Psychoeducation versus CBT         for Bipolar Disorder:           A CANMAT Study      Sagar V. Parikh, Ari Zaretsky, Serg...
About Bipolar Disorder   BD is a serious lifetime condition    – Elevated mood state (mania) + depression   Prevalence o...
Psychosocial Interventions   Complementary psychosocial interventions:    –   Psychoeducation (PE)    –   Cognitive-Behav...
CBT   Several models available, adapted from CBT for    depression   Individual sessions (≈ 20)   Psychoeducation + cog...
Psychoeducation   Component of all psychosocial interventions for    bipolar disorder   Integrated or stand-alone treatm...
HypothesisA full course of CBT for bipolardisorder will be more effective    than psychoeducation.                        ...
Study Design A single-blind RCT 18 month longitudinal assessment Patients with BD-I/BD-II 4 academic research centers ...
PE Intervention 6 weekly ‘didactic’ sessions in group format, 90 minutes long Group size = 4-6 persons Covers topics su...
CBT Intervention   20 sessions of individual CBT, 50 minutes long   Includes some basic psychoeducation   Major emphasi...
Outcome Assessment Primary outcome -- LIFE  – Longitudinal Interval Follow-up Evaluation (LIFE)  – Assesses the longitudi...
Participants Inclusion Criteria   – BD-I or BD-II, age 18-64   – Taking a mood stabilizer   – ≥ 2 episodes of significant...
Participants -- Flowchart                                           537 Prescreened                 240 Patients Excluded ...
Participants – Key Features N = 204 randomized Bipolar I: 73% Mean age of first episode: 22.1 years Hospitalized for m...
Sociodemographic CharacteristicsCharacteristic                             CBT           PE               pGender – % fema...
Illness CharacteristicsBaseline Characteristic                         CBT           PE                 pBipolar Subtype –...
ResultsRetention & compliance                Group PE      Individual CBTTreatment completers (18-20 sess.)      64%      ...
Results: Symptoms                           LIFE mean scores by treatment group – 8 week intervals                        ...
Results: Time to RecurrenceSurvival curves for recurrence with depressive or manic episode   Major Depressive Episode     ...
Results: Cost Psychoeducation                        CBT2 staff hours/90 min. session     1 staff hour/session         x 6...
Discussion No differences in overall mood burden    or rates of relapse   Both treatments associated with significant   ...
Why? Poor fidelity to CBT? Unlikely!   – Established research centres with experience in CBT   – Random tape audit indica...
Limitations   Participants recruited at academic medical centers    – May not be representative of patients in the commun...
Psychoeducation or CBT  in Bipolar Disorder?Psychoeducation!   …is less expensive   …requires less clinician training   …i...
Treatment                                     Hierarchy                            VIII.                      Psychodynami...
Psychoeducation versus CBT        for Bipolar Disorder:          A CANMAT Study  Sagar V. Parikh, Ari Zaretsky, Serge Beau...
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Psychoeducation or Cognitive Behavioural Therapy for Bipolar Disorder

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A study by researchers at the Canadian Network for Mood and Anxiety Treatments (CANMAT) comparing the relative effectiveness of two psychosocial interventions in bipolar disorder has recently been published in the Journal of Clinical Psychiatry.

Bipolar disorder is insufficiently controlled by medication, so several supplementary psychosocial interventions have been tested, all of which are lengthy, expensive, and difficult to disseminate. CREST.BD members Dr. Sagar Parikh and Vytas V. Velyvis co-authored a recent paper along with their collegues at CANMAT, which relates the findings of the recent study that compared psychoeducation (PE) and cognitive behavioural therapy (CBT) in bipolar disorder in bipolar disorder. CBT is a longer, more costly, individualized treatment while PE is less expensive to provide and requires less clinician training to deliver successfully. To date, only a few studies have compared these psychosocial treatments. In this presentation, Dr. Parikh and colleagues compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive, and longer individual cognitive-behavioural therapy intervention (CBT) with a sample of 204 individuals who live with bipolar disorder. They measured long-term outcomes in mood burden of the participants in both treatments. Findings indicate that, despite its longer treatment duration and cost, CBT did not show significantly greater clinical benefit compared to group psychoeducation. The implications of these findings for psychosocial interventions in the condition are provided.

