Page 30 - e-book CPG - Bipolar Disorder

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)

4.2. Non-Pharmacological Therapy
4.2. Non-Pharmacological Therapy

ca
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4.2.
4.2. Non-Pharmacological Therapy
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4.2. Non-Pharmacological Therapy

ha
he

Non-pharmacological treatment in BD includes physical therapies, psychosocial interventions

Non-pharmacological treatment in BD includes physical therapies, psychosocial interventions
and psychotherapies which are discussed further below.
e
ph
soci
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B
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Non-pharmacological treatment in BD includes physical therapies, psychosocial interventions
N
ud
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s
cal
i
on
r
ph

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ncl
i
Non-pharmacological treatment in BD includes physical therapies, psychosocial interventions
and psychotherapies which are discussed further below.

and psychotherapies which are discussed further below. .
d
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and psychotherapies which are discussed further below.

4.2.1. Physical therapy

4.2.1. Physical therapy
Physical therapies are increasingly common in the treatment of BD and newer strategies have
rapy
P

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4.2.1. Physical therapy
.
sical
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t
1
4.2.1. Physical therapy
4.2.
Physical therapies are increasingly common in the treatment of BD and newer strategies have
been developed in recent years. In comparison to pharmacological treatment, the evidence
ne
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si
l

on
o
D
hy

B
m
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he
m

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Physical therapies are increasingly common in the treatment of BD and newer strategies have
t
g
P
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e
i
i
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cr
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ng
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r
v
Physical therapies are increasingly common in the treatment of BD and newer strategies have
e
a
been developed in recent years. In comparison to pharmacological treatment, the evidence
on the effectiveness and safety of physical therapies is diverse. Despite this, the use of
en
o
g
m
nt
n
o

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r
m
el
nce
ece

aco
l
be
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pa
been developed in recent years. In comparison to pharmacological treatment, the evidence
he
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been developed in recent years. In comparison to pharmacological treatment, the evidence
on the effectiveness and safety of physical therapies is diverse. Despite this, the use of
physical therapies would be a good complement to the management strategies and provide
cal

es
ap
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t
e
r
e

h
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i
s
e
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t

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hi
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on the effectiveness and safety of physical therapies is diverse. Despite this, the use of

on the effectiveness and safety of physical therapies is diverse. Despite this, the use of f
ess
o

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use
an
en
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e
si
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erse.
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ct
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physical therapies would be a good complement to the management strategies and provide
alternatives to treatment options.
i
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a
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physical therapies would be a good complement to the management strategies and provide
prov

ph
physical therapies would be a good complement to the management strategies and provide
de
i
eg
t
a
i
d
an
es
o
t
t

alternatives to treatment options.

alternatives to treatment options.
alternatives to treatment options.
alternatives to treatment options.

Electroconvulsive therapy
a.
In a systematic review of six international clinical guidelines on the treatment of mainly mixed
a.
nv
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roco
ec
ulsi
t
r
ap
Electroconvulsive therapy
E
Electroconvulsive therapy
t
y
e
a. a a. . Electroconvulsive therapy
v
l
In a systematic review of six international clinical guidelines on the treatment of mainly mixed
states in BD among adult population, ECT was an effective option in patients with poor

y

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i
t

ew
ea
n a
r
x
i
t
ai
g
f
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i
o

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na
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x

en
c
nl
r

ne
of
In a systematic review of six international clinical guidelines on the treatment of mainly mixed
on
ed
s
al
sy
ema
de
ni
i
l
i
cl
I
In a systematic review of six international clinical guidelines on the treatment of mainly mixed
nter
ui
ev

on
m

he

si
i
t
states in BD among adult population, ECT was an effective option in patients with poor
43
response to pharmacological treatment:
states in BD among adult population,
states in BD among adult population, 43 ECT was an effective option in patients with poor ECT was an effective option in patients with poor
states in BD among adult population, ECT was an effective option in patients with poor
response to pharmacological treatment:

response to pharmacological treatment:
response to pharmacological treatment:
response to pharmacological treatment: 43 4 43 3

In another systematic review of five international clinical guidelines on long-term management

In another systematic review of five international clinical guidelines on long-term management
of BD I in adults, ECT was an effective second-line treatment option in prevention of any mood
r
cl
t
i
e
ema
ev
I
In another systematic review of five international clinical guidelines on long-term management
an

o
g
w
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ne
an
i
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nte
s
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erm
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t

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al
c
i
on
g
v
l
e
In another systematic review of five international clinical guidelines on long-term management t
of BD I in adults, ECT was an effective second-line treatment option in prevention of any mood
episode.
50
oo
n
C
m
d
w
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on

