title: Socio-demographic associations with social disablement in a community sample The long-term natural history of the weekly symptomatic status of bipolar I disorder. Predicting relapse in schizophrenia: the development and implementation of an early signs monitoring system using patients and families as observers, a preliminary investigation. Early intervention in psychiatric emergencies: a controlled clinical trial Does adjunctive family therapy enhance recovery from bipolar I mood episodes? Bipolar disorder and family communication: effects of a psychoeducational treatment program. Job Terminations Among Persons with Severe Mental Illness Participating in Supported Employment Difficulty in implementing a family intervention for bipolar disorder: the predictive role of patient and family attributes. The Effects of Monitoring and Feedback on Compliance A pilot study of cognitive therapy in bipolar disorders. Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial. Effects of psychoeducational intervention for married patients with bipolar disorder and their spouses. Bipolar II illness: course and outcome over a five-year period. Intimate relationships and depression: is there a causal connection? A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment The New Hampshire study of supported employment for people with severe mental illness. Comparison of preventive interventions for families with parental affective disorder. Psycho-education in bipolar disorder: effect on expressed emotion Group therapy for patients with bipolar disorder and substance dependence: results of a pilot study. An evaluation of a six-week intervention designed to facilitate coping with psychological stress. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. Subsyndromal symptoms in bipolar disorder. A comparison of standard and low serum levels of lithium. A randomized controlled trial of cognitive therapy for bipolar disorder: focus on long-term change. Psychoeducation efficacy in bipolar disorders: beyond compliance enhancement. A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Relapse and impairment in bipolar disorder. Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Clinical significance of inpatient family intervention: conclusions from a clinical trial. Prodromal symptoms and signs of bipolar relapse: A report based on prospectively collected data A Study of Client-Focused Case Management and Consumer Advocacy: The Community and Consumer Service Project Explaining Attitudes toward Medication Compliance among a Seriously Mentally 3Population A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission.
abstract: Summary The associations between social disablement and socio-demographic factors have been examined in a r and om sample of 310 adults drawn from the general population of Camberwell , South London . Neither paternal social class nor the subject 's own social class are associated with social disablement in either men or women , except that men ( but not women ) of very low social class show significantly poorer social performance . Age and sex are not associated with social disablement , despite the fact that women in the general population have consistently been found to have higher rates of psychiatric disorder than men . For a given level of psychiatric disorder men show poorer social performance than women . Men who do not have children at home , or who live entirely alone have significantly poorer social performance , as do men who are widowed , separated or divorced , but these factors are not associated with poor social performance in women . By contrast , an unsatisfactory marital relationship is significantly associated with disablement in women , but not in men . The demographic factors associated with poor social performance are all indices of social disadvantage or social isolation BACKGROUND To our knowledge , this is the first prospect i ve natural history study of weekly symptomatic status of patients with bipolar I disorder ( BP-I ) during long-term follow-up . METHODS Analyses are based on ongoing prospect i ve follow-up of 146 patients with Research Diagnostic Criteria BP-I , who entered the National Institute of Mental Health ( Bethesda , Md ) Collaborative Depression Study from 1978 through 1981 .  Weekly affective symptom status ratings were analyzed by polarity and severity , ranging from asymptomatic , to subthreshold levels , to full-blown major depression and mania . Percentages of follow-up weeks at each level as well as number of shifts in symptom status and polarity during the entire follow-up period were examined . Finally , 2 new measures of chronicity were evaluated in relation to previously identified predictors of chronicity for BP-I. RESULTS Patients with BP-I were symptomatically ill 47.3 % of weeks throughout a mean of 12.8 years of follow-up . Depressive symptoms ( 31.9 % of total follow-up weeks ) predominated over manic/hypomanic symptoms ( 8.9 % of weeks ) or cycling/mixed symptoms ( 5.9 % of weeks ) . Subsyndromal , minor depressive , and hypomanic symptoms combined were nearly 3 times more frequent than syndromal-level major depressive and manic symptoms ( 29.9 % vs 11.2 % of weeks , respectively ) . Patients with BP-I changed symptom status an average of 6 times per year and