A perspective on the use of psychoeducation, cognitive-behavioral therapy and interpersonal therapy for bipolar patients

Objectives:  Although pharmacological treatment is at present essential for treating bipolar patients, a number of psychological interventions have recently been shown to be efficacious as add-on therapies for the prophylactic treatment of bipolar illness. The study aimed critically to examine the efficacy of several tested patient-focused therapies.
Methods:  A systematic review of the literature on this topic was performed, using MEDLINE, PSYCLIT and CURRENT CONTENTS. 'Bipolar', 'Psychotherapy', 'Psychoeducation', 'Interpersonal' and 'Cognitive-behavioral' were entered as keywords.
Results:  To date, psychoeducation and cognitive-behavioral therapy are the psychological interventions that have been shown to be more efficacious in the prophylaxis of new recurrences. There remains a need for studies investigating the role and efficacy of psychological interventions during acute phases of the illness.
Conclusions:  As their therapeutic goals are complementary, a combination of psychotherapy and pharmacotherapy may allow patients to achieve better symptomatic and functional recovery. Further research is needed to determine which patients may be better candidates for psychological interventions and to estimate the relative effects of the different components of psychological approaches on outcome.     

Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention – a systematic review

Objectives:  Despite some encouraging outcomes and shared components of psychological therapies specific to bipolar disorders, not all studies found conclusively that the addition of a psychosocial intervention to pharmacological interventions improves outcomes. There was some tentative evidence from post hoc analyses that patients with more than 12 previous episodes did not benefit from psychoeducation or cognitive therapy. This paper presents a systematic review and meta-analysis which examines the overall efficacy of bipolar disorder-specific psychological therapies and the impact of the number of previous episodes on the efficacy of psychological therapies in relapse prevention.
Methods:  Systematic literature searches of electronic databases and reference lists of existing reviews were carried out. The number of participants experiencing relapse in randomized, controlled studies was combined in a meta-analysis to determine the overall treatment effect in relapse prevention. Metaregression modeling was used to examine whether the number of previous episodes confounded the number of relapses experienced by participants by the end of treatment.
Results:  Meta-analysis of relapse calculated an overall relative risk of 0.74 [95% confidence interval (CI): 0.64–0.85] with some heterogeneity present (I² = 43.3%). Metaregression of six studies showed no relationship between number of episodes and number of relapses by endpoint.
Conclusion:  Psychological therapy specifically designed for bipolar disorder is effective in preventing or delaying relapses in bipolar disorders, and there is no clear evidence that the number of previous episodes moderated the effect.     

Identifying and improving non-adherence in bipolar disorders

Objectives:  To review the definition of non-adherence, its clinical and economic impact and identify its role and impact in clinical practice.
Methods:  A selective review of the literature as conducted of articles and literature known to the authors.
Results:  There is a paucity of studies examining specifically treatment non-adherence and its consequences in bipolar disorder. Few studies have systematically examined ways in which treatment adherence can impact treatment and improve outcome.
Conclusion:  Non-adherence is common in the management of bipolar disorder. Clinicians and Researchers alike need to remain alert and be aware of issues related to non-adherence – in particular suicide. Like other course-modifiers non-adherence has to be considered, sought and addressed, and this is perhaps best done by including psychoeducation in routine clinical care.     

