An analysis of 39 randomized clinical trials involving 3,863 patients diagnosed with bipolar disorder has concluded that when drug therapy is supplemented with various forms of structured psychotherapy, patients fare better in several important respects.

This is important because only about 50% of bipolar patients currently receive psychotherapy in addition to medications. Many of these patients would fare better if the new finding were to widely influence care, the new study suggests.

A team led by David Miklowitz, Ph.D., of the University of California, Los Angeles, surveyed and statistically analyzed the clinical trials literature, carefully selecting studies that could be usefully compared. Dr. Miklowitz is winner of the 2011 BBRF Colvin Prize for Outstanding Research in Bipolar Disorder. He is also a 2001 BBRF Distinguished Investigator and among the first group of scientists to receive a BBRF Young Investigator award (1987).

Many past clinical trials have assessed the effectiveness of medications with and without adjunctive psychotherapy, but virtually no effort has been made to compare the relative effectiveness of different forms of psychotherapy in bipolar disorder, noted the team, whose analysis appeared in JAMA Psychiatry.

The team set out to discover, first, the effectiveness of different types of psychotherapy combined with medication on whether patients suffer a relapse within one year. They also assessed the effectiveness of different types of therapy or “therapy components” (specific techniques such as encouraging patients to keep track their moods between sessions) in controlling depressive and manic symptoms of the disorder over one year. Finally, they assessed whether the type of therapy affected whether patients stayed in or dropped out of the 39 trials, which lasted from 1 to 2 years.

The patient population represented in these trials included mostly adults, typically aged between 30 and 40; three of the trials involved adolescents. In trials that noted the sex of patients, 60% were female. Importantly, each of the trials selected for the analysis compared patients who received medication plus a specific form of psychotherapy vs. patients who received medication and “treatment as usual,” (i.e., those who did not receive one-on-one, family, or group therapy, although they met with their psychiatrists to talk about medication side effects). This latter group was considered a “control” in each trial to compare with those who received active psychotherapy along with their medication.

When all the trials were compared, the team concluded that patients who received psychotherapy in addition to medication had lower rates of recurrence than those who received medication and treatment as usual. Interestingly, psychoeducation with “guided practice of illness management skills” was superior when delivered in a family format (i.e., patients with their caregivers) or a group format (patients with other patients) than when delivered in an individual (one-on-one) format.

The team also concluded that medication with cognitive behavioral therapy (CBT), and with lesser certainty, family therapy or interpersonal therapy (IPT), was more effective than medication with “treatment as usual” in stabilizing depressive symptoms.

A third major finding was that patients were more likely to stick with their combined treatment regimens over a year’s time when they received therapy in family or group formats, or when they received brief psychoeducation as opposed to more formalized, didactic versions of psychoeducation given individually.

Dr. Miklowitz and colleagues were careful to stress that different patients, at different stages of the illness, or with a different mix of symptoms, can respond differently to the many varieties of psychotherapy. That’s why the finding about the advantage of family and group vs. individual treatment may prove significant—but for the time being must only be considered suggestive and preliminary.

The researchers also stressed that the success of psychotherapy depends on the training and skill of the therapist, and that those using evidence-based approaches should be sought by patients and their families.

Most of the 39 trials studied did not make distinctions between patients with bipolar I disorder and bipolar II disorder, nor did they recruit participants according to symptom severity. For this reason, the researchers make the case for applying rigorous standards in future trials to make precise comparisons of different treatment combinations based on uniformity of care delivery as well as clearer delineation of patients’ diagnostic subtypes. In this way, they suggest, it might be possible with considerably greater precision to tailor the combination of psychotherapy and medication to the needs of individual patients with bipolar disorder.