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Bipolar disorder: which adjunctive psychotherapies are most helpful?

By Nicole MacKee
Bipolar disorder symptom recurrence may be reduced if pharmacotherapy is teamed with psychotherapy focusing on illness management skills, US researchers say.

A systematic review and meta­ analysis of 39 randomised trials (including 3863 participants), published in JAMA Psychiatry, further found that delivering psychotherapy in a family or group format was particularly beneficial.

The researchers analysed clinical trials that compared pharmacotherapy plus manualised psychotherapy (cognitive behavioural therapy [CBT], family or conjoint therapy, interpersonal therapy or psychoeducational therapy) with pharmacotherapy and a control intervention.

Psychoeducation that reinforced illness management skills – such as keeping regular sleep and wake cycles – and was delivered in a family or group format was found to be associated with fewer recurrent episodes after 12 months compared with the same strategies delivered individually (odds ratio, 0.12).

CBT, family or conjoint therapy, and interpersonal therapy were also more effective in stabilising depressive symptoms than usual treatment (standardised mean difference, −0.32, −0.46 and –0.46, respectively).

Professor Malcolm Hopwood, Ramsay Health Care Professor of Psychiatry at the University of Melbourne, said the meta­-analysis provided important detail on the most beneficial types of psychotherapies in bipolar disorder management.

He noted that psychotherapy strategies that involved education about the illness and treatment were most effective when delivered to the patient with their family, and not to the patient alone. ‘Family members are key in helping to manage illness,’ he said.

Rates of study drop­-out were also lower when psychotherapy was delivered in a family setting.

Professor Hopwood said most guidelines now recommended psychotherapy in conjunction with pharmacotherapy in bipolar disorder management, but its use in clinical practice remained variable.

‘Some of that variation is about patient preference, and that is a perfectly understandable; there are patients who are not interested in psychotherapy,’ he said. ‘One would hope that that would only happen after an appropriate discussion about where it might be beneficial.’

Professor Hopwood said it was important that clinicians emphasised good lifestyle management around issues such as ‘diet, exercise, appropriate levels of social activity and good social rhythms, including sleep’.

‘Bipolar disorder is difficult to treat with very high rates of relapse,’ Professor Hopwood said. ‘So, all of the measures we can put in place to reduce that risk are worthwhile and should be utilised.’
JAMA Psychiatry 2020: e202993; doi: 10.1001/jamapsychiatry.2020.2993.