Neuropsychological functions in patients with bipolar I and bipolar II disorder

Objectives:  The literature reports persistent cognitive impairments in patients with bipolar disorder even after prolonged remission. However, a majority of studies have focused only on bipolar I disorder (BP-I), primarily because bipolar II disorder (BP-II) is often underdiagnosed or misdiagnosed. More attention should be paid to the differences between BP-I and BP-II, especially the aspects of neuropsychological functioning. We examined the different neuropsychological functions in BP-I and BP-II patients and compared them with those of healthy controls.
Methods:  The study included 67 patients with interepisode bipolar disorder (BP-I: n = 30; BP-II: n = 37) and 22 healthy controls compared using a battery of neuropsychological tests that assessed memory, psychomotor speed, and certain aspects of frontal executive function.
Results:  The BP-I group performed poorly on verbal memory, psychomotor speed, and executive function compared to the BP-II and control groups. Both bipolar groups performed significantly less well than the control group on measures of working memory and psychomotor speed, while the BP-II group showed an intermediate level of performance in psychomotor speed compared to the BP-I and control groups. There was no difference between the groups on visual memory.
Conclusions:  BP-I was characterized by reduced performance in verbal memory, working memory, psychomotor speed, and executive function, while BP-II patients showed a reduction only in working memory and psychomotor speed. Cognitive impairment existed in both subtypes of bipolar disorder, and was greater in BP-I patients. Rehabilitation interventions should take into account potential cognitive differences between these bipolar subtypes.     

Developing the BALANCE trail--the role of the pilot study and start-up phase

Objectives:  The initial design of the BALANCE (Bipolar Affective disorder: Lithium / ANtiConvulsant Comparative Evaluation) Trial of maintenance treatment for bipolar disorder was based on the experience of previous trials in bipolar disorder and psychiatry and on the methods developed for large randomized trials in other areas of medicine. This report describes the adaptations to the initial design and trial procedures following the initial phases of the study. The rationale for the trial and full protocol have been published elsewhere.
Methods:  A pilot study and start-up phase were used to check the tolerability of the interventions, refine the trial design and develop trial procedures that are acceptable to both clinicians and patients.
Results:  Changes to the procedures included: the dropping of masking of allocated treatment from clinicians and participants; introduction of the use of postal delivery to supply medication; and dispensing with the proposed schedule of regular follow up appointments. In addition, support was made available to participating psychiatrists who often had limited experience of participating in randomized trials.
Conclusions:  Pilot studies and start-up phases are essential to refine clinical trial design and allow development of procedures that are both methodologically rigorous and flexible and robust enough to promote recruitment and follow up. BALANCE is now actively recruiting in the UK and USA.     

Eliciting Children's and Young People's Views of Child and Adolescent Mental Health Services: A Systematic Review of Best Practice

Background:  A systematic review of children's and young people's views of Child and Adolescent Mental Health Services (CAMHS) was undertaken to identify the methods used, the 'best practice' methods, and the methods most effective in leading to service changes.
Method:  Electronic databases and grey literature were systematically searched. Both authors independently quality-appraised studies using a standard framework. Of 381 studies identified, only 13 were both relevant and of sufficient quality to be included in the review. Interviews, focus groups, brainstorming exercises, and questionnaires were the methods used.
Results:  No study reported a change of practice as a result of hearing children's and young people's views.
Key Practitioner Message:  So few studies have been adequately reported in the literature that it is difficult to make recommendations about good practice for undertaking views studies in CAMHS. Practitioners should use age-appropriate and rigorous methods, report findings clearly, and check beforehand that their organisation is willing and able to implement changes suggested by the young people.     

Publishing affects funding in neurology

Background and purpose:  A new national system for funding research in universities and hospitals in Norway based on publication output is described.
Methods:  All scientific publications were counted and weighted according to the quality of the publication channel. Author addresses were credited. This led to a number of publication points for each institution/department.
Results:  The number of publication points for neurology had increased from 75.0 in 2005 to 98.3 in 2007. Publishing and the quality of publications were given more attention than before, and there was a stronger focus on facilitating research at the institutions. Research was regarded as not only an institutional but also as an individual responsibility.
Conclusions:  The principle of performance-based funding in addition to funding based on project applications has been well received, and it stimulates more and better research. Scientific publications represent a useful marker, whereas the way of counting author addresses and determining quality is still debated.     

