superior to three sessions of individual PE in delaying next hospitalization. Parikh et al. (2013) compared 6 weekly group PE sessions with 20 individual CGT sessions and found no difference between the two groups in weekly mood ratings nor in recurrence rates over the next 18 months (Parikh et al. 2013). ...
... Kallestad et al. (2016) found that 10 weekly sessions of group PE followed by eight booster-sessions over the next 2 years were superior to three sessions of individual PE in delaying next hospitalization. Parikh et al. (2013) compared 6 weekly group PE sessions with 20 individual CGT sessions and found no difference between the two groups in weekly mood ratings nor in recurrence rates over the next 18 months (Parikh et al. 2013). ...
Article
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Background: Psychoeducation (PE) for bipolar disorder (BD) has a first-line recommendation for the maintenance treatment phase of BD. Formats vary greatly in the number of sessions, whether offered individually or in a group, and with or without caregivers attending. Due to a large variation in formats in the Netherlands, a new program was developed and implemented in 17 outpatient clinics throughout the country. The current study investigated the feasibility of a newly developed 12-sessions PE group program for patients with BD and their caregivers in routine outpatient practice and additionally explored its effectiveness. Methods: Participants in the study were 108 patients diagnosed with BD, 88 caregivers and 35 course leaders. Feasibility and acceptance of the program were investigated by measures of attendance, and evaluative questionnaires after session 12. Preliminary treatment effects were investigated by pre- and post-measures on mood symptoms, attitudes towards BD and its treatment, levels of self-management, and levels of expressed emotion. Results: There was a high degree of satisfaction with the current program as reported by patients, caregivers, and course leaders. The average attendance was high and 83% of the patients and 75% of the caregivers completed the program. Analyses of treatment effects suggest positive effects on depressive symptoms and self-management in patients, and lower EE as experienced by caregivers. Conclusions: This compact 12-sessions psychoeducation group program showed good feasibility and was well accepted by patients, caregivers, and course leaders. Preliminary effects on measures of self-management, expressed emotions, and depressive symptoms were promising. After its introduction it has been widely implemented in mental health institutions throughout the Netherlands.
... Later, the authors analysed a subsample of 119 patients to investigate changes in coping styles in response to early symptoms of mania and concluded that both groups had similar improvements in symptom burden. Only the CBT group presented a decrease in denial and blame [56]. ...
... No statistically significant differences were found comparing CBT with FFT and IPSRT [52], with supportive therapy [54] and with psychoeducation [55,56]. One study found that adding CBT to psychoeducation had benefits, with a great reduction in depressed mood and need for antidepressants [53], and other study comparing CBT to psychoeducation concluded that CBT had lower relapse rates and shorter mood episodes [57]. ...
... Later, the authors analysed a subsample of 119 patients to investigate changes in coping styles in response to early symptoms of mania and concluded that both groups had similar improvements in symptom burden. Only the CBT group presented a decrease in denial and blame [56]. ...
... No statistically significant differences were found comparing CBT with FFT and IPSRT [52], with supportive therapy [54] and with psychoeducation [55,56]. One study found that adding CBT to psychoeducation had benefits, with a great reduction in depressed mood and need for antidepressants [53], and other study comparing CBT to psychoeducation concluded that CBT had lower relapse rates and shorter mood episodes [57]. ...
Poster
Introduction Bipolar disorder is a chronic disease with a major impact on patient's functioning and quality of life, not only during episodes of mania/hypomania or depression, but also during euthymic periods. In recent years, it has been noticed that pharmacotherapy, albeit its great value, is not enough to prevent recurrences of the disease. Therefore, it has been a greater investment in psychosocial interventions as adjuvant treatment. The utmost studied of these interventions is Cognitive-Behavioral Therapy (CBT). Objectives and aims Gather information about the efficacy of CBT in bipolar disorder. Methods Literature review. Results Several studies have compared groups of bipolar patients submitted to CBT to controls submitted to treatment as usual. The methods and size of samples differ, but the results are in general concordant. Individual or group CBT has had positive results in reducing symptoms, increasing the euthymic periods, decreasing duration of episodes and improving global functioning and quality of life. Conclusions There are limitations on the application of CBT in bipolar patients, mainly the decrease of its effects over time; less efficiency in patients with more severe disease; major impact on depressive symptoms than manic; and lack of human resources trained to apply these techniques. Notwithstanding these limitations, the demonstrated gain in the use of CBT on bipolar disorder is evident; hence, investment in this area is undoubtedly important. Disclosure of interest The authors have not supplied their declaration of competing interest.
