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Q In patients with DSM-IV bipolar I disorder, is medication plus cognitive therapy (CT) more effective than medication alone for reducing relapses and number of days in bipolar episodes?
METHODS
Design:
randomised controlled trial.
Allocation:
concealed.*
Blinding:
blinded (outcome assessors).*
Follow up period:
30 months.
Setting:
Institute of Psychiatry, King’s College, London, UK.
Patients:
103 patients (mean age 44 y, 56% women) who met DSM-IV criteria for bipolar I disorder. Patients were also required to have had ⩾2 episodes in the last 2 years or 3 episodes in the last 5 years. Actively suicidal or patients with a current substance use disorder were excluded.
Intervention:
medication plus CT (n = 52) or medication alone (n = 51). All patients received mood stabilisers and regular psychiatric follow up. In addition, the CT group received an average of 14 sessions of CT during the first 6 months and 2 booster sessions in the second 6 months.
Outcomes:
DSM-IV bipolar episodes assessed at 6 month intervals with the Structured Clinical Interview for DSM-IV axis I disorders.
Patient follow up:
95% (intention to treat analysis).
MAIN RESULTS
Over the 30 months, about a quarter fewer relapses were observed in the CT group than in the control group (table); the mean number of days in an illness episode was lower (difference –110.5 d, 95% CI –188.9 to –32.1). During the last 18 months, mean number of days in an illness episode was lower in the CT group than in the control group (difference –53.7 d, CI –104.7 to –2.8), but the groups did not differ for relapse rate (table).
Medication plus cognitive therapy (CT group) v medication alone (control group) in DSM-IV bipolar I disorder*
CONCLUSION
In patients with DSM-IV bipolar I disorder, medication plus cognitive therapy was more effective than medication alone for reducing relapses and number of days in bipolar episodes.
Commentary
These findings by Lam et al contribute to the fledgling literature showing that psychosocial interventions contribute to the treatment of bipolar disorder. The conclusion that adding CT to medication reduces relapse is clinically significant for several reasons. Medications alone do not prevent relapse; up to 73% of patients with bipolar disorder who adhere to medications relapse in the 5 years after an episode.1 Each episode of a mood disorder appears to reduce the threshold intensity of the stressor that is required to trigger a subsequent episode2 and result in increased impairment.
These findings deserve careful attention from clinicians who treat bipolar disorder, because many of the interventions in the CT (detailed in Lam’s book3) can be carried out by therapists from various disciplines. The CT interventions studied here include teaching a diathesis-stress model that emphasises the need for combined medication and psychological interventions; teaching patients to monitor prodromes and change behaviour to prevent prodromes from developing into full blown episodes; promoting regular sleep and routine; and helping patients modulate extreme striving to achieve unrealistically high goals.4
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