polarity more than 3 times per year . Longer intake episodes and those with depression-only or cycling polarity predicted greater chronicity during long-term follow-up , as did comorbid drug-use disorder . CONCLUSIONS The longitudinal weekly symptomatic course of BP-I is chronic . Overall , the symptomatic structure is primarily depressive rather than manic , and subsyndromal and minor affective symptoms predominate . Symptom severity levels fluctuate , often within the same patient over time . Bipolar I disorder is expressed as a dimensional illness featuring the full range ( spectrum ) of affective symptom severity and polarity Recognition of prodromal symptoms of schizophrenia offers the potential of early intervention to avert relapse and re-hospitalization ( Carpenter & Heinrichs , 1983 ) . The present study investigated how a strategy to detect prodromal signs might be effectively applied in the clinical setting . A st and ard monitoring system was developed involving completion of a new early signs scale ( ESS ) measuring changes in key symptoms phenomenologically ( self-report ) and behaviourally ( observer report ) . The ESS was subject to rigorous psychometric evaluation and tested in a prospect i ve pilot investigation . The ESS reliably identified early signs and predicted relapse with an overall accuracy of 79 % . Several different patterns of relapse were identified . Observer reports compensated for loss of insight in some patients . In two cases where early signs indices were detected , prompt increases in medication appeared to arrest relapse and avert readmission . The ESS offers itself as a reliable , valid and administratively feasible measure and demonstrates considerable potential as a cost-effective procedure for secondary prevention In the UK , psychiatric care of patients with acute and chronic disorders has increasingly moved from hospital to the community . We have evaluated in a controlled trial patients with severe mental illness , who were assigned to early intervention by community services or to st and ard hospital treatment .  100 patients aged 16 to 65 years presenting as psychiatric emergencies to an inner London teaching hospital were r and omly allocated to a multidisciplinary community-based team ( n = 48 ) or conventional hospital-based psychiatric services ( n = 52 ) and assessed over a 3-month period . Ratings of psychopathology and social functioning were made before treatment and after 2 , 4 , and 12 weeks by independent assessors . 85 patients completed all assessment s , and all patients had evaluable data beyond 2 weeks . 3 patients  died during the study , 2 from natural causes and 1 from an accident . Patients referred to the community service showed greater improvement in symptoms and were more satisfied with services than those in the hospital-based service . Patients treated in the hospital-based service spent eight times as many days as psychiatric in patients as those treated in the community-based service . Patients both prefer and seem to benefit from community-based psychiatric care , and our early-intervention community service might be a good model for such care BACKGROUND Family therapy is sometimes used as adjunctive treatment to pharmacotherapy to help patients recover from mood episodes of bipolar I disorder . However , the efficacy of this practice is not known . METHODS Ninety-two patients meeting criteria for a current bipolar I mood episode were r and omly assigned to family therapy plus pharmacotherapy , multifamily psychoeducational group therapy plus pharmacotherapy , or pharmacotherapy alone . Time to recovery was analyzed with survival analysis . RESULTS The proportion of subjects within each treatment group who recovered did not significantly differ , nor did time to recovery . LIMITATIONS The analyses did not include other outcomes such as psychosocial functioning , prophylaxis against recurrences of mood episodes , or compliance with pharmacotherapy . CONCLUSIONS Neither adjunctive family therapy nor adjunctive multifamily psychoeducational group therapy significantly improves the rate of recovery from mood episodes of bipolar I disorder , compared to treatment with pharmacotherapy alone Family psychoeducational programs are efficacious adjuncts to pharmacotherapy for patients with schizophrenic and bipolar disorders , but little is known about what these programs change about families . The authors assessed changes in face-to-face interactional behavior over 1 year among families of bipolar patients who received a 9-month family-focused psychoeducational therapy ( FFT ; n = 22 ) or crisis management with naturalistic follow-up ( CMNF ; n = 22 ) , both administered with maintenance pharmacotherapy . Members of families who received FFT showed more positive nonverbal interactional behavior during a 1-year posttreatment problem-solving assessment than families who received CMNF , although no corresponding decreases were seen in negative interactional behaviors . The positive effect of family treatment on patients ' symptom trajectories over 1 year was partially mediated by increases in patients ' positive nonverbal interactional behaviors during this same interval For persons with psychiatric disabilities , maintaining a job is often more difficult than acquiring a job . A large proportion of jobs end unsatisfactorily . This study explored job terminations among 63 persons with severe mental illness who participated in competitive jobs through supported employment programs .  