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P.2.e.025 A randomized controlled trial of psychoeducation or cognitive-behavioural therapy in bipolar disorder: a CANMAT study
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P.2.e. Affective disorders and antidepressants − Bipolar disorders (clinical)
bipolar disorder. The methodology has previously been outlined in detail [2]. 67 patients with bipolar I disorder, 43 with bipolar II disorder, and 86 randomly selected population-based healthy controls were compared. An extensive battery of neuropsychological tests was administered assessing estimated premorbid IQ, attention, processing speed, verbal and visual memory, and executive functions. Patients had to be euthymic. Results: The three groups (bipolar I, bipolar II, and healthy controls) did not differ with respect to gender, age, or educational level. Patients with bipolar disorder type I showed a significantly higher occurrence of psychotic symptoms, and were more often treated with lithium and antipsychotics than type II. Patients with bipolar type I and type II were cognitively impaired compared to healthy controls. Out of 40 included test variables, the outcome of 24 indicated an impaired performance in patients. However, there were no statistically significant differences between the two subtypes. The largest effect sizes were observed for tests measuring different aspects of executive function, processing speed and working memory. We found no evidence for a significant deficit in premorbid IQ in our patient sample compared to controls as measured by the verbal comprehension index in WAIS. The strongest predictors of cognitive impairment within the patient group were current antipsychotic treatment and duration of illness. Conclusions: The present study suggests that the type and degree of cognitive dysfunction is similar in bipolar I and II patients. Overall, the magnitude and cognitive domains affected is in agreement with previously published work on euthymic bipolar patients. Notably, treatment with antipsychotics − but not a history of psychosis − was associated with more severe cognitive impairment. Given that patients with bipolar I disorder are more likely to be on antipsychotic drugs, this might explain why some previous studies have found that patients with type I bipolar disorder are more cognitively impaired than those with type II. References [1] Martinez-Aran A, Vieta E, Colom F, Torrent C, Sanchez-Moreno J, Reinares M, et al. Cognitive impairment in euthymic bipolar patients: implications for clinical and functional outcome. Bipolar disorders. 2004; 6: 224−32. [2] Ekman CJ, Lind J, Ryden E, Ingvar M, Landen M. Manic episodes are associated with grey matter volume reduction − a voxel-based morphometry brain analysis. Acta Psychiatr Scand. 2010; 122: 507−15.
P.2.e.025 A randomized controlled trial of psychoeducation or cognitive-behavioural therapy in bipolar disorder: a CANMAT study S. Parikh1 ° , A. Zaretsky2 1 University of Toronto/Toronto Western Hospital, Psychiatry, Toronto Ontario, Canada; 2 University of Toronto/CAMH, Psychiatry, Toronto Ontario, Canada Objective: Bipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder. Methods: This single-blind randomized controlled trial was conducted between November 2003 and September 2006. A total
of 204 participants (ages 18−64) with either bipolar disorder type I or II participated from four Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of Cognitive Behavior Therapy or 6 sessions of group Psychoeducation. The six psychoeducation sessions were drawn from the published manual of the Life Goals program, while the CBT was drawn from the published manual of Lam et al. Medications were prescribed by the subject’s usual treating physician and recorded. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week. Results: No significant differences in medication use between groups were observed. Use of lithium and valproate use remained at baseline levels throughout the study, with absolute use of atypical antipsychotics also remaining constant. Antidepressants were used by approximately 50% of the entire sample during the course of the study. Medication compliance was excellent on patient interview for both groups. All psychosocial sessions were audiotaped: a random sample audit of approximately 20% of all sessions revealed comparable, high treatment fidelity for both interventions. Both treatments were associated with significant decreases in overall mood burden over the 18 month study period. Both treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Approximately 8% of subjects dropped out prior to receiving Psychoeducation, while 64% were treatment completers; rates were similar for Cognitive Behavior Therapy (6% and 66% respectively). Psychoeducation cost $160 per subject compared to Cognitive Behavior therapy at $1200 per subject. Conclusions and Discussion: Despite longer treatment duration and individualized treatment, Cognitive Behavior therapy did not show a significantly greater clinical benefit compared to group Psychoeducation. Psychoeducation is less expensive to provide, and requires less clinician training to deliver, suggesting its comparative attractiveness. The principal outcomes were selected to detect overall mood burden by capturing symptom expression along a full continuum from well to full relapse, over an 18 month period, not just relapse as in most previous studies. Our findings of potential equivalency between treatments mirrors findings of other large effectiveness studies, such at the STAR-D study for depression. Trial Registration: Psychoeducation Versus Cognitive-Behavioral Therapy in Bipolar Disorder. clinicaltrials.gov Identifier: NCT00188838 References [1] Bauer MS, McBride L. Structured Group Psychotherapy for Bipolar Disorder: The Life Goals Program. 2nd ed. New York, NY: Springer Publishing Company; 2003. [2] Zaretsky AE, Lancee W., Miller C., Harris A. and Parikh, S.V. Is CBT More Effective Than Psychoeducation in Bipolar Disorder? Can J Psychiatry 2008; 53(7): 441−8. [3] Parikh S, Scott J. Cognitive-Behavioural Therapy for Bipolar Disorder. In: Yatham LN, Maj M, eds. Bipolar Disorder: Clinical and Neurobiological Foundations. John Wiley & Sons Ltd; 2010: 422–429.
