AD's for Bipolar Depression

I started hijacking another thread with this, so starting over, the below concerns a large-scale study funded by NIMH. One part, below, was about using AD's for acute bipolar depression and, further below, psychosocial interventions (aka therapy) for bipolar depression.

Large-scale study, published in 2007, study of antidepressant use in patients with bipolar disorder: NIMH · Study Sheds Light on Medication Treatment Options for Bipolar Disorder

About this NIMH-funded study: NIMH · Questions and Answers for the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) Study — Background

In short, AD's for acute bipolar depression did not help any more than placebo (both added to mood stabilizers).

And I guess the following basically answers the question of, per this study, what the heck will help bipolar depression if you don't prescribe AD's --answer being, therapy. They compared three types (specifically for bipolar, as part of the study) and the more long-term one narrowly won out --though the message, I suppose, is to use therapy as an adjunct to mood stabilizers (and possible AP's) in the treatment of bipolar depression:

4. Q. What psychosocial interventions did participants receive?

A. Researchers randomly assigned participants to receive either a short-term collaborative care intervention or one of three longer-term intensive therapies that have been shown to help stabilize bipolar symptoms—cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), or family-focused treatment (FFT). Collaborative care was considered the “control” intervention, meaning that the outcomes of this therapy were used as a baseline by which to compare the other three intensive therapies. All of these therapies focused on education about the illness, relapse prevention planning, and bipolar illness management interventions, and all but collaborative care consisted of up to 30, 50-minute sessions that took place over nine months.

Collaborative care, which consisted of three, 50-minute sessions over six weeks, provided participants with a workbook, an educational videotape and other information that aimed to help them understand and manage the illness, maintain adherence to medications, and develop a treatment contract geared toward preventing bipolar episodes.

In the CBT intervention group, participants received education about the illness. They learned to challenge negative thoughts or beliefs about bipolar disorder or its associated stressful life circumstances, developed schedules to stay active, and developed strategies to detect and cope with mood swings.

The focus of IPSRT was on attaining and maintaining regular social rhythms (daily routines and sleep/wake cycles) and the relationship of daily activities to mood and levels of social stimulation. IPSRT therapists encouraged participants to keep track of their daily routines (e.g., when they went to sleep, when they woke up, etc.) while working toward establishing stable social rhythms. Patients also worked to resolve key interpersonal problems related to grief, role transitions, interpersonal disputes, or interpersonal skill deficits.

In FFT, participants and their relatives (e.g., spouses and parents) were taught an understanding of bipolar illness, its course, treatment and management. Family members were taught how to recognize early warning signs that might predict an oncoming depressive or manic episode in the person with bipolar illness, and strategies to intervene when these warning signs occurred. Treatment included enhancing communication between the participants and their family members to improve the quality of family interactions, and problem-solving to manage conflicts related to the illness.
5. Q. What do the results from the STEP-BD psychosocial treatment trial tell us about the treatment of bipolar disorder?

A. The outcome measures that were used to evaluate success of the treatments were “time to recovery” (e.g., how quickly did people get well) and the total amount of time during the study year that participants remained “well” (measured by the probability of being well during any given month). To be considered “well” in the study, participants had to have no more than two symptoms of mild or moderate mania or depression.

Of the 293 STEP-BD participants in the psychosocial treatment study, 59 percent recovered from their depression; 41 percent either did not recover or left the study early.

Over the course of the study year, participants in the intensive psychotherapies (FFT, IPSRT, CBT) had a more successful recovery rate (64 percent) compared to the individuals in the collaborative care group (52 percent). Also, participants in the intensive psychotherapies who recovered did so faster (on average, after about 113 days) than those in the collaborative care group (after about 146 days). Furthermore, the participants in the intensive psychotherapies were one and a half times more likely to remain well during any given month of the study year than those in the collaborative care group.

The study also showed that in each of the four psychosocial treatment groups, participants who were also enrolled in the randomized medication portion of the trial got well faster than those who were not, even though all patients were receiving some type of medication. In addition, recovery time was faster in all four groups for those participants who had family supports available.

Differences among the three intensive psychosocial interventions were not statistically significant, but they are worth noting. Over the yearlong study, 77 percent of participants in the FFT recovered, compared to 65 percent of participants in IPSRT and 60 percent in CBT.
6. Q. What do the results mean for people with bipolar depression and the doctors who provide care for them?

A. This one-year study showed that, in conjunction with adequate mood stabilizing medications, intensive psychotherapy is more effective in helping people recover from a depressive episode, and stay well over a one-year period, than a brief collaborative care treatment. All three types of intensive psychosocial treatments had comparable benefits.

Overall, psychotherapy appears to be a vital part of the effort to stabilize episodes of depression in bipolar illness. These findings should help clinicians plan treatments for individuals recovering from an episode of bipolar depression.

Thanks for posting this!