More than half of the job terminations were unsatisfactory , defined as the client quitting without having other job plans or being fired . Baseline ratings of demographic and clinical characteristics , preemployment skills training , and early ratings of job satisfaction and work environment did not predict unsatisfactory terminations . Clients with better work histories were less likely to experience unsatisfactory terminations . In addition , unsatisfactory terminations were associated retrospectively with multiple problems on the job that were related to interpersonal functioning , mental illness , dissatisfaction with jobs , quality of work , medical illnesses , dependability , and substance abuse . These results suggest that supported employment programs need to address job maintenance with interventions that identify and address different types of difficulties as they arise on the job Family affect was examined as a predictor of difficulty implementing a 9-month , manual-based , psychoeducational family therapy for recently manic bipolar patients . Prior to therapy , family members were administered measures to assess both their expressed emotion and affective behavior during a family interaction task . Following family treatment , both therapists and independent observers rated the overall difficulty of treating the family , and therapists also rated each participant 's problem behaviors during treatment , in the areas of affect , communication , and resistance . Therapists regarded affective problems among relatives and resistance among patients as central in determining the overall difficulty of treating the family . Relatives ' critical behavior toward patients during the pretreatment interaction task predicted both independent observers ' ratings of overall treatment difficulty and therapists ' perceptions of relatives ' affective problems during treatment . Moreover , patients ' residual symptoms predicted independent observers ' ratings of overall difficulty and therapists ' perceptions of patients ' resistance to the family intervention . Results suggest that difficulties in conducting a manual-based family intervention can be predicted from systematic , pretreatment family and clinical assessment A two-group r and omized experimental design was employed to assess the effects of monitoring and feedback on the compliance of 93 psychiatric out patients treated with lithium . Compliance in both groups was measured using self-report , lithium level , appointment-keeping , and medication refill frequency . The experimental group was also monitored using a unique electronic device that records the time and day pills are removed . At the midpoint of the study , the experimental group received feedback about serum lithium levels and patterns of removing medications from the monitoring device while the control group received feedback about serum lithium levels only . The study demonstrated no sustained effect of the monitoring and feedback interventions on compliance BACKGROUND The efficacy and effectiveness of cognitive therapy ( CT ) is well established for unipolar disorders , but little is known about its utility in bipolar disorders . This study aim ed to explore the feasibility and efficacy of using CT as an adjunct to usual psychiatric treatment in this patient population . METHOD Subjects referred by general adult psychiatrists were assessed by and independent rater and then r and omly allocated to immediate CT ( N = 21 ) or 6-month waiting-list control , which was then followed by CT ( N = 21 ) . Observer and self-ratings of symptoms and functioning were undertaken immediately prior to CT , after a 6-month course of CT and a further 6-months later . Data on relapse and hospitalization rates in the 18 months before and after commencing CT were also collected . RESULTS At 6-month follow-up , subjects allocated to CT showed statistically significantly greater improvements in symptoms and functioning as measured on the Beck Depression Inventory , the Internal State Scale , and the Global Assessment of Functioning than those in the waiting-list control group . In the 29 patients who eventually received CT  , relapse rates in the 1 8 months after commencing CT showed a 60 % reduction in comparison with the 18 months prior to commencing CT . Seventy per cent of subjects who commenced therapy viewed CT as highly acceptable . CONCLUSION Although the results of this study are encouraging , the use of CT in subjects with bipolar disorders is more complex than in unipolar disorders and requires a high level of therapist expertise . The therapy may prove to be particularly useful in the treatment of bipolar depression BACKGROUND Few studies have examined the combined effects of psychosocial treatment and pharmacotherapy for bipolar disorder . This study used a r and omized , controlled design to examine a 9-month , manual-based program of family-focused psychoeducational treatment ( FFT ) . METHODS Bipolar patients ( N = 101 ) were recruited shortly after an illness episode and r and omly assigned to 