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 ajp.psychiatryonline.
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 psych and HealthyMinds.
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