A recent study shows that psychotherapy can not only improve depression symptoms, but may also reduce the inflammation that often accompanies them.
Researcher Jean Pierre Oses and colleagues randomly assigned participants with depression to receive Supportive-Expressive psychodynamic therapy, which is designed to help patients understand conflictual relationship patterns, or an alternative therapy. Among the 47 participants who received Supportive-Expressive therapy, depression improved significantly after 16 sessions, and blood levels of the inflammatory markers interleukin-6 and TNF alpha also dropped.
The research was presented at the 2016 meeting of the Society of Biological Psychiatry.
Studies have shown that therapy can be helpful for people with bipolar disorder. In a 2016 article in the British Journal of Psychiatry, researchers led by M. Oud described the findings of their systematic review of studies evaluating different types of therapy for bipolar disorder. The research team reviewed the findings of 55 randomized controlled trials of psychotherapeutic interventions that included a total of 6,010 adult participants with bipolar disorder. The team found moderate-quality evidence that psychological interventions reduced relapses following treatment, and that collaborative care reduced hospital admissions for adults with bipolar disorder. Oud and colleagues found lower-quality evidence that group interventions reduced depression relapses following treatment, and that family psychoeducation reduced symptoms of depression and mania.
The reseachers concluded that there is evidence that therapy can be helpful for people with bipolar disorder. Since some of the evidence was of low quality, more research is needed to identify the most effective therapies for different phases of bipolar disorder.
Editor’s Note: The data are clear that therapy is helpful. In particular, one approach worth emulating is that described in an article by Lars V. Kessing and colleagues in the British Journal of Psychiatry in 2013. They found that comprehensive care in an outpatient mood disorder clinic, which included psychotherapy, psychoeducation, mood monitoring, and drug treatment, reduced relapses significantly compared to treatment as usual.
At the 2015 meeting of the American Academy of Child and Adolescent Psychiatry, researcher Mary A. Fristad reported that omega-3 fatty acid supplements had a small beneficial effect on depression in children aged 7–14. The supplements did not noticeably improve bipolar disorder not otherwise specified (NOS) or mania. The supplements consisted of several types of omega-3 fatty acids, including 1400mg of EPA, 200mg of DHA, and 400mg of others per day. The children were also undergoing psychotherapy during the study.
Childhood onset bipolar disorder can be highly impairing. Treatment usually includes medication, but several types of psychotherapy have also been found to be superior to treatment as usual. These include family focused therapy, dialectical behavior therapy and multifamily psychoeducation groups, including Rainbow therapy.
Family focused therapy, developed by David Miklowitz, consists of psychoeducation about bipolar disorder and the importance of maintaining a stable medication routine. Families are taught to recognize early symptoms of manic and depressive episodes, and how to cope with them. Families also learn communication and problem solving skills that can prevent stressful interactions.
Dialectical behavior therapy was developed by Marsha Linehan, initially for the treatment of borderline personality disorder. It can be useful in bipolar disorder because participants learn how to manage stressors that might otherwise trigger depression or mania. DBT teaches five skills: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self management.
Multifamily psychoeducation was developed by Mary Fristad. In groups, children and parents learn about mood disorders, including how to manage symptoms, and also work on communication, problem solving, emotion regulation, and decreasing family tension.
Rainbow therapy is a type of multifamily approach also known as child and family-focused cognitive-behavioral therapy (CFF CBT). It integrates individual cognitive-behavioral therapy with family psychoeducation and mindfulness skills training. In a recent article in the journal Evidence Based Mental Health, Miklowitz reviewed the current research on Rainbow therapy. While the research to date has many limitations, he highlighted some benefits of Rainbow therapy: its flexibility, and its focus on treating parents’ symptoms along with children’s illness.
At the 2014 meeting of the American Academy of Child and Adolescent Psychiatry, there was an excellent symposium on different psychotherapeutic approaches for children and adolescents with bipolar disorder and related illnesses.