21 sessions of FFT ( n = 31 ) or to a comparison treatment involving two family education sessions and follow-up crisis management ( CM ; n = 70 ) . Both treatments were delivered over 9 months ; patients were simultaneously maintained on mood stabilizing medications . Patients were evaluated every 3 months for 1 year as to relapse status , symptom severity , and medication compliance . RESULTS Patients assigned to FFT had fewer relapses and longer delays before relapses during the study year than did patients in CM . Patients in FFT also showed greater improvements in depressive ( but not manic ) symptoms . The most dramatic improvements were among FFT patients whose families were high in expressed emotion . The efficacy of FFT could not be explained by differences among patients in medication regimes or compliance . CONCLUSIONS Family-focused psychoeducational treatment appears to be an efficacious adjunct to pharmacotherapy for bipolar disorder . Future studies should evaluate family treatment against other forms of psychotherapy matched in amount of therapist-patient contact Recently hospitalized bipolar , manic patients ( N = 53 ) were r and omly assigned to a 9-month , manual-based , family-focused psychoeducational therapy ( n = 28 ) or to an individually focused patient treatment ( n = 25 ) . All patients received concurrent treatment with mood-stabilizing medications . Structured follow-up assessment s were conducted at 3-month intervals for a 1-year period ofactive treatment and a 1-year period of posttreatment follow-up . Compared with patients in individual therapy , those in family-focused treatment were less likely to be rehospitalized during the 2-year study period . Patients in family treatment also experienced fewer mood disorder relapses over the 2 years , although they did not differ from patients in individual treatment in their likelihood of a first relapse . Results suggest that family psychoeducational treatment is a useful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalization frequently associated with bipolar disorder The relative benefit of adding a structured psychoeducational intervention to st and ard medication treatment for married patients with bipolar disorder and their spouses was assessed . Patients were r and omly assigned to receive either medication management or medication management plus a marital intervention with their spouses for an 11-month period . Patients '  symptoms , functioning , and adherence to their medication regimens were measured at study entry and at 11 months . Significant effects favoring the combined treatments were observed for overall patient functioning but not for symptom levels . The marital intervention was associated with improved medication adherence . Combined psychosocial and medication treatment does not affect patients ' symptom levels beyond the effects of medication alone , but it does result in significant incremental gains in overall patient functioning A five year semi-annual follow-up of patients with non-bipolar ( N = 442 ) , bipolar II ( N = 64 ) and bipolar I ( N = 53 ) major depression tracked the courses of prospect ively observed major depressive , hypomanic and manic syndromes . In all three groups , depression was much more likely in any given week than was hypomania or mania . However , during the majority of weeks , no full syndrome was present and none of the groups exhibited evidence of continuing psychosocial deterioration . Though all three groups exhibited similar times to recovery from index and subsequent major depressive episodes , both bipolar groups had substantially higher relapse rates and developed more episodes of major depression , hypomania and mania . The two bipolar groups , in turn , differed by the severity of manic-like syndromes and thus remained diagnostically stable ; the bipolar II patients were much less likely to develop full manic syndromes or to be hospitalized during follow-up . In conjunction with family study data showing that bipolar II disorder breeds true , these data support the separation of bipolar I and bipolar II affective disorder The causal pathways that link  depression and dissatisfaction in intimate relationships were estimated in 115 patients during the first 12 weeks of treatment with cognitive-behavioral therapy for depression .  Depression severity , as measured by the Beck Depression Inventory , was negatively correlated with relationship satisfaction at intake and at 12 weeks . However , structural equation modeling was not consistent with the hypothesis that depression severity has a causal effect on relationship satisfaction levels and suggested that relationship satisfaction may have only a weak reciprocal effect on depression severity . As predicted , married patients were substantially less depressed 12 weeks after the beginning of treatment , when controlling for initial depression severity . Contrary to expectations , marital status predicted improvement even when relationship satisfaction was controlled . Unexpectedly , dysthymia at intake was associated with low relationship satisfaction after 12 weeks , when initial relationship satisfaction was controlled , suggesting that chronic , low-level depression may have a stronger association with interpersonal problems than