Page 33 - e-book CPG - Bipolar Disorder

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

m
nter
a
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e

eta
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ol
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o

con
on
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s
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o
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R
se
en
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compa
art
sm

-
ph
an
g
r
y
si
al
n
i
In a meta-analysis of seven RCTs comparing smartphone-based interventions vs control on
I
In a meta-analysis of seven RCTs comparing smartphone-based interventions vs control on
In a meta-analysis of seven RCTs comparing smartphone-based interventions vs control on
f
t
s
74, level I
e

:
s
nd
adults with BD, the findings were:

w
i
ere
adults with BD, the findings were:
ul
ad
7
l

i
g
e
t

n
i

I
w

4
74, level I
,
,
t
h BD
h
lev
adults with BD, the findings were: 74, level I
y
i
ba
i
he
w
ere

e

l
n
 the former (specifically phone call-based and web-based) were more effective in
-
ba
  the former (specifically phone call-based and web-based) were more effective in

e
t
cal
)
f
l
d
(
spe
-

sed
or
ci
an
on
ph
m
f
or
al
er
eb
f
ectiv
e
c
f
sed
m
w

e
 the former (specifically phone call-based and web-based) were more effective in
S
D
i
-
3
m
%

de
0.19,
0
-
C
pres
04
o

reducing manic (SMD= -0.19, 95% CI -0.33 to -0.04) and depressive symptoms (SMD=
ng
M
.
r
M
3

s
=
e sy

95
)
m
uci
c
D
.
(
an

0
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ed

ptom
an
t
(
I

v
S
-
d
reducing manic (SMD= -0.19, 95% CI -0.33 to -0.04) and depressive symptoms (SMD=
reducing manic (SMD= -0.19, 95% CI -0.33 to -0.04) and depressive symptoms (SMD=

0

.
0.38
I
.

,
)
t

6
%
o

-

-
1
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95
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-0.38, 95% CI -0.61 to -0.14)
-0.38, 95% CI -0.61 to -0.14)
C
1
-0.38, 95% CI -0.61 to -0.14)
g
f
s
ed
s
m

on
 self-monitoring using smartphone apps was effective in reducing manic symptoms
g
 self-monitoring using smartphone apps was effective in reducing manic symptoms
orin
ectiv
f
i
sel
sy
w
c
ap
t
f
an
m
e
e
uci
ph

e
ar
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i
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t

pto
g

n
on
m
usi
n
n
as
ps

r
m
-
 self-monitoring using smartphone apps was effective in reducing manic symptoms
ed
)

=0.

pa
r
m
co
D
S

(
(SMD=0.27, 95% CI 0.02 to 0.51) compared with baseline but NS difference for
(SMD=0.27, 95% CI 0.02 to 0.51) compared with baseline but NS difference for
I

C
ne
d
%
erence

f
u
0.
t
b
95
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f

02
0.51

i
r

ba
M
i
27
w

h
t
,
f
sel
i

o
S
t
o
(SMD=0.27, 95% CI 0.02 to 0.51) compared with baseline but NS difference for

s
pressi
v
e sy
depressive symptoms
m
ptom
de
depressive symptoms
depressive symptoms
Generally, the risk of bias was low based on Cochrane RoB except for inadequate blinding of
Generally, the risk of bias was low based on Cochrane RoB except for inadequate blinding of
Generally, the risk of bias was low based on Cochrane RoB except for inadequate blinding of
Generally, the risk of bias was low based on Cochrane RoB except for inadequate blinding of
participants and personnel in two RCTs.
participants and personnel in two RCTs.
participants and personnel in two RCTs.
participants and personnel in two RCTs.

In another meta-analysis of five RCTs (different RCTs from the earlier meta-analysis) with
In another meta-analysis of five RCTs (different RCTs from the earlier meta-analysis) with
In another meta-analysis of five RCTs (different RCTs from the earlier meta-analysis) with
In another meta-analysis of five RCTs (different RCTs from the earlier meta-analysis) with
more defined use of smartphone-based intervention on adults with BD, the smartphone-based
more defined use of smartphone-based intervention on adults with BD, the smartphone-based
more defined use of smartphone-based intervention on adults with BD, the smartphone-based
more defined use of smartphone-based intervention on adults with BD, the smartphone-based
interventions showed NS difference in effectiveness in reducing depressive or manic
interventions showed NS difference in effectiveness in reducing depressive or manic
interventions showed NS difference in effectiveness in reducing depressive or manic
interventions showed NS difference in effectiveness in reducing depressive or manic
symptoms compared with controls. Although the primary papers were of low risk of bias based
symptoms compared with controls. Although the primary papers were of low risk of bias based
symptoms compared with controls. Although the primary papers were of low risk of bias based
symptoms compared with controls. Although the primary papers were of low risk of bias based

on RoB2, there was considerable heterogeneity among them.
I
,
leve
5

75, level I
on RoB2, there was considerable heterogeneity among them.
l
on RoB2, there was considerable heterogeneity among them.
75, level I
7
on RoB2, there was considerable heterogeneity among them. 75, level I

