Large Federally Funded Study In The September AJP Offers Practical Guidance On Treating Patients With Bipolar Depression

Main Category: Bipolar
Also Included In: Psychology / Psychiatry;  Schizophrenia;  Depression
Article Date: 02 Sep 2007 - 1:00 PDT

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Intensive psychotherapy, in addition to medication, significantly improves functioning in patients with bipolar disorder who are experiencing a depressive episode. However, for those patients experiencing a bipolar depressive episode who also have symptoms of mania - sometimes referred to as a "mixed" episode - the addition of an antidepressant to their mood-stabilizing medication does not improve their chances of recovery and could lead to an increase in the severity of their manic symptoms.

These findings are found in a pair of reports from the multi-site, federally funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Both reports appear in the September issue of The American Journal of Psychiatry (AJP), the official journal of the American Psychiatric Association (APA).

STEP-BD is supported by the National Institute of Mental Health and is the largest treatment study ever conducted for bipolar disorder, also referred to as manic-depression. Data on more than 4,000 participants were collected in real-world clinical settings over a period of five years. STEP-BD investigators are now working with the extensive database to learn about the natural course of bipolar disorder and the best approaches for its treatment and management over time.

The first of the two AJP reports, "Intensive Psychosocial Intervention Enhances Functioning in Patients with Bipolar Depression: Results from a 9-Month Randomized Controlled Trial," by David J. Miklowitz, Ph.D., Gary S. Sachs, M.D., and their STEP-BD colleagues, reveals particular improvements in patients' relationships and life satisfaction associated with combination therapy.

In addition to the patients' medication regimens, intensive psychosocial intervention consisted of 30 sessions of either cognitive behavioral therapy, family-focused therapy or interpersonal and social rhythm therapy. A total of 84 patients were randomly assigned to medication and intensive psychosocial therapy and 68 were assigned to medication with "collaborative care," which consisted of three basic psychoeducational sessions.

Compared with the collaborative care group, those randomly assigned to intensive psychosocial intervention experienced significantly greater improvement in overall functioning beyond the level of improvement expected as a result of improvement in depressed mood. More specifically, intensive psychosocial intervention was associated with significantly greater improvements in relationship functioning and satisfaction with life. However, there was no significant difference between the two groups in work/role performance or recreation.

The authors point out that the study design had several limitations. The nine-month course of the study may not have been long enough to show the full impact of intensive psychosocial intervention, particularly in work/role performance. In addition, because the study did not include a control group with equal treatment intensity (30 sessions) for comparison, the STEP-BD investigators were not able to determine whether the significantly greater improvements seen were due specifically to the content of the interventions, or simply because more sessions were offered in the intensive psychosocial intervention group than the collaborative care group.

"Intensive psychotherapy is a vital part of the effort to stabilize patients' moods and improve functioning and quality of life after an episode of bipolar depression," said lead author David Miklowitz, Ph.D.

In the companion article, "Adjunctive Antidepressant Use and Symptomatic Recovery Among Bipolar Depressed Patients with Concomitant Manic Symptoms: Findings From the STEP-BD," Joseph F. Goldberg, M.D., and his STEP-BD colleagues report that adding an antidepressant to existing treatment with a "mood stabilizer" did not shorten the time to recovery for patients with bipolar depression who also exhibited two or more manic symptoms.

More importantly, the patients who received antidepressant medication in addition to their mood stabilizer experienced more severe manic symptoms at three months, compared with patients who received only a mood stabilizer such as lithium.

AJP Editor-in-Chief Robert Freedman, M.D., observed: "The therapy of bipolar depression, whether by psychotherapy or by medication, has been problematic. These studies provide the data that doctors and patients need to decide on treatment, based on what works and what does not."

STEP-BD was funded by the National Institute of Mental Health (NIMH), which provided additional support for these secondary studies. The work by Miklowitz et al. also received funding from the National Alliance for Research on Schizophrenia and Depression (NARSAD).

About the American Journal of Psychiatry

The American Journal of Psychiatry, the official journal of the American Psychiatric Association, publishes a monthly issue with scientific articles submitted by psychiatrists and other scientists worldwide. The peer review and editing process is conducted independently of any other American Psychiatric Association components. Therefore, statements in this press release or the articles in the Journal are not official policy statements of the American Psychiatric Association. The Journal's editorial policies conform to the Uniform Requirements of the International Committee of Medical Journal Editors, of which it is a member. For further information about the Journal visit http://www.ajp.psychiatryonline.org.

About the American Psychiatric Association

The American Psychiatric Association is a national medical specialty society whose more than 38,000 physician members specialize in diagnosis, treatment, prevention and research of mental illnesses including substance use disorders. Visit the APA at http://www.psych.org and http://www.HealthyMinds.org.