Interpersonal
and Social Rhythm Therapy Prevents Depressive Symptomatology in Bipolar I
Patients
Ellen Frank, Ph.D.
Bibliography
Slide
Presentation
Abstract
For much of the first two decades of lithium
treatment, bipolar disorder was thought of as a problem solved; however, more
recent controlled trials (e.g. Prien et al., 1984; Gelenberg et al., 1989) and
descriptive studies (Markar and Mandar 1989; Goldberg et al., 1995) point to the
relatively poor long-term prognosis for many bipolar I patients.
In particular, effective treatment of bipolar
depression has proven a major challenge. We have conducted a randomized
controlled trial comparing protocol pharmacotherapy in the context of an
intensive clinical management (ICM) paradigm with protocol pharmacotherapy
combined with interpersonal and social rhythm therapy (Frank et al., 1994).
While the two approaches seem equally effective in preventing recurrence of
fully syndromal mania or depression, we are also interested in the impact of
these two treatment approaches on subsyndromal symptomatology. In this
presentation we report on the first year of preventative maintenance treatment
for the first 90 subjects randomly assigned to one of these two maintenance
treatment conditions.
Fluctuation of symptoms during the preventative
phase of the trial was examined by defining the symptomatic state of each
subject for each month. Monthly states were based upon the maximum score of each
month for every subject. The states were defined as euthymic (Hamilton <
8 and
Bech-Rafaelsen < 4), depressed (Hamilton > 8 and Bech-Rafaelsen
< 4) and
manic/mixed (Bech-Rafaelsen > 5).
A mixed-effects nominal logistic regression using
MIXNO (Hedeker, 1998) was used to compare the states of subjects in the two
different treatment conditions during the first year of preventative
maintenance. The MIXNO program provides maximum marginal likelihood estimates
for the mixed-effects model utilizing a Fisher-scoring solution. Each subject
was treated as a random effect by defining intercept as a random effect. Month
(0 through 12) and treatment group (IPSRT or ICM) were treated as fixed effects.
A fixed effect of month by treatment interaction was also included to assess the
difference in proportions of subjects in a particular state as a function of
time.
There was a significant month (p < .02) and
month by treatment interaction (p < .0005) when comparing the depressed state
to the euthymic state, such that the IPSRT group is significantly more likely to
remain in the euthymic state, while the proportion of the ICM group in the
euthymic state decreases over time and the proportion in the depressive state
increases over time. There was no significant difference comparing the
manic/mixed state to the euthymic state.
We conclude the IPSRT may have an important role
in preventing subsyndromal depression in bipolar I patients and, thus, in
improving the quality of long-term remission they experience. It remains to be
seen whether prevention of subsyndromal depression is associated with a reduced
risk of depressive recurrence.
Multifamily Group Treatment for Bipolar
Depression
Gabor I. Keitner, M.D.
Bibliography
Slide Presentation
Abstract
The treatment of bipolar depression continues to
present a clinical challenge. Episodes of depression seem more resistant to
available pharmacological treatments than do manic episodes. This presentation
will describe a standardized 6 session multifamily psychoeducational group
treatment program that is currently being tested in the treatment of bipolar
disorder. Group formation, therapist training and the content of the family
group treatment will be reviewed.
Preliminary results will be presented from a
study of 92 hospitalized bipolar patients (75% manic, 20% depressed, 5% mixed)
treated with pharmacology alone vs. pharmacology with individual family therapy
vs. pharmacology with multifamily psychoeducational group therapy. The focus
will be on bipolar patients who were depressed at the index episode.
Treatment of Bipolar
Depression
Gary S. Sachs, M.D.
Bibliography