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e
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as
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en
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e

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i
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of BD I in adults, ECT was an effective second-line treatment option in prevention of any mood
ad
D
B
ul
E
i
n
of BD I in adults, ECT was an effective second-line treatment option in prevention of any mood

I

o
t

f
,
s
episode.
50

e
ep
episode. . 5 50 0
i
episode.
50
sod

In a 6-week RCT on adults with treatment-resistant bipolar depression, right unilateral

In a 6-week RCT on adults with treatment-resistant bipolar depression, right unilateral
electroconvulsive therapy (ECT) showed lower MADRS score (MD=6.6 points, 95% CI 2.5 to
ea
m
C
t
e
al
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i
ate
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r

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In a 6-week RCT on adults with treatment-resistant bipolar depression, right unilateral
w
I
t
an
t

6
si
e

st
In a 6-week RCT on adults with treatment-resistant bipolar depression, right unilateral
T
on
54, level
electroconvulsive therapy (ECT) showed lower MADRS score (MD=6.6 points, 95% CI 2.5 to I
10.6) and higher response rate (p=0.01) compared with pharmacological treatment.
M
si
E

D
%
i
nts,
er
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electroconvulsive therapy (ECT) showed lower MADRS score (MD=6.6 points, 95% CI 2.5 to
=6.
)
t
R
he
t
ul
electroconvulsive therapy (ECT) showed lower MADRS score (MD=6.6 points, 95% CI 2.5 to
54, level I
10.6) and higher response rate (p=0.01) compared with pharmacological treatment.
6)
se
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e
10.6) and higher response rate (p=0.01) compared with pharmacological treatment. t . 54, level I
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54, level

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10.6) and higher response rate (p=0.01) compared with pharmacological treatment.
10
Based on the same study, there were NS differences in neurocognitive functioning between I 54, level I
esp
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cal

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ea
01
t
i
h

r
d
aco
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Based on the same study, there were NS differences in neurocognitive functioning between
the two groups apart from worsening autobiographical memory in the ECT group.
55, level I

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g
ni

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ase
e
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Based on the same study, there were NS differences in neurocognitive functioning bet
d
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55, level Iween g between

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t
Based on the same study, there were NS differences in neurocognitive functioning between
he
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the two groups apart from worsening autobiographical memory in the ECT group.

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the two groups apart from worsening autobiographical memory in the ECT group.
ob
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55, level I
the two groups apart from worsening autobiographical memory in the ECT group. . 55, level I l I

Observational studies on patients treated with ECT showed:

Observational studies on patients treated with ECT showed:
 NS difference in number of admissions in one year between pre- and post-ECT in bipolar
n
es
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ud
w

t
t
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i
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h EC
r
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Observational studies on patients treated with ECT showed:
en
bse
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T show
t
Observational studies on patients treated with ECT showed: :
 NS difference in number of admissions in one year between pre- and post-ECT in bipolar
56, level II-3
patients in a pre-post study on mood disorder.

l
n
o
i
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i
bi
t
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n
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ce
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ar

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n

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ad
 NS difference in number of admissions in one year between pre- and post-ECT in bipolar


o
f
f
be
ee
C
an
po
 NS difference in number of admissions in one year between pre- and post-ECT in bipolar
patients in a pre-post study on mood disorder.
56, level II-3

 increased illness-free interval and, reduced number of mood episodes and admission in
l

I

so
de
m
r
I
6
-
po

i
n
d di
r
le
t
t
p
ve
t
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oo
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patients in a pre-post study on mood disorder.
r

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on
.
patients in a pre-post study on mood disorder.
e
3
dy

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a
s

5
56, level II-3
s
56, level II-3
 increased illness-free interval and, reduced number of mood episodes and admission in

non-rapid cycling BD in a 5-year pre- and post-ECT.
57, level II-3

u

f

b

,

m

 increased illness-free interval and, reduced number of mood episodes and admission in
i

n
ad
nt
ssi
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nu
an
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ne
r
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al
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ee
o
ss
an
d
-

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l
l
ncreased

 increased illness-free interval and, reduced number of mood episodes and admission in

non-rapid cycling BD in a 5-year pre- and post-ECT.
57, level II-3
 reduced risk for serious AEs e.g. hospitalisation due to medical events, non-suicidal
an
n a
r
57, level II-3
o
n
C
B
non-rapid cycling BD in a 5-year pre- and post-ECT.