other forms of depression , such as major depressive episodes . The theoretical and clinical implication s of the findings are discussed BACKGROUND Despite the use of mood stabilizers , a significant proportion of patients with bipolar affective disorder experience frequent relapses . A pilot study of cognitive therapy ( CT ) specifically design ed to prevent relapses for bipolar affective disorder showed encouraging results when used in conjunction with mood stabilizers . This article reports the outcome of a r and omized controlled study of CT to help prevent relapses and promote social functioning . METHODS We r and omized 103 patients with bipolar 1 disorder according to the DSM-IV , who experienced frequent relapses despite the prescription of commonly used mood stabilizers , into a CT group or control group . Both the control and CT groups received mood stabilizers and regular psychiatric follow-up . In addition , the CT group received an average of 14 sessions of CT during the first 6 months and 2 booster sessions in the second 6 months . RESULTS During the 12-month period , the CT group had significantly fewer bipolar episodes , days in a bipolar episode , and number of admissions for this type of episode . The CT group also had significantly higher social functioning . During these 12 months , the CT group showed less mood symptoms on the monthly mood question naires . Furthermore , there was significantly less fluctuation in manic symptoms in the CT group . The CT group also coped better with manic prodromes at 12 months . CONCLUSION Our findings support the conclusion that CT specifically design ed for relapse prevention in bipolar affective disorder is a useful tool in conjunction with mood stabilizers Abstract Objective : To determine the efficacy of teaching patients with bipolar disorder ( manic-depressive psychosis ) to identify early symptoms of relapse and seek prompt treatment from health services . Design : Single blind r and omised controlled trial with matching on four baseline variables using a minimisation algorithm . Setting : Mental health services in four NHS trusts ( one teaching , three non-teaching ) . Subjects : 69 patients with bipolar disorder who had had a relapse in the previous 12 months . Interventions : Seven to 12individual treatment sessions from a research psychologist plus routine care or routine care alone . Main outcome measures : Time to first manic or depressive relapse , number of manic or depressive relapses , and social functioning examined by st and ardised interviews every six months for 18 months . Results : 25th centile time to first manic relapse in experimental group was 65weeks compared with 17weeks in the control group . Event curves of time to first manic relapse significantly differed between experimental and control groups ( log rank 7.04 , df=1 , P=0.008 ) , with significant reductions in the number of manic relapses over 18months ( median difference 30 % ( 95 % confidence interval 8 % to 52 % ) , P=0.013 ) . The experimental treatment had no effect on time to first relapse or number of relapses with depression , but it significantly improved overall social functioning ( mean difference 2.0(0.7to 3.2 ) , P=0.003 ) and employment ( mean difference 0.7(0.1to 1.3 ) , P=0.030 ) by 18months . Conclusion : Teaching patients to recognise early symptoms of manic relapse and seek early treatment is associated with important clinical improvements in time to first manic relapse , social functioning , and employment This study compared supported employment services in 2 contrasting programs : ( a ) Group Skills Training , a professional rehabilitation agency outside of the mental health center that provided pre-employment skills training and support in obtaining and maintaining jobs , or ( b ) the Individual Placement and Support ( IPS ) model , which integrated clinical and vocational services within the mental health center . People with severe mental disorders who expressed interest in competitive employment ( N = 143 ) were r and omly assigned to 1 of these 2 programs . Results showed that clients in the IPS program were more likely to be competitively employed throughout most of the 18-month follow-up . Among those who obtained jobs , there were few group differences , although workers in the IPS program did work more total hours and earn more total wages during the 18-month follow-up . There were no group differences on nonvocational outcomes Twenty families participated in a r and om assignment trial of two cognitive psychoeducational preventive interventions for families with parental affective disorder . Twelve families were assigned to a clinician-based intervention and eight to a lecture-based intervention  , with assessment prior to intervention and an average of 18 weeks following intervention . Both groups were satisfied and believed they received help from the intervention . The clinician-based group was significantly more satisfied overall , and reported significantly more changes in both behaviors and attitudes about their illness from pre- to postintervention . Both groups showed significant decrease in degree of upset over issues of concern from pre- to postintervention . The clinician-based group reported receiving significantly more help with their primary