That's certainly interesting and may explain why ADs never worked for me, not since I started taking them at age 14. I had a bad year in 2006 and literally tried almost every one and nothing. Still got hospitalized seven times in ten months. Now I am on a MS and AP only and it's the most stable I've been since the BP symptoms worsened in January.

It'd be interesting to see the difference between people with 'pure' BP and one with co-morbid issues as a lot of the co-morbid issues require AD's.

This is my thinking as well. For example, if you suffer from frequent SI and/or attempts, I would think that on the part of pdocs there would be such an urgency in these cases that they would throw everything possible at it, in an attempt to at least keep the pt safe. I think this can lead to serious polypharmacy as well, especially if at least some of the SI is due to psychological issues that will breakthrough meds.

And maybe co-morbid issues would make antidepressants more desirable and/or effective. I think usually in studies they only enroll people with a relatively 'pure' form of whichever disorder they're studying so as not to confound the results; but the fact is, is that in BP as in many other illnesses, there can be a lot of co-morbidity, making such studies -at least potentially- limited in their usefulness. Though I think I've read that anxiety is the or one of the most common co-morbid issues, and I wouldn't think AD's would help too much with this (though I think maybe one or two purport to, so I'm really not sure).

The emphasis on therapy I find very interesting, though, it's not something you find much in articles/studies on BP, except for psychoeducation. Though I think that psychodynamic can also help, not just CBT-type therapies --they're so in vogue right now, though, it's hard to find support for other modalities, though studies proving it's effectiveness in a few different disorders are out there.

I agree. Because of my OCD and general anxiety, I would be a hot mess without an AD! We're talking literally hours of rituals per day and multiple panic attacks per week. ADs also do help me from falling too deep into depression as well though. I can't imagine my life without being on an AD. Not at all.

I take luvox as both anti depressant but it is specifically targeted to my anxiety issues its fda approved for ocd, off label for social anxiety. Wellbutrin as antidepressant and for adhd issues but I am not seeing a difference like with concerta. Not sure she will give me a stimulant though. You guys have brought up lots of questions for me to ask my dr when I see her.

I am on a baby dose of Celexa, which was started by my internist at 20mg/day and made me hypomanic. My pdoc immediately reduced the dose to 10 mg/day and is firm about never increasing it. In fact, the only reason I'm still on it is because even with the reduced dose, I became dysphoric and irrational when he tried taking me off of it.

I don't know that it does a whole lot for me since I'm on the other meds listed below and the Lamictal covers the depression pretty well, but I do know what I'm like without it.

Thanks for posting this! I hear again and again that bi polar can only be treated by meds, and that is simply not true, there are all types of treatments with various rates of success and every case is individual.

I know for me personally CBT has been a huge help in controlling my anxiety which does affect my depression, I am a bit more active in realising when I start to slip lower again too. Im finding my slightly low baseline to be picking up with various therapy methods. Im on a tiny dose of zoloft which was prescribed mainly for the debilitating anxiety and it has got me to the point where I can handle it. I suspect it has an AD effect too, but in saying that my mood hasnt dropped when I have stopped taking it for a few weeks while the anxiety has increased.

I was treated with antidepressants for years, sometimes on huge doses, and none worked long term. I was very surprised when the small dose of zoloft was enough for my anxiety, as before I was on the AP I was on a much higher dose of zoloft to get the same effect.

I agree that therapy is underutilized in bipolar disorder. I credit IPSRT (interpersonal and social rhythm therapy) for my current good mood control. I know it's not as common as CBT or DBT, but it was developed at the university I attend, so it's popular here. I also find that simply talking things through with someone and having someone to check in with is helpful. I also believe in the importance of meds, but think that some psychiatrists (not mine, thankfully!) are too quick to change/add meds when in reality the symptoms can be managed non-pharmacologically.

Best,
Hope

Just to clarify, this study was done with a combination of therapy *and* mood stabilizers. The recommendation, in the end, is no AD's, yes mood stabilizers combined with therapy. I personally don't think I could have ever gotten to how stable I am today without *both* a mood stabilizer (and AP) in combination with therapy. For me personally, this is what has helped -one or the other alone, I don't think would have gotten me this far.

Sorry, I should have been more clear...I just re-read my post, and I did make it seem like meds didn't play a role in my current good mood control. I do take an antipsychotic and two mood stabilizers and can't conceive of managing bipolar without the meds (in conjunction with therapy as you said). I just meant that my psychiatrist won't recommend a med change if it's something that is better addressed by therapy. For example, I recently had to have my dog put to sleep and have been very down--but that type of sadness was much better dealt with in therapy than with a med change/increase that might have masked the sadness to some extent, but would have caused weight gain and made me more sluggish. Sorry if I was unclear!

Best,
Hope

That's great that you're making the distinction between what is a bipolar mood and what is a different kind/situational mood (that doesn't need medication thrown at it, that can be helped by therapy and other things). And therapy can help so much with parsing that stuff out! It's not easy, and can be a constant struggle to make those distinctions, but I think it can make all the difference in maintaining stability. Thanks for your reply.