"Intensive" Treatment Better for Bipolar Disorder

What is the world coming to?   title="Am J Psychiatry">AJP
has an article about "intensive" therapy for bipolar disorder.
 Their definition of intensive?  Thirty sessions over
a
period of nine months.



Back in the day, when you could struggle to stay awake during a seminar
when people read their process notes to their supervisors, and watch
brachiosaurids frolic outside the window, intensive therapy was at
least twice weekly.  More like thrice weekly.  



Gone are the sauropods.  Now, you are likely to see
hitherto-unknown strange creatures with spiked hair and iPods race by
on their Razor scooters.  And "intensive" treatment is less
than
one session per week.



href="http://ajp.psychiatryonline.org/cgi/content/abstract/164/9/1340">Intensive
Psychosocial Intervention Enhances Functioning in Patients With Bipolar
Depression: Results From a 9-Month Randomized Controlled Trial


Am J Psychiatry 164:1340-1347, September 2007

doi: 10.1176/appi.ajp.2007.07020311

© 2007 American Psychiatric Association


OBJECTIVE: Psychosocial interventions are
effective adjuncts to
pharmacotherapy in delaying recurrences of bipolar disorder; however,
to date their effects on life functioning have been given little
attention. In a randomized trial, the authors examined the impact of
intensive psychosocial treatment plus pharmacotherapy on the functional
outcomes of patients with bipolar disorder over the 9 months following
a depressive episode. METHOD: Participants were 152 depressed
outpatients with bipolar I or bipolar II disorder in the multisite
Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
study. All patients received pharmacotherapy. Eighty-four patients were
randomly assigned to intensive psychosocial intervention (30 sessions
over 9 months of interpersonal and social rhythm therapy, cognitive
behavior therapy [CBT], or family-focused therapy), and 68 patients
were randomly assigned to collaborative care (a 3-session
psychoeducational treatment). Independent evaluators rated the four
subscales of the Longitudinal Interval Follow-Up Evaluation-Range of
Impaired Functioning Tool (LIFE-RIFT) (relationships, satisfaction with
activities, work/role functioning, and recreational activities) through
structured interviews given at baseline and every 3 months over a
9-month period. RESULTS: Patients in intensive psychotherapy had better
total functioning, relationship functioning, and life satisfaction
scores over 9 months than patients in collaborative care, even after
pretreatment functioning and concurrent depression scores were
covaried. No effects of psychosocial intervention were observed on
work/role functioning or recreation scores during this 9-month period.
CONCLUSIONS: Intensive psychosocial treatment enhances relationship
functioning and life satisfaction among patients with bipolar disorder.
Alternate interventions focused on the specific cognitive deficits of
individuals with bipolar disorder may be necessary to enhance
vocational functioning after a depressive episode.



The problem with this study is that, these days, it is very difficult
to get 30 sessions of psychotherapy in some places.  Leading
HMOs
(yes, I'm talking to you, Duane and Bruce) give maybe ten sessions.
 Twenty if you are lucky.



One thing I notice about this study, also, is their curious statement:
"Alternate interventions focused on the specific cognitive deficits of
individuals..."



Since when is a focus on the specific individual considered to be an
"alternate" intervention?  Imagine that!  Paying
attention to
the individual, and tailoring the treatment to that person's needs!
 



On a more serious note, it is good to see that people are trying to
figure out how best to restore functioning in persons with bipolar
disorder.  It is clear from reading it that the authors are
very much aware of the need to treat people, not diseases.
 It's just unfortunate that treatment at a level of intensity
that used to be routine, is now considered exceptional.




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Oe of the issues of the current patchwork of health care is that a few people get weekly services over an extended time (3 months or more), most get the 10 or 15 initial sessions, and few get whatever is provided through emergency rooms.
As for the cognitive issue, there's not been a lot of attention paid to cognitive deficits (memory, attention, planning) and specific cognitive remediation & strategies in this population until the last few years. It's starting now, but despite the emphasis on biological psychiatry, concern about the cognitive consequences between acute episodes hasn't been high.

"It's just unfortunate that treatment at a level of intensity that used to be routine, is now considered exceptional. "

The more so since so many patients are now on medications they may end up taking for years. 20 sessions and out seems a bit counterproductive in lifelong diseases like bipolar disorder.