Longitudinal outcome in patients with bipolar disorder assessed by life-charting is influenced by DSM-IV personality disorder symptoms

Objectives:  Few studies have examined the question of how personality features impact outcome in bipolar disorder (BD), though results from extant work and studies in major depressive disorder suggest that personality features are important in predicting outcome. The primary purpose of this paper was to examine the impact of DSM-IV personality disorder symptoms on long-term clinical outcome in BD.
Methods:  The study used a 'life-charting' approach in which 87 BD patients were followed regularly and treated according to published guidelines. Outcome was determined by examining symptoms over the most recent year of follow-up and personality symptoms were assessed with the Structured Clinical Interview for DSM-IV (SCID-II) instrument at entry into the life-charting study.
Results:  Patients with better outcomes had fewer personality disorder symptoms in seven out of 10 disorder categories and Cluster A personality disorder symptoms best distinguished euthymic and symptomatic patients.
Conclusions:  These results raise important questions about the mechanisms linking personality pathology and outcome in BD, and argue that conceptual models concerning personality pathology and BD need to be further developed. Treatment implications of our results, such as need for psychosocial interventions and treatment algorithms, are also described.     

EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force

Background:  Migraine is one of the most frequent disabling neurological conditions with a major impact on the patients' quality of life.
Objectives:  To give evidence-based or expert recommendations for the different drug treatment procedures in the particular migraine syndromes based on a literature search and the consensus of an expert panel.
Methods:  All available medical reference systems were screened for the range of clinical studies on migraine with and without aura and on migraine-like syndromes. The findings in these studies were evaluated according to the recommendations of the European Federation of Neurological Societies (EFNS) resulting in level A, B, or C recommendations and good practice points.
Recommendations:  For the acute treatment of migraine attacks, oral non-steroidal antiinflammatory drug (NSAID) and triptans are recommended. The administration should follow the concept of stratified treatment. Before intake of NSAID and triptans, oral metoclopramide or domperidone is recommended. In very severe attacks, intravenous acetylsalicylic acid or subcutaneous sumatriptan are drugs of first choice. Status migrainosus can be treated by cortoicosteroids, although this is not universally held to be helpful, or dihydroergotamine. For the prophylaxis of migraine, betablockers (propranolol and metoprolol) flunarizine, valproic acid, and topiramate are drugs of first choice. Drugs of second choice for migraine prophylaxis include amitriptyline, naproxen, petasites, and bisoprolol.     

The International Society for Bipolar Disorders (ISBD) Task Force report on the nomenclature of course and outcome in bipolar disorders

Objectives:  Via an international panel of experts, this paper attempts to document, review, interpret, and propose operational definitions used to describe the course of bipolar disorders for worldwide use, and to disseminate consensus opinion, supported by the existing literature, in order to better predict course and treatment outcomes.
Methods:  Under the auspices of the International Society for Bipolar Disorders, a task force was convened to examine, report, discuss, and integrate findings from the scientific literature related to observational and clinical trial studies in order to reach consensus and propose terminology describing course and outcome in bipolar disorders.
Results:  Consensus opinion was reached regarding the definition of nine terms (response, remission, recovery, relapse, recurrence, subsyndromal states, predominant polarity, switch, and functional outcome) commonly used to describe course and outcomes in bipolar disorders. Further studies are needed to validate the proposed definitions.
Conclusion:  Determination and dissemination of a consensus nomenclature serve as the first step toward producing a validated and standardized system to define course and outcome in bipolar disorders in order to identify predictors of outcome and effects of treatment. The task force acknowledges that there is limited validity to the proposed terms, as for the most part they represent a consensus opinion. These definitions need to be validated in existing databases and in future studies, and the primary goals of the task force are to stimulate research on the validity of proposed concepts and further standardize the technical nomenclature.     

