Combining skills-based psychosocial interventions, such as monitoring prodromal symptoms, with pharmacotherapy treatment more effectively reduces recurrences of episodes in outpatients with bipolar disorder than pharmacotherapy with routine monitoring visits, according to a component network meta-analysis (NMA) of randomized clinical trials (RCTs) of patients with bipolar disorder that was published in JAMA Psychiatry.

The researchers included in their NMA 39 RCTs (including 36 enrolling adults and 3 enrolling children 12 years or older) that were published up until June 1, 2019. The RCTs compared the combination of treating individuals with experimental psychotherapy and pharmacotherapy and the combination of another form of psychotherapy and pharmacotherapy or treatment as usual (TAU).

Participants in the trials had a primary diagnosis of bipolar disorder I, bipolar disorder II or unspecified bipolar disorder. Each individual received in-person contact with a trained therapist for psychosocial interventions, which were done individually, with family or in a group setting.

The researchers classified active intervention groups as traditional cognitive behavioral therapy (CBT) with cognitive restructuring, behavioral activation and problem-solving; interpersonal and social rhythm therapy (IPSRT); family or conjoin therapy; or functional remediation. Control groups were classified as brief psychoeducation, supportive therapy, or TAU.


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Psychoeducation with guided skill practice and self-monitoring is more effectively delivered in a family or group format than individually (odds ratios (OR), 0.12; 95% credible intervals (CrI), 0.02-0.94), the researchers found. Delivery of treatment in a family format (incremental odds ratio [iOR], 0.16; 95% CrI, 0.02-1.22) and encouraging patients to monitor prodromal symptoms (iOR, 0.22; 95% CrI, 0.04-1.35) were associated with lower illness recurrence rates, they found.

The investigators found in 20 two-group trials that experimental interventions were associated with a lower probability of recurrence than control interventions (OR, 0.56; 95% CI, 0.43-0.74; statistical heterogeneity: τ2, 0.16). They also found that family or conjoint therapy (OR, 0.30; 95% CI, 0.17-0.53), CBT (OR, 0.52; 95% CI, 0.34-0.79), standard psychoeducation (OR, 0.52; 95% CI, 0.32-0.84), and brief psychoeducation (OR, 0.34; 95% CI, 0.16-0.74) all were associated with better outcomes than TAU, with family or conjoint therapy having the best results.

In 21 trials that were done on 12-month depression symptoms, CBT (standardized mean differences (SMD), –0.32; 95% CI, –0.64 to –0.01), family or conjoint therapy (SMD, –0.46; 95% CI, –1.01 to 0.08) and IPSRT (SMD, –0.46; 95% CI, –1.07 to 0.15) were associated with better outcomes compared with TAU.

In evaluating 19 trials that compared treatment for mania symptoms, the researchers found that CBT (SMD, –0.32; 95% CI, –0.65 to 0.01), psychoeducation (SMD, –0.31; 95% CI, –0.70 to 0.08), and family or conjoint therapy (SMD, –0.35; 95% CI, –0.86 to 0.17) were associated with better outcomes than TAU.

The researchers found that the treatments associated with the greatest benefit for stabilizing manic symptoms were cognitive restructuring (incremental SMDs (iSMD), –1.00; 95% CrI, –2.15 to 0.16) and regulating daily rhythms (iSMD, –0.42; 95% CrI, –1.08 to 0.28) and the best treatments for depression were, again, cognitive restructuring (iSMD, –1.26; 95% CrI, –2.10 to –0.35) and regulating daily rhythms (iSMD, –0.78; 95% CrI, –1.28 to –0.24), followed by communication training (iSMD, –0.84; 95% CrI, –1.81 to 0.23).

Limitations of the analysis included small sample sizes, variable durations of therapy and follow-up intervals, the possibility that relevant published trials were overlooked, and indirect comparisons, the researchers said.

“When the goals center on prevention of recurrences, patients should be engaged in family or group psychoeducation with guided skills training and active tasks to enhance coping skills (eg, monitoring and managing prodromal symptoms) rather than being passive recipients of didactic education,” the study authors said.

 “When the immediate goal is recovery from moderately severe depressive or manic symptoms, cognitive restructuring, regulating daily rhythms, and communication training may be associated with stabilization. It is unclear whether CBT techniques work best in an individual format; in this NMA, family and group formats were more closely associated with depression improvement than individual formats.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Miklowitz DJ, Efthimiou O, Furukawa TA, et al. Adjunctive psychotherapy for bipolar disorder  A systematic review and component network meta-analysis [published online October 14 2020]. JAMA Psychiatry. doi: 10.1001/jamapsychiatry.2020.2993