Adjunctive CBT in bipolar disorder no use if many recurrences

UK researchers report that the use of adjunctive cognitive behavioural therapy (CBT) to prevent recurrence of bipolar disorder is only of benefit in people with 12 or fewer episodes.Previous studies have suggested that drug treatment plus brief evidence-based manualised therapy may significantly reduce recurrence rates compared with treatment as usual, although most were single-centre studies that recruited euthymic patients with relatively little psychiatric co-morbidity.With this is mind the researchers conducted a pragmatic multicentre randomised controlled trial to assess whether CBT plus treatment as usual is more effective than usual treatment alone in reducing recurrence rates and lowering weekly symptom levels in adults with recurrent bipolar disorder. Subjects recruited to the study (n=253) had experienced two or more recurrences of bipolar disorder, with at least one in the past year, and had been in contact with mental health services in the past six months.Subjects were randomised to receive CBT plus treatment as usual (n=127) or usual treatment only (n=126). Subjects were assessed at baseline then every eight weeks for 72 weeks.The CBT element, which was based on Beck's model, comprised 20 sessions, held weekly for the first 15 weeks then with reducing frequency until week 26.Treatment as usual included prescription of medications and contact with key mental health professionals as required.Overall, 52% of subjects experienced a recurrence during follow-up - 53% of those receiving CBT plus usual care, and 51% of those receiving usual care only. The researchers observed no between-group differences in rates of recurrence, with rates of around 30% and 60% at six and 18 months, respectively. This pattern remained when depressive and manic recurrences were considered separately.Symptom levels were assessed using the Longitudinal Interval Follow-Up Evaluation (LIFE-II). The researchers observed no differences between the groups in terms of LIFE scores over 18 months.The results of a post-hoc analysis revealed a significant interaction between treatment type and the number of episodes recorded at baseline whereby adjunctive CBT was more effective than usual care in subjects with less than 12 previous episodes but less effective in those with more than 12 previous episodes.The researchers conclude that their findings do not support the use of brief evidence-based CBT to prevent future recurrence of bipolar disorder if the individual has already experienced a very high number of previous episodes.They add that if CBT is to be offered widely to people with bipolar disorder, it may be better viewed as an early option, rather than an intervention for difficult-to-treat chronic illness.Reference...