-

-
5
i
ap
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a
5
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.

d cy
,
i
r
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e

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non-rapid cycling BD in a 5-year pre- and post-ECT.
T
l
r

i
lev
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57, level II-3
II
 reduced risk for serious AEs e.g. hospitalisation due to medical events, non-suicidal
death or transfer to a medical bed (HR=0.42, 95% CI 0.20 to 0.92) compared with no
satio

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i
s
ed
n
serio
en
f
t
-
al
spi
k
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or
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 reduced risk for serious AEs e.g. hospitalisation due to medical events, non-suicidal
A
 reduced risk for serious AEs e.g. hospitalisation due to medical events, non-suicidal l
t
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o
d
m


ci
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uce
i
r
ho
us
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death or transfer to a medical bed (HR=0.42, 95% CI 0.20 to 0.92) compared with no
58, level II-2

ECT on bipolar depression in a cohort study.

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42
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death or transfer to a medical bed (HR=0.42, 95% CI 0.20 to 0.92) compared with no

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be
92
f
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95
an
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ECT on bipolar depression in a cohort study.
58, level II-2
death or transfer to a medical bed (HR=0.42, 95% CI 0.20 to 0.92) compared with no
.
5
58, level II-2
po
y

ECT on bipolar depression in a cohort study.
E
8
on
ECT on bipolar depression in a cohort study.
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58, level II-2
RANZCP guidelines recommend the use of ECT as first-line treatment in mood disorders with

RANZCP guidelines recommend the use of ECT as first-line treatment in mood disorders with
severe melancholic depression, imminent risk of suicide, severe levels of distress, psychotic
R

Z
t
d
m
e
en
RANZCP guidelines recommend the use of ECT as first-line treatment in mood disorders with
s
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di

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A
sorders

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i
RANZCP guidelines recommend the use of ECT as first-line treatment in mood disorders with
severe melancholic depression, imminent risk of suicide, severe levels of distress, psychotic
depression, catatonia, previously responded to ECT and patients’ preference. It is also
ci
ere
t
m
,
an
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r

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sev

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c
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el
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de
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sk
cho
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of

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severe melancholic depression, imminent risk of suicide, severe levels of distress, psychotic
el
ev
s
severe melancholic depression, imminent risk of suicide, severe levels of distress, psychotic
l
c
l
f
on
i
o
st
essi

sev
,
psy
i
ess
depression, catatonia, previously responded to ECT and patients’ preference. It is also
recommended as second-line in patients who fail to respond to one or more adequate course
de
i
n
t
a
l
on
’
f
s
ev
i
atoni

depression, catatonia, previously responded to ECT and patients’ preference. It is also
,
s
y
t

r

pa
pre
sl
pressi
a
d
a,
s
ou
esp
depression, catatonia, previous responded to ECT and patients’ preference. It is also
i

ca
p
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en
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t

E

on

I
erence
o
.
t
d
o

recommended as second-line in patients who fail to respond to one or more adequate course
of medication. Potential AEs on cognition need to be considered before offering ECT. Adverse
t
en
seco
t

cou
q
o
o
as
ad
m
o
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recommended as second-line in patients who fail to respond to one or more adequate course
t
en
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l

esp
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d
m
i
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ai
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s
recommended as second-line in patients who fail to respond to one or more adequate course
n
on
e
n
m
i
i

r
on
w

e
pa
r
l

f
of medication. Potential AEs on cognition need to be considered before offering ECT. Adverse
memory changes are short-lived and reversible; more common with bitemporal placement,

T.

r
o
o

n.
C
co
i
ers
P
catio
t

t

f
of medication. Potential AEs on cognition need to be considered before offering ECT. Adverse
m
ed
con
be
E

A
i
o
oten
s
si
t

erin

al
of medication. Potential AEs on cognition need to be considered before offering ECT. Adverse
r
on
E
be
de
e
o
ni
f
i
A
ed
f
ed
g
ne
on
dv
e

g

f
memory changes are short-lived and reversible; more common with bitemporal placement,
higher doses, greater number of treatments and three times weekly treatment compared with
m
n
-
emo
e
ort
m
g

;

al
l
i
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en

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memory changes are short-lived and reversible; more common with bitemporal placement,
l
on
ore
d
y
memory changes are short-lived and reversible; more common with bitemporal placement, ,
higher doses, greater number of treatments and three times weekly treatment compared with
twice weekly.
39

higher doses, greater number of treatments and three times weekly treatment compared with
t
t

t
do
ee
m
m
t
e
t
en
r
i
f
hree
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ses

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en
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,
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higher doses, greater number of treatments and three times weekly treatment compared with

k

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pa
a
r
great

i
he
o
d

g
ea
l
twice weekly.
39

twice weekly.
twice weekly. 39 3 39 9
twice weekly.