Dangerous Children: Assessment and Management of Risk

Background:  Workers in the field of child health appear to be presented with increasing numbers of young people who exhibit behaviours that pose a potential or actual risk to the safety of others.
Method:  A review of the current literature on the assessment and management of these children and adolescents was conducted.
Results:  A history taking check-list has been devised on the basis of what is known about current associations with background and current factors and violent acts directed to others. There is emerging evidence of interventions that may be effective in reducing long-term risks in such youths. However, these are often resource intensive and may be less effective in older children and adolescents.
Conclusions:  Faced with the challenge of assessing and managing severely conduct disordered children, child and family mental health teams should develop formalised assessment procedures and protocols for managing risk factors in a multi-agency context.     

Assessment of treatment response in mania: commentary and new findings

Background:  Assessment of therapeutic interventions in bipolar disorder is complicated by rapid, complex clinical changes, high placebo-response rates, and varying times to specific levels of clinical recovery that may not be adequately reflected in averaged rating-scale scores particularly in acute mania, calling for improved methods to evaluate treatment responses. Chengappa et al. ( 1 ) propose operational criteria for specific outcomes based on rating-scale data from two placebo-controlled trials of olanzapine in mania.
Methods:  These trials and other recent research were considered in commenting on the design, conduct, analysis and interpretation of experimental therapeutic trials in mania and to optimize olanzapine versus placebo contrasts by systematically varying end-point criteria for mania (YMRS) and depression (HDRS) ratings.
Results:  Olanzapine versus placebo responses were optimally separated at scores of 10 for final paired mania and depression ratings, or 5 for each rating scale considered separately.
Conclusions:  Use of empirically determined end-points derived from standard rating scales used in experimental therapeutics research in mood disorders can improve both outcome-assessment and separation of active treatment from placebo responses in acute mania.     

Family-focused treatment of the suicidal bipolar patient

Objectives:  Bipolar patients are at high risk for suicidal ideation and attempts. Suicidal behavior is correlated with poor family communication and/or high levels of intrafamilial conflict, particularly among adolescent bipolar patients. This article describes the application of family-focused therapy (FFT) as an adjunct to pharmacotherapy in the management of suicidal ideation and behavior among bipolar patients.
Methods:  We describe the empirical basis of FFT in studies of adult and adolescent patients. We then describe the manner by which the three modules of FFT – psychoeducation, communication skills training and problem solving – are adapted to address the clinical issues presented by suicidal bipolar adults or adolescents and their families.
Results:  Key objectives of the treatment are to help the family recognize that suicidal behavior is a part of the pathophysiology of bipolar disorder but that it is also to some extent under environmental control. Thus, the family is in a unique position to develop and help assure the success of a suicide prevention contract. A case study of an adolescent with suicidal behavior is presented.
Conclusions:  Future research should include a focus on: (i) cross-cultural issues in suicide and bipolar disorder; and (ii) the adaptation of interventions shown to be effective in reducing suicidal behaviors in non-bipolar populations.     

Maintenance treatment in bipolar disorder: a reassessment of lithium as the first choice

Objective:  In consideration of the declining use of lithium over the past several decades, this review focuses on three topics to argue for lithium's status as first choice as the maintenance treatment of bipolar disorder.
Methods:  This review (i) describes success rates for patients assigned to lithium and those assigned to placebo in early (1973–1976) and recent (2000–2003) trials, as well as those assigned to alternative mood stabilizers versus placebo; (ii) summarizes the results of studies that compared lithium to alternative mood stabilizers by the degree of weight gain during maintenance therapy; and (iii) reviews evidence that lithium exhibits unique antisuicidal properties.
Results:  Differing success rates in early and more recent maintenance trials strongly suggest a cohort effect in which the lithium responders are relatively unavailable for recent maintenance trials. Moreover, among mood stabilizers studied in randomized trials, lithium appears least likely to cause substantial weight gain, and a considerable literature has developed to suggest that lithium has antisuicidal effects that extend beyond its benefits in relapse prevention.
Conclusion:  The evidence reviewed here strongly supports the consideration of lithium when prophylactic treatment is first begun for a bipolar patient.     