... Future directions include replication in independent samples and the examination of premorbid factors associated with DUI in mood disorders. To name a few, coping styles (Compton et al., 2015;Paquin et al., 2021b;Parikh et al., 2013), childhood adversity (Leverich and Post, 2006), and genetic liability (Carballo et al., 2008;Pedersen et al., 2021) have been associated with the course of mood and psychotic disorders, and it would be of interest to examine whether these factors are differentially associated with DUI in major depressive and bipolar disorders. Although we found that longer DUI was overall associated with better illness course, early interventions aimed at shortening treatment delays may nonetheless benefit a subpopulation of at-risk youth. ...
... We can also hypothesize that for patients with high scores in cyclothymic temperament it may be more difficult to identify prodromes, an essential component of psychoeducation, easily. Parikh et al. (2013) concluded that psychoeducation and cognitive-behavioural therapy had similar impact on coping styles for the prodromes of mania. Unfortunately, scarce research to assess the potential psychotherapeutic implications of temperamental subtypes has been carried out. ...
Article
Background : The efficacy of adjunctive group psychoeducation in bipolar disorder has been proven although treatment response differ among individuals. The aim of this study was to characterize responders and non-responders to group psychoeducation in order to identify baseline variables that could predict treatment response. Methods : The sample was composed of 103 medicated euthymic patients with bipolar disorder referred to 21 sessions of group psychoeducation (6 months). Sociodemographic and clinical variables, temperament, circadian rhythms, BDNF, cognitive and psychosocial functioning were collected. At the 18-month endpoint, the patients were split in two groups on the basis of having suffered any recurrence. Significant group differences were included in a logistic regression analysis. Results : Ninety patients out of 103 engaged in group psychoeducation, 47 of whom (52.2%) responded to psychoeducation and 43 (47.8%) did not. Recurrences occurred more often in the follow-up, the most common being depression. Responders and non-responders differed in gender, age at diagnosis, latency of diagnosis, temperament, attention composite score and BDNF. Lower age at diagnosis of bipolar disorder, lower cyclothimic temperament scores and being male -which was associated with bipolar type I and a trend to more previous manic episodes- were significantly related to a better response to psychoeducation in the regression analysis. Limitations : No control group. Conclusions : This study identifies age at diagnosis as a significant modifiable risk factor of treatment response, highlighting the need for early identification of bipolar disorder. Existing programs should be adjusted to the characteristics of specific subpopulations in the framework of a personalized approach.
... Previous studies of coping strategies showed that frequently displayed strategies included self-blame, rumination, problem-direct coping, venting of emotions, substance use, or risk-taking (14,16). It has also been reported that bipolar disorder patients use maladaptive coping strategies more frequently and at a higher level than healthy controls (46). It was found that psychosocial interventions and psychoeducation can provide adequate ways of coping, thus improving functionality in bipolar disorder and reducing hospitalization (47). ...
