Use of CBT for Severe Mood Disorders in “Real World” Settings

CBT studyThe current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, “real world” settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.

Björgvinsson, T., Kertz, S. J., Bigda-Peyton, J., Rosmarin, D. H., Aderka, I. M., & Neuhaus, E. C. (2014). Effectiveness of cognitive behavior therapy for severe mood disorders in an acute psychiatric naturalistic setting: A benchmarking study. Cognitive Behaviour Therapy, 43, 3, 209-220.

Child- and Family-Focused CBT for Pediatric Bipolar Disorder

OBJECTIVE: Previous studies have found that family-based psychosocial treatments are effective adjuncts to pharmacotherapy among adults and adolescents with bipolar disorder (BD). The objective of this study was to compare the efficacy of adjunctive child- and family-focused cognitive-behavioral therapy (CFF-CBT) to psychotherapy as usual (control) for mood symptom severity and global functioning in children with BD.

METHOD: Sixty-nine youth, aged 7 to 13 years (mean = 9.19, SD = 1.61) with DSM-IV-TR bipolar I, II, or not otherwise specified (NOS) disorder were randomly assigned to CFF-CBT or control groups. Both treatments consisted of 12 weekly sessions followed by 6 monthly booster sessions delivered over a total of 9 months. Independent evaluators assessed participants at baseline, week 4, week 8, week 12 (posttreatment), and week 39 (6-month follow-up).

RESULTS: Participants in CFF-CBT attended more sessions, were less likely to drop out, and reported greater satisfaction with treatment than controls. CFF-CBT demonstrated efficacy compared to the control treatment in reducing parent-reported mania at posttreatment and depression symptoms at posttreatment and follow-up. Global functioning did not differ at posttreatment but was higher among CFF-CBT participants at follow-up.

CONCLUSION: CFF-CBT may be efficacious in reducing acute mood symptoms and improving long-term psychosocial functioning among children with BD.

West, A. E., Weinstein, S. M., Peters, A. T., Katz, A. C., Henry, D. B., Cruz, R. A., & Pavuluri, M. N. ( 2014). Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder: A Randomized Clinical Trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 11, 1168.

Mental Imagery in Bipolar Affective Disorder versus Unipolar Depression during Times of ‘Positive’ Mood

OBJECTIVE: Compared to unipolar depression (UD), depressed mood in bipolar disorder (BD) has been associated with amplified negative mental imagery of the future (‘flashforwards’). However, imagery characteristics during positive mood remain poorly explored. We hypothesise first, that unlike UD patients, the most significant positive images of BD patients will be ‘flashforwards’ (rather than past memories). Second, that BD patients will experience more frequent (and more ‘powerful’) positive imagery as compared to verbal thoughts and third, that behavioural activation scores will be predicted by imagery variables in the BD group.

METHOD: BD (n=26) and UD (n=26) patients completed clinical and trait imagery measures followed by an Imagery Interview and a measure of behavioural activation.

RESULTS: Compared to UD, BD patients reported more ‘flashforwards’ compared to past memories and rated their ‘flashforwards’ as more vivid, exciting and pleasurable. Only the BD group found positive imagery more ‘powerful’, (preoccupying, ‘real’ and compelling) as compared to verbal thoughts. Imagery-associated pleasure predicted levels of drive and reward responsiveness in the BD group.

CONCLUSIONS: This study reveals BD patients experience positive ‘flashforward’ imagery in positive mood, with more intense qualities than UD patients. This could contribute to the amplification of emotional states and goal directed behaviour leading into mania, and differentiate BD from UD.

Ivins, A., Di, S. M., Close, H., Goodwin, G. M., & Holmes, E. (September 01, 2014). Mental imagery in bipolar affective disorder versus unipolar depression: Investigating cognitions at times of ‘positive’ mood. Journal of Affective Disorders, 166, 12, 234-242.