MOH guideline on ECT recommends the use of ECT as first-line in mental disorders when

MOH guideline on ECT recommends the use of ECT as first-line in mental disorders when
rapid definitive response is required, the risk of other alternatives outweighs the risk of ECT,

t
di
m
al
en
T
eco

MOH guideline on ECT recommends the use of ECT as first-line in mental disorders when
M
C
e
r

w

l
use

en
E
i
ui
m
l
MOH guideline on ECT recommends the use of ECT as first-line in mental disorders when
-

T
he
f
de

H
t
on
r
as
st

ds
i
O
e
i
f
g

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o
m
n
n
n
i
h
ne
sorders
E

rapid definitive response is required, the risk of other alternatives outweighs the risk of ECT,
previous good response to ECT, and patients’ preference. ECT may also be considered as
d
r

ni
he
h
de
e
T,
i
e
s
r

al
f
k
k
se
r
s
o
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ot
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f
i
i
v

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es
ui
i
r
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v
ei
q
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s
r
w
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e
e
i
ou
e
ap
i
gh
r
esp
f
,
rapid definitive response is required, the risk of other alternatives outweighs the risk of ECT,
i
t
on
t
na

r
d
e
t

t
rapid definitive response is required, the risk of other alternatives outweighs the risk of ECT,
previous good response to ECT, and patients’ preference. ECT may also be considered as
second-line treatment in treatment-resistant cases, patients with severe AEs to medication
a
si

con
r
ed
previous good response to ECT, and patients’ preference. ECT may also be considered as

s
de
T
oo
an
m
C

d
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o

d
,
ay
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e
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en
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i

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on
prev
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se

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esp
t
be
previous good response to ECT, and patients’ preference. ECT may also be considered as
second-line treatment in treatment-resistant cases, patients with severe AEs to medication
and deterioration of psychiatric conditions e.g. severe or prolonged mania with persistent or
st
t
w
r
i
n
n
s
t
esi
s
en
i

ed
E
s

-
t
ca
m
en
es,
t
nd
a
i
pa
nt
l
A
m
e
sev

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e
n

ea
second-line treatment in treatment-resistant cases, patients with severe AEs to medication
m

t
r
e
n
a
t
i
-
catio
t
i
seco
t
t
second-line treatment in treatment-resistant cases, patients with severe AEs to medication
ere
o
h
r
and deterioration of psychiatric conditions e.g. severe or prolonged mania with persistent or
life-threatening symptoms. The same guideline recommends bitemporal ECT for rapid
g
atr
erio
.
si
f
o
t

hi
or
on
s
st
en
c
di
i
t
on

i
e
c
con
r
ati
psy
and deterioration of psychiatric conditions e.g. severe or prolonged mania with persistent or
an
or
de
an
v
ere
t
h
d
ed
pe
g
prol
m
on

i
t
w
a

r
se
.
i
and deterioration of psychiatric conditions e.g. severe or prolonged mania with persistent or
life-threatening symptoms. The same guideline recommends bitemporal ECT for rapid
response, bifrontal placement for those with ischaemic heart disease or cardiac arrhythmias
d

sy
i
life-threatening symptoms. The same guideline recommends bitemporal ECT for rapid
t
r

sa

bi
C
i
f
m
s.
life-threatening symptoms. The same guideline recommends bitemporal ECT for rapid
i
pto
m

E
po
r
he
e
n
al
ap

l
T
g
i
ne
en
m
T
r

en
m
or

t
de
-
ui
e
m
ds
t
g

hrea
l
e
eco
f
m
response, bifrontal placement for those with ischaemic heart disease or cardiac arrhythmias
and unilateral ECT for patients susceptible to profound confusional state.
59
m
on
on
i
o
ac
t
pl
al
i
ardi
t

se,
scha
r

emic
h
hy
r
c
ace
t
r

s
o
se
se
t
bi
hmia
ho
sea
esp

t
di
ar
w
t
r
r
en
ar
response, bifrontal placement for those with ischaemic heart disease or cardiac arrhythmias
he
f
f

response, bifrontal placement for those with ischaemic heart disease or cardiac arrhythmias
and unilateral ECT for patients susceptible to profound confusional state.
59

and unilateral ECT for patients susceptible to profound confusional state. 59 5 59 9
and unilateral ECT for patients susceptible to profound confusional state.
and unilateral ECT for patients susceptible to profound confusional state.

16
16
6
1
16
16
16