P.2.e. Affective disorders and antidepressants − Bipolar disorders (clinical)
bipolar disorder. The methodology has previously been outlined in detail [2]. 67 patients with bipolar I disorder, 43 with bipolar II disorder, and 86 randomly selected population-based healthy controls were compared. An extensive battery of neuropsychological tests was administered assessing estimated premorbid IQ, attention, processing speed, verbal and visual memory, and executive functions. Patients had to be euthymic. Results: The three groups (bipolar I, bipolar II, and healthy controls) did not differ with respect to gender, age, or educational level. Patients with bipolar disorder type I showed a significantly higher occurrence of psychotic symptoms, and were more often treated with lithium and antipsychotics than type II. Patients with bipolar type I and type II were cognitively impaired compared to healthy controls. Out of 40 included test variables, the outcome of 24 indicated an impaired performance in patients. However, there were no statistically significant differences between the two subtypes. The largest effect sizes were observed for tests measuring different aspects of executive function, processing speed and working memory. We found no evidence for a significant deficit in premorbid IQ in our patient sample compared to controls as measured by the verbal comprehension index in WAIS. The strongest predictors of cognitive impairment within the patient group were current antipsychotic treatment and duration of illness. Conclusions: The present study suggests that the type and degree of cognitive dysfunction is similar in bipolar I and II patients. Overall, the magnitude and cognitive domains affected is in agreement with previously published work on euthymic bipolar patients. Notably, treatment with antipsychotics − but not a history of psychosis − was associated with more severe cognitive impairment. Given that patients with bipolar I disorder are more likely to be on antipsychotic drugs, this might explain why some previous studies have found that patients with type I bipolar disorder are more cognitively impaired than those with type II. References [1] Martinez-Aran A, Vieta E, Colom F, Torrent C, Sanchez-Moreno J, Reinares M, et al. Cognitive impairment in euthymic bipolar patients: implications for clinical and functional outcome. Bipolar disorders. 2004; 6: 224−32. [2] Ekman CJ, Lind J, Ryden E, Ingvar M, Landen M. Manic episodes are associated with grey matter volume reduction − a voxel-based morphometry brain analysis. Acta Psychiatr Scand. 2010; 122: 507−15.
P.2.e.025 A randomized controlled trial of psychoeducation or cognitive-behavioural therapy in bipolar disorder: a CANMAT study S. Parikh1 ° , A. Zaretsky2 1 University of Toronto/Toronto Western Hospital, Psychiatry, Toronto Ontario, Canada; 2 University of Toronto/CAMH, Psychiatry, Toronto Ontario, Canada Objective: Bipolar disorder is insufficiently controlled by medication, so several adjunctive psychosocial interventions have been tested. Few studies have compared these psychosocial treatments, all of which are lengthy, expensive, and difficult to disseminate. We compared the relative effectiveness of a brief psychoeducation group intervention to a more comprehensive and longer individual cognitive-behavioral therapy intervention, measuring longitudinal outcome in mood burden in bipolar disorder. Methods: This single-blind randomized controlled trial was conducted between November 2003 and September 2006. A total
of 204 participants (ages 18−64) with either bipolar disorder type I or II participated from four Canadian academic centers. Subjects were recruited via advertisements or physician referral when well or minimally symptomatic, with few exclusionary criteria to enhance generalizability. Participants were assigned to receive either 20 individual sessions of Cognitive Behavior Therapy or 6 sessions of group Psychoeducation. The six psychoeducation sessions were drawn from the published manual of the Life Goals program, while the CBT was drawn from the published manual of Lam et al. Medications were prescribed by the subject’s usual treating physician and recorded. The primary outcome of symptom course and morbidity was assessed prospectively over 72 weeks using the Longitudinal Interval Follow-up Evaluation, which yields depression and mania symptom burden scores for each week. Results: No significant differences in medication use between groups were observed. Use of lithium and valproate use remained at baseline levels throughout the study, with absolute use of atypical antipsychotics also remaining constant. Antidepressants were used by approximately 50% of the entire sample during the course of the study. Medication compliance was excellent on patient interview for both groups. All psychosocial sessions were audiotaped: a random sample audit of approximately 20% of all sessions revealed comparable, high treatment fidelity for both interventions. Both treatments were associated with significant decreases in overall mood burden over the 18 month study period. Both treatments had similar outcomes with respect to reduction of symptom burden and the likelihood of relapse. Approximately 8% of subjects dropped out prior to receiving Psychoeducation, while 64% were treatment completers; rates were similar for Cognitive Behavior Therapy (6% and 66% respectively). Psychoeducation cost $160 per subject compared to Cognitive Behavior therapy at $1200 per subject. Conclusions and Discussion: Despite longer treatment duration and individualized treatment, Cognitive Behavior therapy did not show a significantly greater clinical benefit compared to group Psychoeducation. Psychoeducation is less expensive to provide, and requires less clinician training to deliver, suggesting its comparative attractiveness. The principal outcomes were selected to detect overall mood burden by capturing symptom expression along a full continuum from well to full relapse, over an 18 month period, not just relapse as in most previous studies. Our findings of potential equivalency between treatments mirrors findings of other large effectiveness studies, such at the STAR-D study for depression. Trial Registration: Psychoeducation Versus Cognitive-Behavioral Therapy in Bipolar Disorder. clinicaltrials.gov Identifier: NCT00188838 References [1] Bauer MS, McBride L. Structured Group Psychotherapy for Bipolar Disorder: The Life Goals Program. 2nd ed. New York, NY: Springer Publishing Company; 2003. [2] Zaretsky AE, Lancee W., Miller C., Harris A. and Parikh, S.V. Is CBT More Effective Than Psychoeducation in Bipolar Disorder? Can J Psychiatry 2008; 53(7): 441−8. [3] Parikh S, Scott J. Cognitive-Behavioural Therapy for Bipolar Disorder. In: Yatham LN, Maj M, eds. Bipolar Disorder: Clinical and Neurobiological Foundations. John Wiley & Sons Ltd; 2010: 422–429.