Sameer Jauhar Consultant Psychiatrist and Research Fellow IoPPN Kings College London What I will cover Existing therapies for bipolar disorder Evidence based approach NICE CG 185 My Background ID: 789218
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Slide1
A critical review of the evidence base for talking therapies in Bipolar Disorder, with a focus on the NICE Guidelines
Sameer Jauhar
Consultant Psychiatrist and Research Fellow,
IoPPN
.
King’s College, London.
Slide2What I will coverExisting therapies for bipolar disorderEvidence based approach
Slide3NICE CG 185
Slide4My BackgroundPsychosis researcherSat on SIGN Scz GuidelineEarly intervention Consultant PsychiatristPrior Meta analyses of CBT and Schizophrenia (BJP, 2014)
Slide5CaveatsEveryone would agree that some form of psychotherapy is of use for anyone with severe mental illnessIssues with evidenceControl groups (Usually TAU/waiting listc
controls)
Under-powered
Blinding
Researcher allegiance
Outcome measures
Slide6Current psychotherapiesPsychoeducationCognitive Behavioural Therapy (CBT)Family focused psychotherapy
Interpersonal and social rhythm therapy (IPSR)
Slide7PsychoeducationIndividual and groupOutcomes; medication adherence, symptoms, relapseIndividual psychoeducation (6-21 sessions)Systematic review, Bond and Anderson, 2015Measured relapse
16 trials, data on around 7
Bipolar illness, in remission
Slide8Main findingsWide heterogeneity, I2=43% when including individual, 19% with groupTwo methods of analysing, conservative (all dropouts relapsed) vs optimistic (all dropouts remained well)
Median follow up 60
wks
, duration of
tx
20.5 hours.
Decreased odds ratio of manic relapse (OR 1.68, 95% CI 0.99-2.85), though not depression relapse (1.39, 95% CI 0.78-2.48)
NNT 4-8
Slide9ODDS RATIO, PE VS TAU/PLACEBO, ANY RELAPSE
Slide10Cognitive Behavioural TherapyAcute treatment of bipolar depressionNICE 2014 meta-analysis Individual CBT vs TAU for acute
sx
depression
N=6, effect size 0.31 (95% Cis -0.53-0.08)
Maintained at 12 month follow-up (-0.19, -0.46-0.08)
Slide11Cognitive behavioural therapyRelapseScott 2006, no significant difference to controls, though difference in those with less than 12 episodes
(
H
azard
ratio=0.74, 95% CI 0.56–0.98,
p
=0.04)
Slide12Functional remediationTorrent et al 2013PE vs FR vs TAUFunctional improvement in FR group vs TAU, and (almost) vs PELarge effect size of FR vs TAU (C
ohen’s d=0.93)
Slide13Family focused therapyVery differing methodologies, comparisons and outcomesEg Miklowitz 2000, 2003; 3 sessions crisis management vs 21 sessions FFT
When looking at recurrence, there are two clear positive trials
See STEP BD trial, 2007
Slide14Interpersonal and social rhythm therapyInterpersonal rhythms and social problems, Frank et al, 2005Sleep/wake schedules, exerciseFrank et al, 2005, N=175, randomised to IPSRT or crisis management, hazard ratio 0.38
Possible use in acute BP depression (STEP BD,
Miklowitz
, 2007)
Slide15STEP BD30 sessions of CBT, FFT or IPSRT vs 3 sessions of collaborative careshorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08–2.00; p=.01).
Patients
in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17–2.13) more likely to be clinically well during any study
month
No difference between groups
Slide16Slide17NICE, 2014Psychological treatments for bipolar disorderIllness phaseAcute treatmentRelapse prevention
Slide18Slide19NICE CG 185Bipolar depression“should be offered a specific intervention d for bipolar disorder and has a published evidence based manual…or a high intensity psychosocial intervention (IPT, CBT, behavioural couples therapy) in line with NICE guideline on depression
1st line tx for bipolar depression in primary care
Family therapy for people living close to family
Structured intervention to prevent relapse (individual, group or family, manualized)
Slide20Meta-analyses of bipolar depression
Slide21Psychoeducation2 MAs with 2 trials, no benefit for group psychoeducation, post treatment, SMD 0.14 (-0.17-0.46) and follow-up (0.4, -0.07-0.87).Family psychoeducation beneficial vs control post-tx though not at 12 month follow-up (SMD -0.73, -1.35 to -0.01), (S D-0.1, -0.56 to 0.36)
However the meta analysis included only one trial
Slide22Meta-analysis of relapse preventionIndividual CBT vs TAU for any relapse, risk ratio 0.67, 0.53-0.86)Excluded Scott et al, 2006 Include Scott et al, risk ratio 0.79 (0.59-1.07)
Slide23Slide24Methodological issuesOver 130 separate meta-analyses, some of only one trial and multiple outcome measuresNo control for comparisons (FDR would seem appropriate)Composite meta-analyses of differing therapies togetherIndividual CBT and psychoeducation was significant, but other composite analyses non-significant
Slide25Risk of BiasBlinding of studies, randomisation, controlling for attritionAll studies included re outcome were low or very low quality?Selective reporting of findings from composite MA?
Slide26The Mental Elf Blog
Slide27The aftermath…..Response from the Guidleine groupResponse form ourselves….