CBT Improves Memory Functioning in Patients with Bipolar I Disorder

According to a recent study published in the Journal of Behavior Therapy and Experimental Psychiatry, cognitive behavior therapy (CBT) improves explicit memory recall and reduces explicit memory bias for negative words in patients with bipolar type I disorder.  Both mania and depression are associated with impaired memory.  In tests in which participants learn words and are then asked to recall them, bipolar patients, both manic and depressive, have been shown to recall less words overall but more words with negative emotional valence than non-bipolar or depressed people.  This suggests that bipolar disorder affects global memory performance and introduces a negative memory bias.  The present study sought to examine if a CBT intervention would improve global memory performance and reduce the negative memory bias in bipolar I patients using a randomized, wait-list controlled design.

Participants (n=73) were bipolar I patients aged 18-65 on a treatment waiting list.  The experimental group (N=53) was given CBT in addition to medication, and the control group (N=20) was treated with just medication.  Participants were assessed for memory at baseline and at a 6-month follow up.  In this procedure, they were given 30 words that had either positive, neutral, or negative affective valence (10 words for each category).  They were first asked to rate the emotional valence of each word on a one to five scale.  Then, they were told to write down as many words as they could recall.  Participants were also assessed for disorder levels with the Hamilton Depression Rating Scale (HDRS), Mania Rating Scale (MRS), and the Hamilton Anxiety Rating Scale (HARS), and completed the Dysfunctional Attitudes Scale (DAS).

Before treatment, there were no significant differences between the two groups in the number of words recalled in any affective valence category or in the severity of bipolar symptoms.   At the follow-up, 11 patients from the experimental group had dropped out.  Of the remaining 42, significant improvements on the HDRS, HARS, and DAS were observed.  No such improvements were observed in the control group.  The primary effect of interest, explicit memory recall, was also improved in the CBT group.  Futher, recall for positive and neutral words was significantly improved, and recall for negative words significantly decreased in this group.  No memory effects were observed in the control group.

These results indicate that CBT is not only effective in improving the general dysfunctional symptoms of bipolar I disorder, but also in improving explicit memory functioning and reducing negative memory bias in patients.  By reducing negative memory bias, CBT may help modify bipolar patients’ cognitive schemas and can contribute to decreased cognitive vulnerabilities such as the negative memory bias. Further, CBT techniques for regulating both positive and negative thoughts and emotions can allow patients to modify unhelpful and intrusive past memories.

Docteur, A., Mirabel-Sarron, C., Guelfi, J.-D., Rouillon, F., & Gorwood, P. (2013). The role of CBT in explicit memory bias in bipolar I patients. Journal of Behavior Therapy and Experimental Psychiatry, 44, 3, 307-311.

Combined Therapy is Effective for Patients with Refractory Bipolar Disorder in the Long-Term

According to a recent study published in European Psychiatry, a combined treatment, including cognitive behavior therapy (CBT), psycho-education, and pharmacology results in greater long-term efficacy in patients with refractory bipolar disorder than standard pharmacological treatment.

The current study is a 5-year follow-up to a previous trial which examined the differences in efficacy for patients (n=40) with treatment resistant bipolar disorder who were randomly assigned to an experimental group that used a combined therapy, or control group that used pharmacology alone.  There were multiple evaluation points (6-months, 12-months, and 5-years) and at each follow-up, the between-group differences remained significant.

At all follow-up points, the combined therapy group had lower depression and anxiety scores. They also showed significant differences in mania and maladjustment at post-treatment, which were sustained through the 6-month, 12-month, and 5-year evaluation points. Further, the experimental group had fewer hospitalizations at the 12-month evaluation point. At the 5-year follow-up, 88.9% of patients who received pharmacological treatment alone continued to show persistent affective symptoms and/or difficulties in social-occupational functioning, compared to just 20% of patients who received the combined therapy treatment.

These findings suggest that a combined therapy, including CBT, psycho-education, and pharmacology may be quite helpful for patients with refractory bipolar disorder in the long term and superior to pharmacological treatment, alone.

González, I. A., Echeburúa, E., Limiñana, J. M., & González-Pinto, A. (2012) Psychoeducation and cognitive-behavioral therapy for patients with refractory bipolar disorder: A 5-year controlled clinical trial. European Psychiatry. In Press