A 2-years cohort study examining effects of religiosity/spirituality beliefs and practices on
st
ng
e

a
ua
e
i
t

t
y
t
l
i
p
r
ac
amin

an
d
t
y
n

o
i
ces
ex
-
l
i
be
i

y
e
A
ud

s
f
A 2-years cohort study examining effects of religiosity/spirituality beliefs and practices on
2
spi
g
ec
s
coh
s
i
t
or
f
/

t
i
y
osi

el
r

r
o
f
f
r
A 2-years cohort study examining effects of religiosity/spirituality beliefs and practices on
adults with BD showed a reduction in symptoms of mania (p<0.001) and depression (p=0.001)
adults with BD showed a reduction in symptoms of mania (p<0.001) and depression (p=0.001)
adults with BD showed a reduction in symptoms of mania (p<0.001) and depression (p=0.001)
adults with BD showed a reduction in symptoms of mania (p<0.001) and depression (p=0.001)
based on YMRS and MADRS respectively. Positive religious coping predicted better QoL
based on YMRS and MADRS respectively. Positive religious coping predicted better QoL
based on YMRS and MADRS respectively. Positive religious coping predicted better QoL
based on YMRS and MADRS respectively. Positive religious coping predicted better QoL
across physical, mental, social and environmental domains.
-

across physical, mental, social and environmental domains.
across physical, mental, social and environmental domains.
2
e
lev
I
l
,
76, level II-2
76, level II-2
7
6
I
across physical, mental, social and environmental domains. 76, level II-2

There is limited evidence available on psychospirituality in BD. .
T
he

ai
t
spi
psy
t
r
i
i
ev
i
y
t
av
There is limited evidence available on psychospirituality in BD.
ed
l
nce
ua
l
de
r
l
e on
i
e is li
m
i
ab

cho
n BD

There is limited evidence available on psychospirituality in BD.

Supported employment is an intervention to help individuals with severe mental illness

t
t
ne
i
i
l
s
ss
l
o
nter
t
i
w
i
i
nd
i
du
en
v
a
l
s
i
v
i

m
an
he
t
al

en
on
h

t
l
ere
p
sev

t
r
m
ed
pl
oy
po
e
m
up
en
S
Supported employment is an intervention to help individuals with severe mental illness
Supported employment is an intervention to help individuals with severe mental illness
compet
ng
ea
p
i

m
m
s
ud
t
n

pl
ni
ncl

ud
ntai
ul
ncl
i
r
ng
e
secu
nci
e
i
d
i
.
including BD to secure and maintain meaningful work. Its principles include competitive
B

t
ai
v
including BD to secure and maintain meaningful work. Its principles include competitive

i
f
o
r
w
e
an
t
I
D
i
es
ork
including BD to secure and maintain meaningful work. Its principles include competitive
7
employment, rapid job search and attention to patients’ preferences, among many others.
77
7
77
employment, rapid job search and attention to patients’ preferences, among many others.
employment, rapid job search and attention to patients’ preferences, among many others.
77
employment, rapid job search and attention to patients’ preferences, among many others.
E
i
ncl
en
pe

ui

i
i
com
m
t
al
t
l
t
ss
ere

de
ha
ne

g
m
D

nd
t
h se
e
B
N
w
sh t
op
i
e w
i
w

ho
l
l
i
C
e
o
v
ud

i
NICE guideline recommends that people with severe mental illness including BD who wish to
r

NICE guideline recommends that people with severe mental iilness including BD who wish to
s
I
ne
ng
NICE guideline recommends that people with severe mental iilness including BD who wish to
find work receive supported employment services. These services are available in places These services are available in places
find work receive supported employment services. These services are available in places
3
find work receive supported employment services.
7
73
73
73
find work receive supported employment services. These services are available in places f
m
N
I
r
o
T
A
m
R
un

