Adjunctive psychotherapy may benefit patients with bipolar disorder

Psychosocial interventions in combination with psychotherapy appeared beneficial for outpatients with bipolar disorder, according to results of a systematic review and component network meta-analysis published in JAMA Psychiatry.

“There is increasing recognition that pharmacotherapy alone cannot prevent recurrences of bipolar disorder or fully alleviate post-episode symptoms or functional impairment,” David J. Miklowitz, PhD, of the department of psychiatry and biobehavioral sciences at UCLA’s Semel Institute for Neuroscience and Human Behavior, and colleagues wrote. “Psychotherapy, when provided at all, is viewed as an adjunctive treatment. Evidence from randomized clinical trials indicates that combining pharmacotherapy with manualized psychotherapies — including cognitive behavioral therapy (CBT), family-focused therapy, interpersonal and social rhythm therapy (IPSRT) and group psychoeducation — is more effective than pharmacotherapy alone in stabilizing symptoms and reducing recurrences among outpatients with bipolar disorder.”

However, research is scarce regarding the comparative effectiveness of these approaches. To address this research gap, the investigators aimed to evaluate the association between use of manualized psychotherapies/therapy components and reduction in recurrences and stabilization of symptoms among patients with bipolar disorder. They searched three major bibliographic databases and trial registries from inception to June 1, 2019, and included 39 randomized clinical trials with 3,863 participants that compared pharmacotherapy plus manualized psychotherapy with pharmacotherapy plus a control intervention for patients with bipolar disorder. Illness recurrence served as the primary outcome. Secondary outcomes included depressive and manic symptoms at 12 months, as well as study retention.

Results of 20 two-group trials with usable information suggested manualized treatments were linked to lower recurrence rates vs. control treatments (OR = 0.56; 95% CI, 0.43-0.74). The researchers also noted reduced recurrences (OR = 0.12; 95% CI, 0.02-0.94) linked to psychoeducation with guided practice of illness management skills in a family or group format vs. identical strategies in an individual format. CBT and, with less certainty, family or conjoint therapy and interpersonal therapy appeared to better stabilize depressive symptoms vs. treatment as usual. Study retention rates were higher for family or conjoint therapy (OR = 0.46; 95% CI, 0.26-0.82) and brief psychoeducation (OR = 0.44; 95% CI, 0.23-0.85) vs. standard psychoeducation.

“There is a need to evaluate the most effective combinations of therapy components for patients with different illness presentations treated across public and private settings,” Miklowitz and colleagues wrote. “All of these strategies are required to translate the benefits of adjunctive psychotherapies into effective personalized treatments for individuals with bipolar disorder.”

In a related editorial, Tina R. Goldstein, PhD, and Danella M. Hafeman, MD, PhD, both of the department of psychiatry at the University of Pittsburgh School of Medicine, noted the implications of these study findings for future treatment and research.

“Miklowitz and colleagues’ findings reinforce the treatment guidelines recommending adjunctive psychotherapy for individuals with [bipolar disorder] and further identify specific treatment components and formats most strongly associated with preventing relapse and addressing mood symptoms,” they wrote. “Future steps for the field include demonstrating effectiveness of evidence-based treatment approaches for [bipolar disorder] in the community, maximizing accessibility and furthering knowledge that informs individualized treatment selection with substantial promise to optimize outcomes for individuals with [bipolar disorder].”