The Pyramid Club Primary School-Based Intervention: Evaluating the Impact on Children's Social-Emotional Health

Background:  Children with poor social-emotional health are at risk of failing to reach their potential.
Method:  The impact of the Pyramid Club year 3 preventive intervention on children's social-emotional health was investigated. Children were allocated to an intervention or non-problem comparison group.
Results:  Post-intervention both groups had improved Total Difficulty scores (Strengths and Difficulties Questionnaire) with the Pyramid group showing a significantly stronger effect size ( r  = .71) than the non-problem comparison group ( r  = .44).
Conclusions:  The Pyramid Club intervention improves the social-emotional health of vulnerable children. The need to evaluate such interventions and to extend research are discussed.     

Newer treatment studies for bipolar depression

Objective:  Depressive symptoms of bipolar disorder have more negative impact on a patient's life than manic symptoms. This review focused on the emerging efficacy data for treatments in bipolar depression.
Methods:  English-language literature cited in Medline was searched with terms bipolar depression, clinical trial, and trial. Randomized, placebo-controlled trials of newer studies with older agents and all studies with newer or novel agents were prioritized. Open-label studies of novel agents presented at major scientific meetings were also included.
Results:  Olanzapine, olanzapine–fluoxetine combination (OFC), and quetiapine were superior to placebo in the acute treatment of bipolar depression. Lamotrigine only significantly reduced core symptoms of depression compared with placebo. Pramipexole, a dopamine D2/D3 receptor agonist and omega-3 fatty acids, a polyunsaturated fatty acid, augmentation to mood stabilizer (MS) had superiority to placebo in reducing depressive symptoms. Topiramate augmentation of an MS was equally as effective as Bupropion-SR. Patients treated with an MS responded well to the addition of agomelatine, a melatonin receptor agonist with 5-HT2C antagonist properties. However, inositol and repetitive transcranial magnetic stimulation did not separate from placebo. Lamotrigine and olanzapine, and to a lesser extent, divalproex, are superior to placebo in preventing depressive relapses. All agents were relatively well tolerated.
Conclusions:  Olanzapine, OFC, and quetiapine are effective in the acute treatment of bipolar depression. Compared with lithium and divalproex, lamotrigine is more effective in preventing bipolar depression. Larger controlled studies of the other agents in the acute and maintenance treatment of bipolar depression are warranted.     

Anticonvulsants in bipolar disorders: current research and practice and future directions

Objectives:  To determine the clinical effectiveness of drugs with anticonvulsant properties for interventions in persons with bipolar disorder and to place these findings in the context of clinicians' practices and their implications for future research to more effectively manage bipolar disorders.
Methods:  Major electronic databases were searched up to February 2009 for clinical trial data, both original studies and reviews, on drugs with anticonvulsant properties studied for bipolar disorders.
Results:  Valproate, principally as divalproex, has strong evidence for effectiveness in mania, moderately strong evidence for benefits in prophylaxis of recovered states, and recent proof-of-concept evidence for benefits in bipolar depression. Lamotrigine has strong evidence for evidence for effectiveness in maintenance treatment of bipolar disorder, principally for benefits in depressive states. Lamotrigine has been established as ineffective in mania and has lacked efficacy in acute bipolar depression in most randomized trials. Carbamazepine has strong evidence for effectiveness in mania, but lacks adequate studies in other aspects of bipolar disorder treatment. Its adverse effect profile and pharmacokinetic interference with a wide range of drugs, including many employed in bipolar disorder, warrants limitation of use to patients who have responded inadequately to other regimens.
Conclusions:  Three drugs, valproate, lamotrigine, and carbamazepine, have strong evidence-based support for use in clinical states of bipolar disorder. Other anticonvulsant drugs investigated in bipolar disorder either have evidence of lack of benefits in bipolar disorder or have been inadequately studied to determine possible effectiveness.