Amy West of the university of Illinois at Chicago started off this symposium by describing the effectiveness of child-and family-focused cognitive-behavior therapy or what is sometimes called RAINBOW therapy. Rainbow stands for Routine, Affect regulation, I can do it, No negative thinking, Be a good friend and balance life stressors, Oh how can we solve problems, and Ways to find support.
West emphasized the importance of routine in sleep, diet, medications, and homework, and indicated that frequent soothing is necessary. Posted reminders are also helpful.
Affect regulation can be encouraged by promoting coping skills, particularly around identifying what triggers mood swings and rage attacks and creating plans for dealing with them.
“I can do it” reminds parents and children to focus on strengths, successes, positive feedback, and the ability to call for help.
“No negative thinking” encourages positive restructuring and reframing of negative perspectives. Part of this includes mindfulness training for children and parents, who are taught to focus on breathing and accepting thoughts and emotions.
Being a good friend focuses on listening, engaging friends, and enhancing communication.
“Oh how can we solve problems” reminds families to have an attitude of problem solving.
Remembering ways to find support reminds parents to connect with relevant resources, and also coaches parents to be advocates for their children.
In a randomized study of 12 sessions of child and family focused cognitive behavior therapy, the children did much better than those receiving treatment as usual and showed greater improvement in mania and depression as well as overall functioning.
The second presentation was given by Mary Fristad of Ohio State University. She treated children with bipolar disorder not otherwise specified (BP-NOS) with psychotherapy and omega-3 fatty acids. Some research had suggested the efficacy of omega-3 fatty acids in childhood mood disorders and a much larger literature was positive in adult mood disorders. Given the safety of the manipulation, she felt it was worth trying in young children and those with BP-NOS who are rarely studied formally. She also cited a 2010 study by Amminger et al. in children who were at ultra high risk for schizophrenia. In that study, patients were randomized to 12 weeks of omega-3 fatty acids or placebo, and omega-3 fatty acids were associated with a very low conversion rate to full-blown psychosis, 4.9%, compared to 27.5% for those receiving placebo. Fristad’s psychotherapy also emphasized education, support, and skill building in order to enhance understanding of the illness and its treatment. This would help ensure better compliance and better treatment outcome. Her formal treatment manual is available at www.moodychildtherapy.com.
Fristad randomized children with bipolar not otherwise specified, average age 10.2 +/- 0.2 years to either her psychotherapy plus omega-3 fatty acids or therapy plus placebo. Therapy plus omega-3 was much more effective on most outcome measures.
Editor’s Note: Given the safety of omega-3 fatty acids, even these limited data would appear to justify their use in children with BP-NOS in the context of psychotherapy and psychoeducation.
The third presenter was David Miklowitz of UCLA who discussed family focused therapy. This approach has proven effective in studies of both adults and adolescents with bipolar disorder, and as well for those with prodromal symptoms. Read more
Psychotherapy More Effective Than Collaborative Care in Bipolar Depression with Anxiety Disorder Comorbidity
The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a long-term study of treatments for bipolar disorder, recently found that psychotherapy was more effective than their normal collaborative care model (consisting of regular illness evaluation and treatment) for patients with bipolar disorder and a current or lifetime presence of an anxiety disorder.
An anxiety disorder comorbidity is consistently associated with a poor outcome in patients with bipolar disorder. In a 2014 article by Deckersbach et al. in the American Journal of Psychiatry, the STEP-BD research group reported that the effect of psychotherapy was particularly strong in those with comorbid post-traumatic stress disorder (PTSD) or generalized anxiety disorder.
While antidepressants are typically used to treat anxiety disorders in unipolar depression, this has not been proven effective in bipolar disorder. Not only do patients with bipolar disorder tend to respond poorly to antidepressants, but in research collected by this editor Robert Post and colleagues in the Bipolar Collaborative Network, patients with bipolar disorder who had an anxiety disorder fared even more poorly on antidepressants as adjuncts to mood stabilizers than those with bipolar disorder without an accompanying anxiety disorder.
