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Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial

  • F. Colom (a1), E. Vieta (a2), J. Sánchez-Moreno (a2), R. Palomino-Otiniano (a3), M. Reinares (a4), J. M. Goikolea (a4), A. Benabarre (a4) and A. Martínez-Arán (a4)...
Abstract
Background

The long-term efficacy of psychological interventions for bipolar disorders has not been tested.

Aims

This study assessed the efficacy of group psychoeducation to prevent recurrences and to reduce time spent ill for people with bipolar disorders.

Method

A randomised controlled trial with masked outcome assessment comparing group psychoeducation and non-structured group intervention during 5-year follow-up. One hundred and twenty people with bipolar disorders were included in the study and 99 completed 5-year follow-up. Time to any recurrence, number of recurrences, total number of days spent ill, frequency and length of hospitalisations were the main outcome measures.

Results

At the 5-year follow-up, time to any recurrence was longer for the psychoeducation group (log rank=9.953, P<0.002). The psychoeducation group had fewer recurrences (3.86 v. 8.37, F=23.6, P<0.0001) of any type and they spent less time acutely ill (154 v. 586 days, F=31.66, P=0.0001). The median number of days of hospitalisation per hospitalised participant was also lower for the psychoeducation group (45 v. 30, F=4.26, P=0.047).

Conclusions

Six-month group psychoeducation has long-lasting prophylactic effects in individuals with bipolar disorders. Group psychoeducation is the first psychological intervention showing such a long-term maintained efficacy in people with bipolar disorders.

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Copyright
Corresponding author
Correspondence: E. Vieta, Bipolar Disorders Program, Hospital Clinic of Barcelona, Villarroel 170, 08036 Barcelona, Spain. Email: EVIETA@clinic.ub.es
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Declaration of interest

E.V. has served as consultant, advisor or speaker for the following companies: AstraZeneca, Bial, Bristol-Myers, Eli Lilly, Glaxo-Smith-Kline, Jannssen-Cilag, Lundbeck, Merck-Sharp and Dohme, Novartis, Organon, Otsuka, Pfizer Inc, Sanofi-Aventis, Servier and UCB Pharmaceuticals. F.C. has served as advisory or speaker for the following companies: Astra Zeneca, Eli-Lilly, Sanof-Aventis, Tecnifar and Shire. Funding detailed in Acknowledgements.

Footnotes
References
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1 Colom, F, Vieta, E. A perspective on the use of psychoeducation, cognitive–behavioral therapy and interpersonal therapy for bipolar patients. Bipolar Disord 2004; 6: 480–6.
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3 Colom, F, Vieta, E, Martinez-Aran, A, Reinares, M, Goikolea, JM, Benabarre, A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003; 60: 402–7.
4 Colom, F, Vieta, E, Sanchez-Moreno, J, Martinez-Aran, A, Reinares, M, Goikolea, JM, et al. Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium levels. Bipolar Disord 2005; 7 (suppl 5): 32–6.
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Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial

  • F. Colom (a1), E. Vieta (a2), J. Sánchez-Moreno (a2), R. Palomino-Otiniano (a3), M. Reinares (a4), J. M. Goikolea (a4), A. Benabarre (a4) and A. Martínez-Arán (a4)...
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eLetters

Outcome of group psychoeducation for stabilised bipolar disorders: everything is quite clear (now)

Francesc Colom, Senior Researcher
13 May 2009

Dear Sir,

In response to Dr Navendu Gaur kind queries on our article “Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial” (Colom et al., The British Journal of Psychiatry 2009; 194: 260-265), we would like to provide some clarifications:

1.Only those patients with “severe” axis I comorbidity diagnoses were excluded. This means that patients were excluded in the case that they presented with a coexisting axis-I condition that might have a major impact on their ability to effectively participate in the groups, such as severe social phobia or obsessive compulsive disorder, for instance.

2.Regarding details of status and/or type of Axis-I/II comorbidities, we would like to point out that this was already covered for the 2-year follow-up in a previous paper (Colom et al., 2004).