Psychoeducation or Cognitive Behavioural Therapy for Bipolar Disorder

  1. 1. Psychoeducation versus CBT for Bipolar Disorder: A CANMAT Study Sagar V. Parikh, Ari Zaretsky, Serge Beaulieu, Lakshmi N. Yatham, L. Trevor Young, Irene Patelis-Siotis, Glenda M. MacQueen, Anthony Levitt, Tamara Arenovich, Pablo Cervantes, Vytas Velyvis, Sidney H. Kennedy, and David L. Streiner.Journal of Clinical Psychiatry, 2012 Jun;73(6):803-10. www.canmat.org
  2. 2. About Bipolar Disorder BD is a serious lifetime condition – Elevated mood state (mania) + depression Prevalence of 1-3% worldwide High disability and mortality 1st line of treatment: Complex pharmacotherapy Limitations of pharmacotherapy: – Relapses are common – Residual symptoms may persist www.canmat.org
  3. 3. Psychosocial Interventions Complementary psychosocial interventions: – Psychoeducation (PE) – Cognitive-Behavioural Therapy (CBT) – Family focused Therapy (FFT) – Interpersonal /Social Rhythm Therapy (IP/SRT) Why psychosocial interventions? – May modify stressors that could trigger episodes – Enhance collaboration with treatment providers – Can improve treatment compliance – Could have direct biological treatment effects – Help patients deal with psychological sequelae of illness www.canmat.org
  4. 4. CBT Several models available, adapted from CBT for depression Individual sessions (≈ 20) Psychoeducation + cognitive and behavioral techniques Maintenance, relapse prevention, Studies to date: small to modest impact – underpowered? www.canmat.org
  5. 5. Psychoeducation Component of all psychosocial interventions for bipolar disorder Integrated or stand-alone treatment Symptom recognition, relapse management & prevention Group format Variable duration www.canmat.org
  6. 6. HypothesisA full course of CBT for bipolardisorder will be more effective than psychoeducation. www.canmat.org
  7. 7. Study Design A single-blind RCT 18 month longitudinal assessment Patients with BD-I/BD-II 4 academic research centers (Toronto, Hamilton, Montreal, Vancouver) Comparison of the relative effectiveness of… vs. Brief Group PE Individual CBT (6 sessions) (20 sessions) www.canmat.org
  8. 8. PE Intervention 6 weekly ‘didactic’ sessions in group format, 90 minutes long Group size = 4-6 persons Covers topics such as illness recognition, treatment approaches, monitoring and coping strategies Based on manual by Bauer & McBride: The Life Goals Program - Phase I Delivered by experienced psychiatric staff (nurses, psychotherapists and psychiatrist) www.canmat.org
  9. 9. CBT Intervention 20 sessions of individual CBT, 50 minutes long Includes some basic psychoeducation Major emphasis on activity scheduling / behavioral activation Major emphasis on dysfunctional cognitions, both depressive and manic Based on manual by Lam et al. www.canmat.org
  10. 10. Outcome Assessment Primary outcome -- LIFE – Longitudinal Interval Follow-up Evaluation (LIFE) – Assesses the longitudinal course of depressive and manic symptoms for every week – Done for 72 weeks – Additional outcomes – time to relapse www.canmat.org
  11. 11. Participants Inclusion Criteria – BD-I or BD-II, age 18-64 – Taking a mood stabilizer – ≥ 2 episodes of significant symptoms during the last 3 years, excluding month preceding randomization – Could be in remission or have subsyndromal symptoms Exclusion Criteria – Episode of significant symptoms during the month preceding randomization – Current substance dependence, life-threatening medical illness – Antisocial or severe borderline personality disorder – Acute suicidality or homocidality – Significant cognitive deficits or language problems www.canmat.org
  12. 12. Participants -- Flowchart 537 Prescreened 240 Patients Excluded 297 Patients Screened 93 Patients Excluded for Eligibility 69 Did not meet inclusion criteria 24 Refused to participate 204 Randomized 95 Patients Allocated to CBT 109 Patients Allocated to PE63 “completers” (18-20 sessions) 70 “completers” received 5-6 sessions26 received partial intervention 30 received partial intervention6 received no sessions 9 received no sessions63 completed all 18 months of assessment 63 completed all 18 months of assessment15 completed partial assessment 19 completed partial assessment17 did not provide any follow-up data 27 did not provide any follow-up data www.canmat.org
  13. 13. Participants – Key Features N = 204 randomized Bipolar I: 73% Mean age of first episode: 22.1 years Hospitalized for mood episode: 66% Lifetime number of episodes: – 13% had fewer than 5 – 70% had more than 10 – Depressive episodes far more frequent www.canmat.org
