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QUESTION: Does group psychoeducation reduce recurrence in people from bipolar disorder?
Randomised single-blind controlled trial.
Hospital clinic, Barcelona, Spain.
120 people aged 18–65 years with bipolar disorder Type I or Type II (DSM-IV criteria), in remission for at least 6 months and not undergoing current psychotherapy. Exclusion criteria included, other psychiatric comorbidities, deafness, IQ < 70; or enrolment in other studies.
21 weekly sessions of group psychoeducation (identifying prodromal symptoms and encouraging adherence to treatment and a regular lifestyle), compared with unstructured group sessions. All groups included 8 to 12 people. All participants also received standard psychiatric care.
Main outcome measures
Recurrence - defined as a new acute episode according to DSM-IV criteria and scores on Young Mania Rating Scale; Hamilton Depression Rating Scale-17, hospitalisations, and length of hospital stay.
At 2 years, group psychoeducation was associated with significantly fewer recurrences, hospitalisations and shorter hospital stays than unstructured group sessions (recurrence rate 67% v 92%, p<0.01; mean number hospitalisations 0.3 v 0.8, p<0.05; mean length of hospital stay: 5 days v 15 days, p<0.05).
The intervention reduced recurrence and hospitalisation. Which aspect of the intervention was most effective remains unknown.
Bipolar disorders are common, severe mental disorders with a similar lifetime prevalence (1%) to schizophrenia. The mean relapse rate is 50% at one year and over 70% at four years.1 A recent prospective twelve year follow-up study showed that individuals with bipolar disorder were symptomatic for 47% of the time.2 This poor outcome in naturalistic settings suggests an efficacy effectiveness gap for mood stabilisers that has resulted in a re-assessment of the role of adjunctive psychological therapies in bipolar disorder.3 Recent randomised controlled trials show that the combination of pharmacotherapy and about 20–25 sessions of an evidence-based manualised therapy such as individual cognitive behaviour therapy4 or family focused therapy5 may reduce relapse rates in comparison to a control intervention (mainly treatment as usual) in currently euthymic people with bipolar disorder. However, these approaches are labour intensive and require a high level of therapist expertise. The use of a group psycho-education programme may be an important, potentially more cost-effective alternative.
The study by Colom et al demonstrates that group psycho-education is equally acceptable to, but more effective than a non-directive group intervention provided for an equivalent period of time by the same therapists. As with family therapy, this effect was primarily a result of a significant reduction in depressive relapses. Although we do not know enough about mechanisms of action, differential efficacy or cost versus benefit of the different psychological approaches now being evaluated in randomised controlled trials, the clear picture emerging is that adjunctive psychotherapies are beneficial in terms of reducing symptoms, relapse rates, medication non-adherence and improving social adjustment. The number needed to treat to prevent one relapse in Colom et al’s study is 4 (95% CI 3–9), which makes this intervention worthy of consideration as an addition to usual treatment in general adult psychiatry settings and as an alternative to more traditional cognitive behaviour therapy and family focused therapy approaches. The greater ease of delivery will make this option particularly attractive to services where no experts in cognitive behaviour therapy or family focused therapy are available.
Sources of funding: Supported in part by a grant from the Stanley Medical Research Institute, Bethesda, MD, grant 98/0700 from Instituto de Salud Carlos-III Fondospara la Investigacion Sanitaria, Madrid, Spain, grant 028/97 from Fundacio Marato de TV3, Barcelona, Catalonia, Spain and Fundacio Roviralia, Barcelona, Catalonia.
Correspondence to: Eduard Vieta, Clinical Institute of Psychiatry and Clinical Psychology, Hospital Clinic de Barcelona, Villarroel 170, Barcelona, 08036, Barcelona, Spain.
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