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Psychotherapy for Bipolar Depression

Any sort seems to help.

Bipolar depression remains a therapeutic challenge, and manual-based psychotherapies may prove useful additions to the armamentarium. In this 1-year STEP-BD study, 293 bipolar depressed patients without mixed hypomania were randomized to receive one of four psychotherapies added to guideline-based pharmacotherapy with mood stabilizers, with or without antidepressants.

The experimental psychotherapies (30 sessions over 9 months) were cognitive-behavioral therapy; interpersonal and social rhythm therapy (IPSRT), which focuses on regular daily schedules and social zeitgebers; and family-focused therapy (FFT), which involves education, intervention for prodromal symptoms of relapse, family communication skills, and problem solving. The control treatment (collaborative care [CC]; three 50-minute sessions over 6 weeks) educated patients about the disorder, medication adherence, mood charting, schedule management, depressive thinking, communication skills, and treatment contracts.

Training for the experimental psychotherapies was more intensive than for CC. Dropout rates and mean frequency and number of sessions attended were similar among the experimental psychotherapies (mean number of sessions, 14.3). There were 195 completers out of the 293. Of the intent-to-treat population, 59% achieved recovery from depression at 1 year (experimental therapies, 64%; CC, 52%; hazard ratio, 1.47). The median time to recovery was 103 to 127 days for the experimental therapies and 146 days for CC. Experimental psychotherapy recipients were 1.58 times as likely as CC recipients to be well in any study month. Outcomes were similar among the experimental therapies.

Comment: When added to protocol-driven pharmacotherapy, CBT, IPSRT, and FFT seemed to be equally better than CC in hastening and maintaining recovery from bipolar depression. However, this finding might be unrelated to specific features of these fairly similar psychotherapies, which differed from CC primarily in duration and, perhaps, the therapists’ expertise. Any psychotherapy that provides a stable therapeutic relationship, addresses biological rhythms, deals with nonadherence, plans for relapse, and involves the family might be an effective adjunct in treating bipolar depression. While more labor-intensive, such therapies are ultimately less risky than antidepressants in this population.

— Steven Dubovsky, MD

Published in Journal Watch Psychiatry June 4, 2007

Citation(s):

Miklowitz DJ et al. Psychosocial treatments for bipolar depression: A 1-year randomized trial from the Systematic Treatment Enhancement Program. Arch Gen Psychiatry 2007 Apr; 64:419-27.

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