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.

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. 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. 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. 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. 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. Hypothesis
A full course of CBT for bipolar
disorder will be more effective
than psychoeducation.
www.canmat.org

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. 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. 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. 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. 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. 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 PE
63 “completers” (18-20 sessions) 70 “completers” received 5-6 sessions
26 received partial intervention 30 received partial intervention
6 received no sessions 9 received no sessions
63 completed all 18 months of assessment 63 completed all 18 months of assessment
15 completed partial assessment 19 completed partial assessment
17 did not provide any follow-up data 27 did not provide any follow-up data
www.canmat.org

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. Sociodemographic Characteristics
Characteristic CBT PE p
Gender – % female 63.2 53.2 0.15
Age at baseline – mean (SD) 40.9 (10.7) 40.9 (10.8) 0.96
Education – 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. Illness Characteristics
Baseline Characteristic CBT PE p
Bipolar 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) 0.55
Hospitalization – no. (%) 63 (66.3) 71 (65.1) 0.93
Anxiety Disorder (Lifetime) – no. (%) 49 (51.6) 48 (44.0) 0.28
Substance use disorder (Lifetime) – no. (%) 24 (25.3) 29 (26.6) 0.83
LIFE-Mania – mean (SD), across 4 weeks 1.3 (0.7) 1.3 (0.6) 0.96
LIFE-Depression – mean (SD), across 4 weeks 2.5 (1.4) 2.4 (1.2) 0.59
HAM – D – mean (SD) 6.5 (4.8) 7.3 (5.0) 0.25
CARS-M – mean (SD) 1.7 (2.6) 2.3 (3.5) 0.22
www.canmat.org

16. Results
Retention & compliance Group PE Individual CBT
Treatment 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. 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. Results: Time to Recurrence
Survival 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. Results: Cost
Psychoeducation CBT
2 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. 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. 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. 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. Psychoeducation or CBT
in Bipolar Disorder?
Psychoeducation!
…is less expensive
…requires less clinician training
…is as effective as CBT
www.canmat.org

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. 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