Article
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Objective: In patients with bipolar disorder, functional losses may be observed even during remission of the disease, and psychopathological traits such as impulsivity, subthreshold clinical symptoms, or stigmatization may influence functionality. Coping strategies are defined as a person's attitudes towards daily life events and their adaptedness. This study aimed to investigate the effects of coping strategies and impulsivity on functionality in bipolar disorder and whether the effect of impulsivity is mediated by dysfunctional coping strategies. Method: This study was conducted with patients suffering from bipolar disorder (n=74) in remission and healthy controls (n=74) matched with the patient group in terms of age, gender and education. Patients were assessed using the Bipolar Disorder Functioning Questionnaire (BDFQ), Coping Strategies Inventory (COPE), Barratt Impulsiveness Scale-11 (BIS-11), Hamilton Depression Rating Scale (HAM-D), Young Mania Rating Scale (YRMS) and Hamilton Anxiety Rating Scale (HAM-A). Results: The functionality score of the bipolar disorder group was significantly lower than in the healthy control group (p=0.027). Moreover, attention (p=0.020) and motor (p=0.006) impulsivity scores were higher and the maladaptive coping strategies score (p=0.032) was lower in the bipolar disorder group. The correlation between the total score of the BIS and the maladaptive coping strategies subscale of the COPE in the bipolar disorder group was statistically significant (r=0.38, p < 0.01). Hierarchical multiple regression analysis showed that adaptive coping strategies (B=0.23, p=0.020), attention (B=-0.31, p=0.037), motor (B=0.29, p=0.027) and nonplanning (B=-0.35, p=0.003) impulsivity were the determinants of the functionality in the regression model (F=8.44, p < 0.001). Conclusion: The study has detected that functionality is affected negatively by impulsivity and positively by adaptive coping strategies in bipolar disorder, whereas the effect of coping strategies on functionality is not mediated by impulsivity. While there was a correlation between impulsivity and maladaptive coping strategies, there was no mediation between impulsivity and coping strategies, which may suggest that these dimensions are independent from each other. Prospective studies with large sample sizes should investigate the clinical determinants of functional losses in the future.
... Future research could investigate the extent to which improvements in this putative change mechanism moderate therapeutic improvements in BD. In relation to preventing hypo/manic relapse, provisional linking themes around planning and intervening early are entirely consistent with existing guidelines (e.g., Malhi et al., 2015) and prior research (e.g., Parikh et al., 2013). The theme of 'decreasing use of stimulants' is noteworthy; while decreasing stimulant use is an implicit or explicit goal of clinical management approaches, the present finding is one of the first pieces of evidence showing that lived experience experts share this insight about interrupting manic ascent. ...
Article
Background: Self-management represents an important complement to psychosocial treatments for bipolar disorder (BD), but research is limited. Specifically, little is known about self-management approaches for elevated mood states; this study investigated self-management strategies for: (1) maintaining balance in mood, and (2) stopping progression into hypomania/mania. Methods: To identify the common components of BD self-management, Delphi Consensus Consultation methods were combined with a Community-Based Participatory Research (CBPR) approach across five study phases: (1) Qualitative dataset content analysis; (2) Academic/grey literature reviews; (3) Content analysis; (4) Two Delphi rounds (rating strategies on a 5-point Likert scale, Very Unhelpful-Very Helpful), and; (5) Quantitative analysis and interpretation. Participants were people with BD and healthcare providers. Results: Phases 1 and 2 identified 262 and 3940 candidate strategies, respectively; 3709 were discarded as duplicates/unintelligible. The remaining 493 were assessed via Delphi methods in Phase 4: 101 people with BD and 52 healthcare providers participated in Round 1; 83 of the BD panel (82%) and 43 of the healthcare provider panel (83%) participated in Round 2-exploratory factor analysis (EFA) was conducted on Round 2 results. Limitations: EFA was underpowered and sample was not ethnically diverse, limiting generalizability. Discussion: High concordance was observed in ratings of strategy effectiveness between the two panels. Future research could usefully investigate the provisional discovery here of underlying factors which link individual strategies. For example, 'maintaining hope' underpinned strategies for maintaining balance, and 'decreasing use of stimulants' underpinned strategies to interrupt hypo/manic ascent. There is merit in combining CBPR and Delphi methods.
