Person:

Bauer, Mark

Background

This report describes baseline characteristics and functional outcomes of subjects who have prospectively observed subsyndromal symptoms after a major depressive episode (MDE).

Methods

All subjects were participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). We identified subjects with at least 2 years of observation whose prior or current episode was a MDE, and who were in a stable clinical state of either recovered (no more than 2 moderate symptoms for at least 8 weeks), a MDE by DSM IV criteria, or with continued subsyndromal symptoms. The subsyndromal group was defined a priori as 3 or more moderate affective symptoms but without meeting diagnostic criteria for major depression.

Results

The final cohort included 1094 recovered, 112 subsyndromal, and 310 individuals in a MDE. The average time spent in each clinical status ranged from 120 to 132 days. The subsyndromal group was most similar to those in a MDE, differing only on the intensity of depressive symptoms and the number of work days missed due to ongoing symptoms. Reported sadness, inability to feel and lassitude were each associated with multiple measures of impairment.

Limitations

This study is limited by the cross sectional approach to defining outcomes.

Conclusions

These findings are consistent with studies in unipolar major depression that indicate that functional impairment observed in the context of subsyndromal depressive symptoms is comparable to that of a full episode. This work underscores the need to include subsyndromal symptoms in study outcomes and to target full remission in clinical practice.

Background

There are 14 randomized trials that indicate the benefits of various adjunctive psychosocial interventions for bipolar disorder. Efficient planning of future interventions requires identification of the common, putatively active components of these treatments. We investigated whether different forms of psychotherapy consisted of overlapping versus modality-specific ingredients.

Methods

We identified five categories of active psychosocial treatment in 14 trials: cognitive-behavioral therapy (CBT; 4 studies), family psychoeducation (5 studies), interpersonal and social rhythm therapy (IPSRT; 2 studies), individual psychoeducation (3 studies), and group psychoeducation (5 studies). In this study, 31 investigators and therapists who participated in these trials completed a questionnaire in which they rated the frequency of 17 treatment strategies in their active and treatment-as-usual (TAU) conditions. A content analysis of the results of this questionnaire was then done, in which the active treatments were compared with each other and with TAU on the frequency of use of each strategy.

Results

The active modalities were distinguished from TAU by more frequent use of problem-solving and interventions to enhance patients’ ability to cope with the stigma of mental illness. With regard to specific approaches, CBT made frequent use of cognitive restructuring and self-rated mood charts. The signature features of IPSRT—regulation of sleep/wake cycles and daily routines—were also regular features in the CBT and group psychoeducation interventions. Communication skills training was a distinctive feature of family treatments.

Conclusions

Whereas active psychosocial interventions for bipolar disorder have common ingredients, they can also be distinguished from each other and from TAU by the degree to which specific strategies are emphasized. Future research should compare the treatment ingredients identified in this study in terms of their ability to bring about clinical change.

Introduction

Bipolar disorder is associated with functional impairment across a number of domains, including health-related quality of life (HRQOL). Many patients are treated exclusively in primary care (PC) settings, yet little is known how HRQOL outcomes compare between PC and community mental health (CMH) settings. This study aimed to explore the correlates of HRQOL across treatment settings using baseline data from a multisite, randomized controlled trial for adults with bipolar disorder.

Methods

HRQOL was measured using the SF-12 physical (PCS) and mental (MCS) health scales. Independent sample t-tests were calculated to compare differences in HRQOL between settings. Multivariate regression models then examined the effect of treatment setting on HRQOL, adjusting for covariate demographic factors, mood symptoms (Internal State Scale), hazardous drinking (AUDIT-C), and substance abuse.

Results

A total of 384 enrolled participants completed baseline surveys. MCS and PCS scores reflected similar impairment in HRQOL across PC and CMH settings (p = .98 and p = .49, respectively). Depressive symptoms were associated with lower MCS scores (B = −.68, p < .001) while arthritis/chronic pain was strongly related to lower PCS scores (B = −5.23, p < .001).

Limitations

This study lacked a formal diagnostic interview, relied on cross-sectional self-report, and sampled from a small number of sites in two states.

Discussion

Participants reported similar impairments in both mental and physical HRQOL in PC and CMH treatment settings, emphasizing the need for integrated care for patients with bipolar disorder regardless of where they present for treatment.