Combination therapy brought lasting benefits in bipolar disorder

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.