Article
Background: Mindfulness as an intervention approach in mental health has been increasingly used to promote health in young people. The aim of this study was to investigate the effectiveness of mindfulness training on coping with stress, test anxiety, and happiness to promote health in female high school students. Materials and methods: The design of this study was quasi-experimental with control group, with pretest and posttest. The statistical population of the study included all the female students studying in the secondary high school in the city of Sanandaj in Iran with 2890 students, 40 of whom were selected by simple random sampling method and were randomly assigned to the experimental (20 individuals) and control groups (20 individuals). Participants completed the Oxford Happiness (0.79), Sarason Exam Anxiety (0.87), and Andler and Parker Stress Management (0.81) Questionnaires. The method of intervention was training based on mindfulness. Data were analyzed using covariance analysis. Results: The results showed that in the posttest, a significant difference was seen between the mean scores of the participants of the experimental and control groups in the variables of problem-oriented, emotion-oriented, and avoidant coping variables (P < 0.05). In addition, the results showed that in the posttest, there was a significant difference between the mean scores of test anxiety; happiness; and happiness components including life satisfaction, self-esteem, active well-being, satisfaction, and positive mood (P < 0.05). Conclusions: Based on the results of the present study, it can be said that mindfulness training is an effective intervention to improve coping styles, test anxiety, and happiness in students.
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Resumen Introducción El trastorno bipolar (TB) es una enfermedad mental grave con un curso crónico y una morbimortalidad importante. El TB tiene una tasa de prevalencia a lo largo de la vida del 1 al 1,5% y se caracteriza por episodios recurrentes de manía, depresión o una mezcla de ambas fases. Aunque tiene tratamiento farmacológico y psicoterapéutico, la terapia cognitiva conductual (TCC) ha mostrado efectos beneficiosos, pero no se cuenta con suficiente información clínica en la literatura actual. Métodos El objetivo principal es determinar la eficacia de la TCC sola o como complemento del tratamiento farmacológico para el TB. Se realizó una revisión sistemática de 17 artículos. Los criterios de inclusión fueron: investigación cuantitativa o cualitativa dirigida a examinar la eficacia de la TCC en pacientes con TB con/sin medicación, publicaciones en idioma inglés y tener 18-65 años de edad. Los criterios de exclusión fueron: artículos de revisión y metanálisis, artículos que incluían a pacientes con otros diagnósticos además de TB y no separaban los resultados basados en dichos diagnósticos y estudios con pacientes que no cumplían los criterios de TB del DSM o ICD. Se realizaron búsquedas en las bases de datos PubMed, PsycINFO y Web of Science hasta el 5 de enero de 2020. La estrategia de búsqueda fue: “Bipolar Disorder” AND “Cognitive Behavioral Therapy”. Resultados Se incluyó en total a 1.531 pacientes de ambos sexos. La media de edad ponderada fue 40,703 años. El número de sesiones varió de 8 a 30, con una duración total de 45-120 min. Todos los estudios muestran resultados variables en la mejora del nivel de depresión y la gravedad de la manía, mejora de la funcionalidad, disminución de recaídas y recurrencias, reducción de los niveles de ansiedad y reducción de la gravedad del insomnio. Conclusiones Se considera que la TCC sola o complementaria para pacientes con TB muestra resultados prometedores después del tratamiento y durante el seguimiento. Los beneficios incluyen niveles reducidos de depresión y manía, menos recaídas y recurrencias y niveles más altos de funcionamiento psicosocial. Se necesitan más estudios.
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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.
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Cited By :4, Export Date: 11 October 2015
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Bipolar disorder (BD) is a prevalent and highly disabling psychiatric condition. Despite the widely acknowledged importance of psychosocial interventions that involve a complex cognitive, behavioral, and biological process to help patients cope better with their illness, few studies have systematically evaluated coping in BD. Therefore, our objective was to examine recent developments in current research on coping in BD. Several studies have documented a strong association between BD and numerous neuroanatomical and neuropsychological abnormalities, particularly multiple episodes and longer durations of the disorder. The most marked effects of BD encompass brain areas involved in executive function, which may affect the mechanisms underlying an adequate selection of coping strategies. Thus, the ability of individuals to reduce their own stress burden is impaired, increasing vulnerability to stressful life events and negatively affecting the course of BD. Psychosocial interventions that focus on BD should be evaluated for their ability to improve coping abilities, and research on BD should consider neuropsychological impairment and cognitive-behavioral strategies for coping with stress.
