Bipolar Treatment Study Assesses Psychotherapy Efficacy

Depressed patients with bipolar disorder and a coexisting anxiety disorder were more likely to recover with an intensive form of psychotherapy than they were with a brief psychoeducational approach, according to a study comparing the two types of treatments.

The findings come from the National Institute of Mental Health’s Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and were published September 30 online in AJP in Advance. STEP-BD is a large multisite study to examine the effectiveness of treatments for bipolar disorder. There are 4,361 subjects with bipolar disorder enrolled at 21 sites across the United States.

The findings point to the importance for psychiatrists of screening their patients with bipolar disorder for comorbid conditions, said lead author Thilo Deckersbach, Ph.D. “If depressed patients with bipolar disorder also have an anxiety disorder,” he told Psychiatric News, “intensive psychotherapy such as cognitive-behavioral therapy (CBT), family-focused therapy (FFT), or interpersonal and social-rhythm therapy (IPSRT) may be the best treatment options,” in addition to pharmacotherapy.

Deckersbach is an associate professor of psychology at Harvard Medical School and director of psychology at the Bipolar Clinic and Research Program at Massachusetts General Hospital.

He and his colleagues analyzed data from 293 subjects who were randomized to receive either intensive psychotherapy consisting of up to 30 sessions over a nine-month period of either CBT, FFT, or IPSRT or to three sessions over a six-week period of a brief psychoeducational intervention, which the authors referred to as collaborative care. The intervention was designed to help patients learn to recognize signs that a relapse may be imminent and to seek help before a full-blown depressive or manic episode takes hold. The researchers monitored the clinical status of subjects at each outpatient visit using the Clinical Monitoring Form.

Of the subjects in this phase of the study, 66 percent had a current or lifetime anxiety disorder and 34 percent did not.

For subjects with lifetime comorbid anxiety, 66 percent of the participants recovered with the intensive form of psychotherapy, while only 49 percent recovered with the psychoeducation program, the researchers reported.

Recovery status was defined as having two or fewer moderate mood symptoms for eight or more consecutive weeks.

However, for patients without comorbid lifetime anxiety disorders, there was no difference in recovery rates between those assigned to intensive psychotherapy or to psychoeducation: 64 percent of patients without an anxiety disorder recovered with psychotherapy, and 62 percent of patients without a lifetime anxiety disorder recovered with psychoeducation.

When Deckersbach and colleagues examined the relationship between specific types of lifetime anxiety disorder and treatment outcome for depressed patients with bipolar disorder, they found a large difference in recovery rates for patients with generalized anxiety disorder or posttraumatic stress disorder (PTSD) depending on the intervention to which they were assigned. Sixty percent of patients with a lifetime generalized anxiety disorder recovered with intensive psychotherapy, while only 27 percent recovered with psychoeducation. Where the anxiety disorder was PTSD, 63 percent of patients recovered with psychotherapy versus 44 percent with psychoeducation.

Only small differences in recovery rates between the two types of treatments were found for other types of current anxiety disorders such as social phobia, obsessive-compulsive disorder, and panic disorder, for example.

In addition, the researchers looked at the number of lifetime anxiety disorders of the study participants and found that 84 percent of those with one lifetime anxiety disorder recovered after treatment with psychotherapy, while only 53 percent recovered with the psychoeducation intervention. However, for participants with two or more lifetime anxiety disorders, the benefits of the intensive psychotherapeutic treatment seemed to be lost—the recovery rates were similar regardless of the treatment used.

The researchers speculated that it is possible that “individuals with one anxiety disorder need the more-intensive intervention to achieve recovery, whereas individuals with multiple anxiety disorders have more treatment-resistant symptoms and are unlikely to achieve recovery even with intensive psychosocial approaches.”

Deckersbach acknowledged that more research is needed to further clarify the results of the analysis. For example, research more fully exploring the effects of medication changes from baseline assessments on treatment effects throughout the trial or an analysis further exploring the components of various types of the intensive psychotherapy (problem solving or cognitive restructuring) used in the study on anxiety symptoms may further elucidate the results, he said. ■

“Do Comorbid Anxiety Disorders Moderate the Effects of Psychotherapy for Bipolar Disorder?” is posted at http://ajp.psychiatryonline.org/data/Journals/AJP/0/appi.ajp.2013.13020225.pdf.