The poor response to antidepressants in bipolar depression in general, and particularly in those with a comorbid anxiety disorder, together with the finding that psychotherapy is highly effective, suggest that adjunctive psychotherapy is a more appropriate choice for patients with bipolar depression and a comorbid anxiety disorder.
The choice of the best pharmacological treatment of this comorbid anxiety disorder deserves specific comparative study. Candidates would include the mood stabilizing anticonvulsants valproate, lamotrigine, and carbamazepine; the atypical antipsychotics with efficacy in bipolar depression (quetiapine, lurasidone, and olanzapine combined with fluoxetine); and those used as an adjunct in unipolar depression (quetiapine again and aripiprazole).
Psychotherapy can play an important role in treating mental illness. At the 2014 meeting of the International Society for Bipolar Disorders, researcher F. Colom gave a plenary talk indicating that just like pharmacotherapy, psychotherapy should differ depending on characteristics of the illness—both its severity and whether the patient has more manic or more depressive symptoms.
For less severe illness with more depression, Colom explained that cognitive behavioral therapy (CBT) is ideal.
Psychoeducation and family focused therapy (FFT) is recommended for intermediate severity, with a focus on maintaining remission. Family focused therapy also works for early (prodromal) symptoms, as reported by researcher David Miklowitz et al. in 2013.
Lars Kessing et al. recently reported that specialty treatment in a clinic (including psychoeducation and vigilance to breakthrough symptoms that may suggest a new episode is imminent) is highly effective following a first episode of mania.
For more severe illness, Colom recommends cognitive remediation and rehabilitation to decrease illness burden and increase functioning. Functional remediation focuses on communication, includes homework, and teaches skills such as how to deal with money, time, and organization. It also helps improve social cognition.
For the most severe illness, palliative care to relieve symptoms and decrease illness impact is recommended. Colom noted that cognitive behavioral therapy is less effective with patients who have experienced more than 12 episodes (reported by Jan Scott et al. in the British Journal of Psychiatry in 2006), as is psychoeducation (Renares et al. 2010, Colom et al. 2014). These data re-emphasize the importance of early intervention, when these psychotherapeutic approaches are more helpful. Colom stresses the importance of behavioral cognitive therapy (BCT) rather than cognitive behavioral therapy (CBT) for those late in the illness whose episodes often arrive spontaneously, unprecipitated by psychosocial stress, and one needs more behavioral approaches to the brain’s habit memory system located in the striatum, which may drive highly recurrent illness.
Our editor Robert M. Post served as discussant at a symposium on special topics in bipolar disorder at the 2013 meeting of the American Psychiatic Association. Here are some of the findings that were presented at the symposium.
Michael Gitlin of the University of California, Los Angeles (UCLA) emphasized the importance of treating patients until remission in order to achieve functional recovery and prevent cognitive impairment.
Michael Bauer of Dresden, Germany reviewed data showing that early onset of the illness and long delays to first treatment are important predictors of poor response to treatment.
Mark Frye of the Mayo Clinic discussed the promise of pharmacogenomics to aid in the selection of the best medicine for a given individual (i.e. personalized medicine). Currently the presence of one of a few relatively rare gene variations—HLA-B 1502 (in Asian populations) and HLA-A 3101 (in European populations)—can predict that an individual may develop a severe rash when taking the anticonvulsant carbamazepine. Researcher J. Rybakowski has found that a somewhat common variant in the gene responsible for producing brain-derived neurotrophic factor (the val-66-met allele for proBDNF) is associated with a good response to lithium. This may be explained by the fact that lithium increases BDNF, and this could be crucial in those with the val-66-met allele, which functions less efficiently than the more common and better functioning allele val-66-val.
David Miklowitz, also of UCLA, reviewed data that strongly indicates psychotherapy is effective in the treatment and prevention of bipolar depression. He and Kiki Chang of Stanford University found that family focused therapy (FFT) was effective in treating early syndromes that sometimes lead to bipolar disorder (including depression, anxiety, or BP-NOS) in children at high risk for bipolar disorder because of a family history that includes bipolar disorder in a first degree relative. Yesterday we shared the 8 key ingredients to family focused therapy.