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A thoroughly updated version of a key practitioner text, this new edition includes a treatment manual of cognitive-behavioural therapy for Bipolar Disorder which incorporates the very latest understanding of the psycho-social aspects of bipolar illness. Updated to reflect treatment packages developed by the authors over the last decade, and the successful completion of a large randomized controlled study which shows the efficacy of CBT for relapse prevention in Bipolar Disorder Demonstrates the positive results of a combined approach of cognitive behavioural therapy and medication Provides readers with a basic knowledge of bipolar disorders and its psycho-social aspects, treatments, and the authors' model for psychological intervention Includes numerous clinical examples and case studies.
Article
• The Longitudinal Interval Follow-up Evaluation (LIFE) is an integrated system for assessing the longitudinal course of psychiatric disorders. It consists of a semistructured interview, an instruction booklet, a coding sheet, and a set of training materials. An interviewer uses the LIFE to collect detailed psychosocial, psychopathologic, and treatment information for a six-month follow-up interval. The weekly psychopathology measures ("psychiatric status ratings") are ordinal symptom-based scales with categories defined to match the levels of symptoms used in the Research Diagnostic Criteria. The ratings provide a separate, concurrent record of the course of each disorder initially diagnosed in patients or developing during the follow-up. Any DSM-III or Research Diagnostic Criteria disorder can be rated with the LIFE, and any length or number of follow-up intervals can be accommodated. The psychosocial and treatment information is recorded so that these data can be linked temporally to the psychiatric status ratings.
Article
Randomized trials of adjunctive psychotherapy for bipolar disorder are reviewed, in tandem with discussion of cost-effectiveness, mediating mechanisms, and moderators of effects. Systematic searches of the MEDLINE and PSYCHLIT databases yielded 19 randomized controlled trials of individual family and group therapies. Outcome variables included time to recovery, relapse or recurrence, symptom severity, medication adherence, and psychosocial functioning. Meta-analyses consistently show that disorder-specific psychotherapies [cognitive-behavioral therapy (CBT), interpersonal, family, and group] augment mood stabilizers in reducing rates of relapse (OR = 0.57; 95% CI: 0.39-0.82) over 1-2 years. Specific mediating mechanisms include, but are not limited to, increasing medication adherence, teaching self-monitoring and early intervention with emergent episodes, and enhancing interpersonal functioning and family communication. All therapies have strengths and weaknesses. One group psychoeducation trial, demonstrated effect sizes for recurrence that are at least equivalent to individual therapies, but findings await replication. Family interventions have been successfully administered in both single and multi-family formats, but no studies report the comparative cost-effectiveness of these formats. The best-studied psychotherapy modality, CBT, can have beneficial effects on depression, but findings are inconsistent across studies and vary with sample characteristics and comparison treatments. Adjunctive psychotherapies can be cost-effective when weighed against observed reductions in recurrence, hospitalization and functional impairments. Future trials need to (i) clarify which populations are most likely to benefit from which strategies; (ii) identify putative mechanisms of action; (iii) systematically evaluate costs, benefits, and generalizability; and (iv) record adverse effects. The application of psychosocial interventions to young-onset populations deserves further study.
Article
Bipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder. This single-blind randomized controlled trial was conducted between June 2002 and September 2006. A total of 204 participants (ages 18-64 years) with DSM-IV bipolar disorder type I or II participated from 4 Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of cognitive-behavioral therapy or 6 sessions of group psychoeducation. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week. Both treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Eight percent of subjects dropped out prior to receiving psychoeducation, while 64% were treatment completers; rates were similar for cognitive-behavioral therapy (6% and 66%, respectively). Psychoeducation cost $180 per subject compared to cognitive-behavioral therapy at $1,200 per subject. Despite longer treatment duration and individualized treatment, cognitive-behavioral therapy did not show a significantly greater clinical benefit compared to group psychoeducation. Psychoeducation is less expensive to provide and requires less clinician training to deliver, suggesting its comparative attractiveness. ClinicalTrials.gov identifier: NCT00188838.