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CLINICAL PRACTICE GUIDELINES MANAGEMENT OF BIPOLAR DISORDER (2ND ED.)
therapy are useful to prevent relapse. These interventions vary in method of delivery (e.g.
therapy are useful to prevent relapse. These interventions vary in method of delivery (e.g.
individual vs group format), its contents and duration of intervention.
individual vs group format), its contents and duration of intervention.
A meta-analysis on adults with BD demonstrated that psychoeducation: 91, level I
A meta-analysis on adults with BD demonstrated that psychoeducation: 91, level I
was more effective than TAU in not relapsing (preventing relapse) into any episode
was more effective than TAU in not relapsing (preventing relapse) into any episode
(OR=1.98, 95% CI 1.09 to 3.58; NNT=7, 95% CI 4 to 25)
(OR=1.98, 95% CI 1.09 to 3.58; NNT=7, 95% CI 4 to 25)
subgroup analysis showed that group delivery was effective in not relapsing (preventing
subgroup analysis showed that group delivery was effective in not relapsing (preventing
relapse) into:
relapse) into:
o any episode (OR=2.80, 95% CI 1.63 to 4.82; NNT=4, 95% CI 3 to 7)
o any episode (OR=2.80, 95% CI 1.63 to 4.82; NNT=4, 95% CI 3 to 7)
o manic episode (OR=2.07, 95% CI 1.11 to 3.85; NNT=6, 95% CI 3 to 39)
o manic episode (OR=2.07, 95% CI 1.11 to 3.85; NNT=6, 95% CI 3 to 39)
o depressive episode (OR=2.08, 95% CI 1.05 to 4.12; NNT=6, 95% CI 3 to 77)
o depressive episode (OR=2.08, 95% CI 1.05 to 4.12; NNT=6, 95% CI 3 to 77)
subgroup analysis also showed that individual delivery was not effective in not relapsing
subgroup analysis also showed that individual delivery was not effective in not relapsing
(preventing relapse) into any mood, manic and depressive episodes
(preventing relapse) into any mood, manic and depressive episodes
The quality of most of the primary papers was moderate based on RoB.
The quality of most of the primary papers was moderate based on RoB.
The above was supported by another meta-analysis of patients with BD on pharmacotherapy
The above was supported by another meta-analysis of patients with BD on pharmacotherapy
where the following adjuvant group interventions were more effective than TAU in the
where the following adjuvant group interventions were more effective than TAU in the
prevention of relapse:
92, level I
prevention of relapse: 92, level I
psychoeducation (RR=0.65, 95% CI 0.55 to 0.77)
psychoeducation (RR=0.65, 95% CI 0.55 to 0.77)
CBT (RR=0.68, 95% CI 0.50 to 0.94)
CBT (RR=0.68, 95% CI 0.50 to 0.94)
Quality assessment of primary papers however was not mentioned.
Quality assessment of primary papers however was not mentioned.
Another meta-analysis, however, on relapse prevention in a similar study population showed
Another meta-analysis, however, on relapse prevention in a similar study population showed
effectiveness in group psychoeducation (OR=0.43, 95% CI 0.28 to 0.62) but not in group CBT
effectiveness in group psychoeducation (OR=0.43, 95% CI 0.28 to 0.62) but not in group CBT
(OR = 0.72, 95% CI 0.19 to 2.66) when compared with control. The authors concluded that
(OR = 0.72, 95% CI 0.19 to 2.66) when compared with control. The authors concluded that
studies included in group CBT were of small size and hence might not achieve adequate
studies included in group CBT were of small size and hence might not achieve adequate
79, level I
Most of the primary
statistical power to detect the differences between the groups.
statistical power to detect the differences between the groups. 79, level I Most of the primary
papers used in this meta-analysis had some concern of bias based on Cochrane RoB2.
papers used in this meta-analysis had some concern of bias based on Cochrane RoB2.
In a large NMA on adults with BD on adjunctive psychosocial interventions, two high-quality
In a large NMA on adults with BD on adjunctive psychosocial interventions, two high-quality
RCTs showed carer-focused interventions e.g. psychoeducation was more effective than TAU
RCTs showed carer-focused interventions e.g. psychoeducation was more effective than TAU
in relapse prevention (RR=0.61, 95% CI 0.44 to 0.86).
93, level I
in relapse prevention (RR=0.61, 95% CI 0.44 to 0.86). 93, level I
In another large NMA on patients with BD, the following adjunctive psychotherapies were more
In another large NMA on patients with BD, the following adjunctive psychotherapies were more
78, level I
effective than TAU for relapse prevention:
effective than TAU for relapse prevention: 78, level I
standard psychoeducation ≥6 group or individual sessions (OR=0.52, 95% CI 0.32 to
standard psychoeducation ≥6 group or individual sessions (OR=0.52, 95% CI 0.32 to
0.84)
0.84)
brief psychoeducation ≤3 group or individual sessions (OR=0.34, 95% CI 0.16 to 0.74)
brief psychoeducation ≤3 group or individual sessions (OR=0.34, 95% CI 0.16 to 0.74)
family or conjoint therapy (OR=0.30, 95% CI 0.17 to 0.53)
family or conjoint therapy (OR=0.30, 95% CI 0.17 to 0.53)
CBT (OR=0.52, 95% CI 0.34 to 0.79)
CBT (OR=0.52, 95% CI 0.34 to 0.79)
Most of the primary papers were rated to have low to moderate risk of bias.
Most of the primary papers were rated to have low to moderate risk of bias.
Meanwhile, in a small RCT on adults with BD, adjunctive mindfulness-based cognitive therapy
Meanwhile, in a small RCT on adults with BD, adjunctive mindfulness-based cognitive therapy
was not effective compared with TAU in preventing the recurrence of depressive or
was not effective compared with TAU in preventing the recurrence of depressive or
94, level I
hypo/manic episodes over a 12-month follow-up period.
hypo/manic episodes over a 12-month follow-up period. 94, level I
7.2. Strategies to Improve Adherence
7.2. Strategies to Improve Adherence
Adherence to treatment within patients with BD may change over time and vary between
Adherence to treatment within patients with BD may change over time and vary between
different pharmacotherapies. About half of patients with BD become non-adherent during long-
different pharmacotherapies. About half of patients with BD become non-adherent during long-
term treatment.
Non-adherence in BD is a complex phenomenon determined by a
95, level I
term treatment. 95, level I Non-adherence in BD is a complex phenomenon determined by a
multitude of factors.
multitude of factors.
Significant risk factors for non-adherence are:
6
Significant risk factors for non-adherence are:
6
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