In his discussion, Post emphasized several points from each presentation. Among these was the recommendation by both Gitlin and Bauer that patients use a personal calendar to monitor symptoms and side effects. (We offer an easy download of a personal calendar.)
Post also endorsed Bauer’s emphasis on the need for early intervention, since delay to first treatment is an independent risk factor for a poor outcome in adulthood. (This finding has been replicated in three studies — Franchini et al. in 1999, Post et al. in 2010, and Drancourt et al. in 2012.
Each of these factors and family focused therapy need greater attention in the US, since Post noted that all aspects of bipolar disorder are more difficult for patients in the US compared to those in Germany, the Netherlands, and many other European countries. About two-thirds of the adults with bipolar disorder in the US had onset of the illness before age 19, while in most European countries, only about one-third of adult patients had an early onset. These data are also consistent with the low incidence of bipolar disorder in children at high risk for the disorder because of a parent with bipolar disorder in studies from the Netherlands, Switzerland, and Germany. In contrast, similar studies of children with at least on parent diagnosed with bipolar disorder in the US (by Chang et al., Nurnberger et al., Wozniak et al., and Birmaher et al.) show a higher incidence of the illness. Canadian studies by Duffy et al. and studies of an isolated Amish community in Pennsylvania by Egeland et al. show a low incidence much like the Europeans.
Given the great need for care of children with signs of bipolar disorder in the US and the shortage of child psychiatrists and pediatricians knowledgeable about bipolar disorder, Post recommended that in the absence of other alternatives, adult psychiatrists of parents with bipolar disorder who have children with the disorder should fill this gap by treating the children themselves. If the child has only early symptoms, family focused therapy as described by Miklowitz above would be recommended.
Tomorrow and Friday we’ll share tables with recommendations for the treatment of parents with bipolar disorder and their children.
Family focused therapy (FFT), developed by David Miklowitz, a professor of psychiatry at the University of California, Los Angeles, has been effective in treating early syndromes that sometimes lead to bipolar disorder (including depression, anxiety, or BP-NOS) in children at high risk for bipolar disorder because of a family history that includes bipolar disorder in a first degree relative. There are 8 key ingredients to family focused therapy.
- Consistent monitoring of the illness and developing an early warning system with a plan for responding if early symptoms emerge
- Stress management
- Development of a relapse prevention plan
- Emphasis on sleep hygiene and the importance of regular sleep patterns
- Work on medication adherence
- Development of self-regulatory skills
- Improvement of family relationships
- Avoidance of substances of abuse
New research shows that psychotherapy lowers the risk of relapse in unipolar major depression more than “treatment as usual” does, and also heads off depression in children at high risk.
At the 2013 meeting of the American Psychiatric Association, researcher Pim Cuijpers reviewed 32 trials of cognitive behavior therapy, intensive behavioral therapy, and problem solving therapy used for the prevention of depression and found that these therapies were associated with a 21% lower risk of relapse compared to treatment as usual.
There were five critical elements that made these therapies useful: they supported coping with depression, and they included exercise, mindfulness, internet-based cognitive behavior therapy, and problem solving.
Among those who presented at the meeting, Greg Clarke of Kaiser Permanente, Oregon discussed an 8-week course on coping with stress given to a group of adolescents (aged 14 to 16) who had four times the normal risk of developing depression because each had a parent with depression. Clarke found a significant reduction in depression among the adolescents who received therapy compared to controls.
Insomnia can be a precursor to a first depression or to recurrent depression. Cognitive behavior therapy was more effective in improving sleep than a comparative sleep hygiene course.
Researcher Judy Garber presented data showing that cognitive behavior therapy was effective in 13- to 17-year-olds who had a parent with depression and had themselves had a prior depression or were currently sub-syndromal. The effect of the therapy was only significant if the parent was not depressed at intake.