Intensive psychotherapy most effective for treating bipolar depression

Patients taking medications to treat bipolar disorder are more likely to get well faster and stay well if they receive intensive psychotherapy, according to results from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), funded by the National Institutes of Health's (NIH) National Institute of Mental Health (NIMH).

The results are published in the April 2007 issue of the Archives of General Psychiatry.

Bipolar disorder is a debilitating illness marked by severe mood swings between depression and mania that affects 2.6 percent of Americans in any given year. "We know that medication is an important component in the treatment of bipolar illness. These new results suggest that adding specific, targeted psychotherapy to medication may help give patients a better shot at lasting recovery," said NIH Director Dr. Elias A. Zerhouni.

"STEP-BD is helping us identify the best tools - both medications and psychosocial treatments - that patients and their clinicians can use to battle the symptoms of this illness," said NIMH Director Thomas R. Insel, M.D.

Psychotherapy is routinely employed as a means to treat bipolar illness in conjunction with medication, but the extent to which psychotherapy is effective has been unclear. In addition, most psychotherapeutic studies have been limited to a single site and compared only one type of treatment to routine care. Thus, in addition to examining the role of medication, STEP-BD set out to compare several types of psychotherapy and pinpoint the most effective treatments and treatment combinations.

With 293 participants, David Miklowitz, Ph.D., of the University of Colorado and colleagues set out to test the effectiveness of three types of standardized, intensive, nine-month-long psychotherapy compared to a control group that received a three-session, psychoeducational program called collaborative care. The intensive therapies were:

• family-focused therapy, which required the participation and input of patients' family members and focused on enhancing family coping, communication and problem-solving;
• cognitive behavioral therapy, which focused on helping the patient understand distortions in thinking and activity, and learn new ways of coping with the illness; and
• interpersonal and social rhythm therapy, which focused on helping the patient stabilize his or her daily routines and sleep/wake cycles, and solve key relationship problems.

All participants were already taking medication for their bipolar disorder, and most were also enrolled in a STEP-BD medication study reported in the New England Journal of Medicine online on March 28, 2007. The researchers compared patients' time to recovery and their stability over one year.

Over the course of the year, 64 percent of those in the intensive psychotherapy groups had become well, compared with 52 percent of those in collaborative care therapy. Patients in intensive psychotherapy also became well an average of 110 days faster than those in collaborative care. In addition, patients who received intensive psychotherapy were one and a half times more likely to be clinically well during any month out of the study year than those who received collaborative care. Discontinuation rates among the groups were similar 36 percent of those in the intensive programs discontinued and 31 percent of those in collaborative care discontinued. None of the three intensive psychotherapies appeared to be significantly more effective than the others, although rates of recovery were higher among those in family-focused therapy compared to the other groups.

"Intensive psychotherapy, when used as an adjunctive treatment to medication, can significantly enhance a person's chances for recovering from depression and staying healthy over the long term," said Dr. Miklowitz. "It should be considered a vital part of the effort to treat bipolar illness."