  14. 14. Sociodemographic CharacteristicsCharacteristic CBT PE pGender – % female 63.2 53.2 0.15Age at baseline – mean (SD) 40.9 (10.7) 40.9 (10.8) 0.96Education – no. (%) Up to high school graduation 16 (16.8) 17 (15.6) Some university/university graduate 60 (63.2) 81 (74.3) 0.13 Graduate studies 16 (16.8) 9 (8.3) Unknown 3 (3.2) 2 (1.8)Marital status – no. (%) Married or common law 31 (32.6) 42 (38.5) Single 37 (38.9) 44 (40.4) 0.44 Divorced or separated or widowed 27 (28.4) 23 (21.1) www.canmat.org
  15. 15. Illness CharacteristicsBaseline Characteristic CBT PE pBipolar Subtype – no. (%) Type I 68 (71.6) 79 (72.5) 0.89 Type II 27 (28.4) 30 (27.5)Age of first mood episode – mean (SD) 22.2 (9.6) 22.0 (9.0) 0.88> 10 episodes – no. (%) 68 (71.6) 74 (67.9) 0.55Hospitalization – no. (%) 63 (66.3) 71 (65.1) 0.93Anxiety Disorder (Lifetime) – no. (%) 49 (51.6) 48 (44.0) 0.28Substance use disorder (Lifetime) – no. (%) 24 (25.3) 29 (26.6) 0.83LIFE-Mania – mean (SD), across 4 weeks 1.3 (0.7) 1.3 (0.6) 0.96LIFE-Depression – mean (SD), across 4 weeks 2.5 (1.4) 2.4 (1.2) 0.59HAM – D – mean (SD) 6.5 (4.8) 7.3 (5.0) 0.25CARS-M – mean (SD) 1.7 (2.6) 2.3 (3.5) 0.22 www.canmat.org
  16. 16. ResultsRetention & compliance Group PE Individual CBTTreatment completers (18-20 sess.) 64% 66%Dropout rate prior to first session 8% 6%Nb. sessions attended (M) 5 15• Excellent medication compliance for both groups (ns)• Use of mood stabilizers and atypical antipsychotics remained constant www.canmat.org
  17. 17. Results: Symptoms LIFE mean scores by treatment group – 8 week intervals Depression Mania Depression Mania 2.8 1.6 2.6 1.5 2.4 1.4 Mean (+/- SE) Mean +/- SE 2.2 1.3 2.0 1.2 1.8 1.1 1.6 1.4 1.0 0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70 Week Week PE PE CBT CBT• Significant decline in LIFE scores in both groups• No significant difference by treatment group www.canmat.org
  18. 18. Results: Time to RecurrenceSurvival curves for recurrence with depressive or manic episode Major Depressive Episode (Hypo)manic Episode N = 95 recurrences N = 59 recurrences • No difference in recurrence rate by treatment group www.canmat.org
  19. 19. Results: Cost Psychoeducation CBT2 staff hours/90 min. session 1 staff hour/session x 6 sessions x 20 individual sessions @ 4 participants / group = $180 per participant = $1200 per participant www.canmat.org
  20. 20. Discussion No differences in overall mood burden or rates of relapse Both treatments associated with significant decreases in overall mood burden Similar rates of completion/compliance CBT superiority hypothesis not confirmed www.canmat.org
  21. 21. Why? Poor fidelity to CBT? Unlikely! – Established research centres with experience in CBT – Random tape audit indicated good fidelity CBT is not superior? Likely! – No satisfactory theoretical model of CBT for BD – All psychosocial interventions for bipolar disorder address early symptom recognition and response – CBT for BD is currently a non-specific psychoeducational intervention with some cognitive & behavioural techniques – Not a specific, empirically driven approach based on a cognitive formulation www.canmat.org
  22. 22. Limitations Participants recruited at academic medical centers – May not be representative of patients in the community No study control of medication use – But no differences between groups noted… No untreated control group – PE and CBT were equally ineffective? • Unlikely since improvement rates mirror those seen in earlier controlled trials… – Each treatment appears to have been (equally) effective www.canmat.org
  23. 23. Psychoeducation or CBT in Bipolar Disorder?Psychoeducation! …is less expensive …requires less clinician training …is as effective as CBT www.canmat.org
  24. 24. Treatment Hierarchy VIII. Psychodynamic/ Insight Therapy VII. Occupational Therapy/ Rehabilitation VI. Detailed Family/Marital Therapy V. Brief Family/Marital Psychoeducation LIFE Goals IV. CBT or IPT if indicated After PE or For Depression III. Patient Psychoeducation (6 sessions) II. Tailored Health Services (Health Care Team) I. Pharmacotherapy and Clinical Management Bipolar Disorder Treatment Model (Parikh, 2002) www.canmat.org
  25. 25. Psychoeducation versus CBT for Bipolar Disorder: A CANMAT Study Sagar V. Parikh, Ari Zaretsky, Serge Beaulieu, Lakshmi N. Yatham, L. Trevor Young, Irene Patelis-Siotis, Glenda M. MacQueen, Anthony Levitt, Tamara Arenovich, Pablo Cervantes, Vytas Velyvis, Sidney H. Kennedy, and David L. Streiner.Journal of Clinical Psychiatry, 2012 Jun;73(6):803-10. www.canmat.org

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