)
M
y
(

t
t
es
i
r
E
com
.
t
c
L

l
psy
h
i
atr
.
i
ces.

g
chi
al

e.g. community mental health centres (MENTARI) or in local psychiatric services. List of
he
i
n
cen

al

t
o

s
oca
i
e
serv
t
en
l
e.g. community mental health centres (MENTARI) or in local psychiatric services. List of
e.g. community mental health centres (MENTARI) or in local psychiatric services. List of
m
-
N
i
a
T
i
available MENTARI can be accessed via https://mentari.moh.gov.my/mentari-minds/
v
s/
nd
htt
available MENTARI can be accessed via https://mentari.moh.gov.my/mentari-minds/
av
i
l
h.
e
g
en
.
ov
o
.
i
r
M
t
m
a
E
ntar
e
/
ps
ai
:
/
l
ab
m
y
m
m
/
I

R
be

A

ssed
acce
can
available MENTARI can be accessed via https://mentari.moh.gov.my/mentari-minds/

4.2.3. Psychotherapy
4.2.3. Psychotherapy
otherap
s

P
4.2.
3
.
ch
y
y
4.2.3. Psychotherapy e n use d a s ad j un c t i v e t o ph ar m aco t he r ap y f o r B D . T he se i ncl ud e
y
ha
he
Psychotherapy has been used as adjunctive to pharmacotherapy for BD. These include
t
Psychotherapy has been used as adjunctive to pharmacotherapy for BD. These include
cho

sy
be
ap
r
s
P
Psychotherapy has been used as adjunctive to pharmacotherapy for BD. These include

i
y
l
r
i
ni
nte
d
be

B

ha
t
son
T
sed
al
r

cognitive behavioural therapy (CBT), family-focused therapy (FFT), interpersonal and social
ou
-
)
cognitive behavioural therapy (CBT), family-focused therapy (FFT), interpersonal and social
cog
he
ocu
pe
r
an
f
C
t
erapy
t
e
soci
f
r
(

T),
,

(
h
a
y
m
v
al
i
i
FF
al
ap

v
cognitive behavioural therapy (CBT), family-focused therapy (FFT), interpersonal and social l
rhythms therapy (IPSRT), mindfulness-based cognitive therapy (MBCT) and dialectical
t
r
R
f
an

y
r
rhythms therapy (IPSRT), mindfulness-based cognitive therapy (MBCT) and dialectical
cog
ap
r
he
I
d

T
ul
ni
,
s
)
S
hy

T
m
di
y
M
he
P
t
s
v

ap
al
e
)
t
nd
ectica
ba
t
hms

C
i
ne
(
i
sed
B
-
(
rhythms therapy (IPSRT), mindfulness-based cognitive therapy (MBCT) and dialectical
eren
other
f
he
B
t
es
dd
y
i
i

i
ap
ess
ou
a
ha

r
v

v
ario
f
can

D
r
(
ch
T)

t
be
f
asp
ap
behaviour therapy (DBT). Different types of psychotherapies can address various aspects of
us
.
psy
t
s

o
r

D

pe
f
y
o
ects
behaviour therapy (DBT). Different types of psychotherapies can address various aspects of
behaviour therapy (DBT). Different types of psychotherapies can address various aspects of l
en
ess
di
the condition, helping patients cope with mood swings, manage stress and improve overall
pi
oo
t
d
h
nd
the condition, helping patients cope with mood swings, manage stress and improve overall

con
co
r
a
i

m

t
t
m
ov
an

he
s,
eral

w
pa
a
s
,
l
on
s
i
e
m
ng
e
pe
g
i

prov
t
he
ng
t
st
w
i

i
the condition, helping patients cope with mood swings, manage stress and improve overall
functioning.

functioning.
functioning.
functioning.

A meta-analysis of 11 RCTs on adults with bipolar depression examined the effectiveness of
A m e t a - a n a l y si s o f 11 R C T s on ad ul t s w i t h bi po l ar de p r essi on ex amin ed t he e f f ectiv en ess o f
A meta-analysis of 11 RCTs on adults with bipolar depression examined the effectiveness of
A meta-analysis of 11 RCTs on adults with bipolar depression examined the effectiveness of
ha
m
t
st
i
r
e sy
nd
t
uc
v
ou

f

de
he

es in
u
i
dy
ng
p
t
he
s.
psychotherapies in reducing depressive symptoms. The study found that:
r
ap
ed