3.We defined recurrence both based on severity ratings AND DSM-IV criteria; these are narrow criteria which are much more reliable than justasking for diagnostic criteria alone OR rating scale scores. We disregarded the possibility of using a life-chart method to catch subsyndromal fluctuations because this method has not shown good reliability and would likely capture a lot of noise.

4.Criteria for hospitalization were those used at the Barcelona Bipolar Disorders Program; any patient presenting an episode that due to its severity can not be managed in an outpatient setting and/or any patient presenting suicide risk or representing a risk for third persons.

5.As clearly explained in our manuscript, the primary outcome of thetrial was time to recurrence. Secondary outcomes included time spent ill and number of recurrences. Our original submission included a full data report on those secondary variables, which had to be condensed due to space constraints. The analysis of number of recurrences was, as explainedin methods, perfomed by means of ANCOVA and therefore the mean values for each group are just orientative.

6.We acknowledge a typo mistake on table 2 referring to the number of days spent in depression. The right values should be: Control group 398.55 (364.16), Psychoeducation group 93,28 (165,46). Apparently, the standard deviation for the control group was mistakenly repeated replacingthe mean number of days spent in depression for the Psychoeducation group.After correcting this error, data regarding mean number of days spent in each episode tally with the total duration for both groups. As this was only a typo mistake, it does not change any statistics. We have been informed of this mistake by other readers and have already proceeded to issue the corresponding erratum.

We would like to thank Dr Gaur for his comments and British Journal of Psychiatry for giving us the opportunity to further clarify them.
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Conflict of interest: None Declared

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Outcome of group psychoeducation for stabilised bipolar disorders: needs further clarification

Navendu Gaur, Senior Resident, Department of Psychiatry, PGIMER, Chandigarh, India
07 April 2009

The article by Colom et al.1 further enhanced our understanding aboutthe role of psychoeducation in the management of bipolar disorders. The study draws its strengths from the fact that it included an active controlgroup, included subjects of bipolar disorder with axis-II comorbidity, follow-up rates were excellent and the authors assessed the outcome in theform of number and type of recurrences, time to recurrence, time spent illand number of hospitalizations at 5 years. However, some of the issues require further clarification. When one looks at the article reporting 2 year follow-up of the same cohort2, there the authors report that subjectswith Axis-I comorbidity were excluded, but at 5 year follow-up the authorsreport that only those with severe axis-I diagnosis were excluded. Furtherthe authors don’t define “severe”. Subjects with bipolar disorders can have high rate of comorbidity, hence clarification of this fact is very important from the perspective of generalizability of the findings of the study. Further, authors don’t provide details of status and/or type of Axis-I/II comorbidities and whether the drop out and completers had any difference with regard to clinical and demographic features. Another important aspect is the way the authors defined recurrence based on ratingscale scores. This kind of definition in true sense doesn’t include the subsyndromal symptoms and can influence almost all the outcome measures like time spent ill, time to recurrence and also the number of recurrences, especially when the cohort is being followed up at a frequency of every 2 weeks. Similarly, although the study included number and duration of hospitalization as an outcome measure the author have not discussed the criteria for hospitalization. Another important aspect whichneeds clarification is the analysis of data. At many places the authors have used parametric test to compare the numerical variables although the standard deviation is more than the mean. Similarly, mean values are given for number of recurrence without standard deviations while comparison statistics are given as F values. In the Table 2, again the authors have compared the mean values using Fisher F statistics and have presented that there was significant difference in number of days spent ineach episode for all types of episodes. However when one looks at the data, it is difficult to understand this contention. In the same table when one adds the mean number of days spent in each episode for the control group the data regarding each episode and the total duration do tally, but same is not the case for the psychoeducation group.

References:

1.Colom F, Vieta E, Sánchez-Moreno J, Palomino-Otiniano R, Reinares M, Goikolea JM, Benabarre A, Martínez-Arán A. Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial. Br J Psychiatry 2009; 194:260-5.

2.Colom F, Vieta E, Martinez-Aran A, Reinares M, Goikolea JM, Benabarre A, Torrent C, Comes M, Corbella B, Parramon G, Corominas J. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003; 60: 402-7.
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Conflict of interest: None Declared

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