1. Consultant Psychiatrist and Research Fellow, IoPPN.
A critical review of the evidence base for talking therapies in Bipolar Disorder, with a focus on the NICE Guidelines
Sameer Jauhar
Consultant Psychiatrist and Research Fellow, IoPPN.
King’s College, London.

2. What I will cover Existing therapies for bipolar disorder
Evidence based approach

3. NICE CG 185

4. My Background Psychosis researcher Sat on SIGN Scz Guideline
Early intervention Consultant Psychiatrist
Prior Meta analyses of CBT and Schizophrenia (BJP, 2014)

5. Caveats
Everyone would agree that some form of psychotherapy is of use for anyone with severe mental illness
Issues with evidence
Control groups (Usually TAU/waiting listc controls)
Under-powered
Blinding
Researcher allegiance
Outcome measures

6. Current psychotherapies
Psychoeducation
Cognitive Behavioural Therapy (CBT)
Family focused psychotherapy
Interpersonal and social rhythm therapy (IPSR)

7. Psychoeducation Individual and group
Outcomes; medication adherence, symptoms, relapse
Individual psychoeducation (6-21 sessions)
Systematic review, Bond and Anderson, 2015
Measured relapse
16 trials, data on around 7
Bipolar illness, in remission

8. Main findings
Wide heterogeneity, I2=43% when including individual, 19% with group
Two methods of analysing, conservative (all dropouts relapsed) vs optimistic (all dropouts remained well)
Median follow up 60 wks, duration of tx 20.5 hours.
Decreased odds ratio of manic relapse (OR 1.68, 95% CI ), though not depression relapse (1.39, 95% CI )
NNT 4-8

9. ODDS RATIO, PE VS TAU/PLACEBO, ANY RELAPSE

10. Cognitive Behavioural Therapy
Acute treatment of bipolar depression
NICE 2014 meta-analysis
Individual CBT vs TAU for acute sx depression
N=6, effect size 0.31 (95% Cis )
Maintained at 12 month follow-up (-0.19, )

11. Cognitive behavioural therapy
Relapse
Scott 2006, no significant difference to controls, though difference in those with less than 12 episodes (Hazard ratio=0.74, 95% CI 0.56–0.98, p=0.04)

12. Functional remediation
Torrent et al 2013
PE vs FR vs TAU
Functional improvement in FR group vs TAU, and (almost) vs PE
Large effect size of FR vs TAU (Cohen’s d=0.93)

13. Family focused therapy
Very differing methodologies, comparisons and outcomes
Eg Miklowitz 2000, 2003; 3 sessions crisis management vs 21 sessions FFT
When looking at recurrence, there are two clear positive trials
See STEP BD trial, 2007

14. Interpersonal and social rhythm therapy
Interpersonal rhythms and social problems, Frank et al, 2005
Sleep/wake schedules, exercise
Frank et al, 2005, N=175, randomised to IPSRT or crisis management, hazard ratio 0.38
Possible use in acute BP depression (STEP BD, Miklowitz, 2007)

15. STEP BD
30 sessions of CBT, FFT or IPSRT vs 3 sessions of collaborative care
shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08–2.00; p=.01).
Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17–2.13) more likely to be clinically well during any study month
No difference between groups

17. NICE, 2014 Psychological treatments for bipolar disorder Illness phase
Acute treatment
Relapse prevention

19. NICE CG 185 Bipolar depression
“should be offered a specific intervention d for bipolar disorder and has a published evidence based manual…or a high intensity psychosocial intervention (IPT, CBT, behavioural couples therapy) in line with NICE guideline on depression
1st line tx for bipolar depression in primary care
Family therapy for people living close to family
Structured intervention to prevent relapse (individual, group or family, manualized)

20. Meta-analyses of bipolar depression

21. Psychoeducation
2 MAs with 2 trials, no benefit for group psychoeducation, post treatment, SMD 0.14 ( ) and follow-up (0.4, ).
Family psychoeducation beneficial vs control post-tx though not at 12 month follow-up (SMD -0.73, to -0.01), (S D-0.1, to 0.36)
However the meta analysis included only one trial

22. Meta-analysis of relapse prevention
Individual CBT vs TAU for any relapse, risk ratio 0.67, )
Excluded Scott et al, 2006
Include Scott et al, risk ratio 0.79 ( )

24. Methodological issues
Over 130 separate meta-analyses, some of only one trial and multiple outcome measures
No control for comparisons (FDR would seem appropriate)
Composite meta-analyses of differing therapies together
Individual CBT and psychoeducation was significant, but other composite analyses non-significant

25. Risk of Bias
Blinding of studies, randomisation, controlling for attrition
All studies included re outcome were low or very low quality
?Selective reporting of findings from composite MA?

26. The Mental Elf Blog

27. The aftermath….. Response from the Guidleine group
Response form ourselves….