I
72, level I
:
m
psychotherapies in reducing depressive symptoms. The study found that:
pto
7

essi
cho
r

T
leve
l
2

,
psy

72, level I
psychotherapies in reducing depressive symptoms. The study found that: 72, level I
t
a
p
s
t
-

m

-
 at post-treatment -
 at post-treatment -
e
a
o
r
t
t
e
n
t


 at post-treatment - e f f ec t i v e i n r ed uci n g de pressi v e sy m pto m s co m pa r ed w i t h T A U
as
w
o CBT was more effective in reducing depressive symptoms compared with TAU

T
C
m
ore
B

o CBT was more effective in reducing depressive symptoms compared with TAU
o
o CBT was more effective in reducing depressive symptoms compared with TAU
-
o

95

I
M
0.51,
7
.
0
5
)
S
(SMD= -0.51, 95% CI -0.75 to -0.27)
C

%
2

-
(SMD= -0.51, 95% CI -0.75 to -0.27)
.

t
D
-
0
(
=

7
(SMD= -0.51, 95% CI -0.75 to -0.27)
y
pre
ompared
v
c
e
ssi
pto
r
o MBCT group therapy was more effective in reducing depressive symptoms compared
m
m
o MBCT group therapy was more effective in reducing depressive symptoms compared
ap
he
sy

s

t

i
v
de
as
o
C
t

g
i
uci
m
n
B
e
f
M
e
T
r
e
f
ec

r
w
group
ed
n
o
o MBCT group therapy was more effective in reducing depressive symptoms compared

g
6
M
0
9
)
b
a

A
w
u
with TAU (SMD= -0.47, 95% CI -0.88 to -0.06) but not with waiting list
(
=
i
n
t
w

i

8
U
-
o
t
h

0

-
T
8

.

i
i
0
.

l
I
s
5%

0.47
t
t
-
t
h
o
n
,
t

i
S
t
w
C
D

with TAU (SMD= -0.47, 95% CI -0.88 to -0.06) but not with waiting list
with TAU (SMD= -0.47, 95% CI -0.88 to -0.06) but not with waiting list
T
m
ap
as
du
r
s

d
ng
ep
sy
w
ectiv
m
f
i

on
e
f
n
f
e
r

t
y
ci
m
r
o
o
group
o DBT group therapy was more effective in reducing symptoms of depression

he
o DBT group therapy was more effective in reducing symptoms of depression
pto
e
r
essi
B
D
e

o
o DBT group therapy was more effective in reducing symptoms of depression

t
s
w
95

h
-
i
o
D
t
%
i
a
compared
i
compared with waiting list (SMD= -1.18, 95% CI -2.06 to -0.30)

-
i
C
t

l
I
n

-
2.06
S
M
=

g
(
w

t
0.30
1.18,
compared with waiting list (SMD= -1.18, 95% CI -2.06 to -0.30) )
compared with waiting list (SMD= -1.18, 95% CI -2.06 to -0.30)
g
t
w
ap
n
f
g
i
he
uci
t
amil
t
o
r
y
ou
r
ere
ed
h
o both group therapy for family therapy and IPSRT were not effective in reducing
he

p
o both group therapy for family therapy and IPSRT were not effective in reducing

ap
e
r
f
I
r

T
ec
d
y
n
f
R
t
no
r
S

e

P

bo
y

t
f
i
an
v

o
o both group therapy for family therapy and IPSRT were not effective in reducing
depressive symptoms compared with placebo

depressive symptoms compared with placebo
depressive symptoms compared with placebo
depressive symptoms compared with placebo
 at 3 - 12 months follow-up, both CBT and MBCT group therapy had NS effect on
d

f
he
B
bo
a
hs
d
on
r
n
ap

ct
u

T
-
f
ol
 at 3 - 12 months follow-up, both CBT and MBCT group therapy had NS effect on
,
e
C

C
p
S
M

N

group

t

h
-

ha

t
t
t
ow
y
f
12
l
3
m

e
o
an
B
T



 at 3 - 12 months follow-up, both CBT and MBCT group therapy had NS effect on
sy

m
s
bo
T
A
U
d

uci
r
.

pto
r
ep
reducing symptoms of depression compared with TAU or placebo.

reducing symptoms of depression compared with TAU or placebo.
ace

or
pl
ed
h
ng
o
ed
r
co

pa
m

i
f
on
essi
m
w
t
reducing symptoms of depression compared with TAU or placebo.
1
9
19
19
19
19