Studies Refine Understanding of Treatments for Bipolar Disorder

September 1, 2007 • Science Update

Two new studies provide additional details on best practices for treating people with bipolar disorder, a sometimes debilitating illness marked by severe mood swings between depression and mania. The two studies are part of the NIMH-funded Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Both were published in the September 2007 issue of the American Journal of Psychiatry.

Antidepressants provide no added benefit for people with mixed symptoms, and may worsen existing mania

Among STEP-BD participants who experienced manic symptoms while also in the midst of a depressive episode, those who received antidepressant medication along with a mood stabilizer recovered no faster than those who received a mood stabilizer plus placebo (sugar pill). The results, reported by Joseph Goldberg, M.D, of the Mount Sinai School of Medicine, and colleagues, are consistent with the March 2007 STEP-BD results that indicated a mood stabilizer alone appears to be just as effective as a mood stabilizer plus antidepressant for treating bipolar patients in a major depressive episode.

Moreover, Goldberg and colleagues found that at the three-month follow-up, manic symptoms were more severe among those who had received the antidepressant, compared to those who had received the placebo. Hence, the researchers caution that adjunctive antidepressant medication may actually exacerbate existing manic symptoms.

Intensive psychotherapies improve relationships and life skills

STEP-BD participants who received intensive psychotherapy in addition to medication reported better life satisfaction and better relationship skills than those who received only brief therapy and medication. However, patients in intensive psychotherapy fared no better in vocational skills.

David Miklowitz, PhD., of the University of Colorado, and colleagues evaluated participants' improvements in relationship, life and work skills over a nine-month period of psychotherapy. Participants received one of three types of psychotherapy:

• Family-focused therapy (FFT), which required the participation and input of participants' family members and focused on enhancing family coping with the illness, communication, and problem-solving.
• Cognitive behavioral therapy (CBT), which focused on helping the person understand distortions in thinking and activity, and learn new ways of coping with the illness.
• Interpersonal and social rhythm therapy (IPSRT), which focused on helping the participant stabilize his or her daily routines and sleep/wake cycles, and solve key relationship problems.

All three therapies incorporated ways to overcome life challenges, such as finding a place to live, finding a satisfying job, or improving personal finances. They also taught participants strategies for managing mood states that interfere with enjoyment of activities.

Previous STEP-BD results reported in April 2007 revealed that those participants who received any of the three intensive psychotherapies recovered from depression faster and stayed well longer than those who received a brief, three-session educational program. In this follow-up study, the researchers found that although relationship skills improved and participants felt more satisfied with life overall, they reported little or no improvement in their work functioning.

Miklowitz and colleagues suggest that a different approach that targets specific vocational skills may be necessary. For example, certain vocational rehabilitation programs designed for people with schizophrenia may be adapted to the needs of people with bipolar disorder.

Colleen Labbe