concern . The implication s of these findings are discussed In a waiting-list controlled study on a multi-family psycho-educational intervention in bipolar disorder , key relatives in the treatment group showed a significant change from high to low levels of expressed emotion ( EE ) compared with the control group . In addition , patients with low-EE key relatives had a significantly lower number of hospital admissions compared with those living with high-EE key relatives . The multi-family groups were well received by the participants , and there were only a few drop-outs BACKGROUND The authors ' goal was to pilot test a newly developed manual-based group psychotherapy , called Integrated Group Therapy ( IGT ) , for patients with bipolar disorder and substance dependence . METHOD In this open trial , patients with DSM-IV bipolar disorder and substance dependence ( N = 45 ) were recruited in sequential blocks to receive either group therapy ( N = 21 ) or 6 monthly assessment s , but no experimental treatment ( N = 24 ) . RESULTS When compared with patients who did not receive group therapy , patients who received IGT had significantly better outcomes on the Addiction Severity Index drug composite score ( p < .03 ) , percentage of months abstinent ( p < .01 ) , and likelihood of achieving 2 ( p < .002 ) or 3 ( p < .004 ) consecutive abstinent months . CONCLUSION IGT is a promising treatment for patients with bipolar disorder and substance dependence , who have traditionally had poor outcomes . It is unclear , however , how much of the improvement among the group therapy patients is attributable to the specific content of the treatment . A study comparing this treatment with another active psychotherapy treatment is warranted Community dwelling Korean adults ( N = 40 ) coping with the stress of severe mental illness were r and omly assigned to a six-week differentiation furthering intervention ( experimental ) or a directed problem-solving treatment program ( control ) and administered pre- and posttreatment measures including the Morey Personality Assessment Screener ( PAS ) and Group Embedded Figures Test ( GEFT ) . As predicted , the experimental group showed greater improvement on 6 out of 10 mental health subscales ( PAS ) and on the GEFT than the controls . For the entire sample , differentiation gainers showed more improvement on three PAS subscales compared with the no change or loss in differentiation groups . A three-month follow-up showed greater attendance at mental health appointments for the experimental group over controls and for total sample differentiation gainers over nongainers . Implication s are discussed of this empirically tested model of a community intervention to facilitate coping with stress and enhancing competence OBJECTIVE In a previous r and omized controlled study , the authors reported significant beneficial effects of cognitive therapy for relapse prevention in bipolar disorder patients up to 1 year . This study reports additional 18-month follow-up data and presents an overview of the effect of therapy over 30 months . METHOD Patients with DSM-IV bipolar I disorder ( N=103 ) suffering from frequent relapses were r and omly assigned into a cognitive therapy plus medication group or a control condition of medication only . Independent raters , who were blind to patient group status , assessed patients at 6-month intervals . RESULTS Over 30 months , the cognitive therapy group had significantly better outcome in terms of time to relapse . However , the effect of relapse prevention was mainly in the first year . The cognitive therapy group also spent 110 fewer days ( 95 % CI=32 to 189 ) in bipolar episodes out of a total of 900 for the whole 30 months and 54 fewer days ( 95 % CI=3 to 105 ) in bipolar episodes out of a total of 450 for the last 18 months . Multivariate analyses of variance showed that over the last 18 months , the cognitive therapy group exhibited significantly better mood ratings , social functioning , coping with bipolar prodromes , and dysfunctional goal attainment cognition . CONCLUSIONS Patients in the cognitive therapy group had significantly fewer days in bipolar episodes after the effect of medication compliance was controlled . However , the results showed that cognitive therapy had no significant effect in relapse reduction over the last 18 months of the study period . Further studies should explore the effect of booster sessions or maintenance therapy Ninety-four patients with bipolar disorder participating in a r and om-assignment , double-blind , prospect i ve maintenance trial of st and ard- ( 0.8 to 1.0 mmol/L ) vs  low-range ( 0.4 to 0.6 mmol/L )  serum lithium levels  were assessed to determine the presence and significance of subsyndromal symptoms during periods of remission and recovery . A significant relationship was found between prescribed serum lithium level and the probability of major affective relapse and the occurrence of subsyndromal symptoms . Patients given lithium carbonate to achieve low-range levels had 2.6 times the risk of major affective relapse as those given lithium for st and ard-range levels and nearly twice the risk of developing subsyndromal symptoms . Patients given the low-range therapy showed a greater variance in weekly Psychiatric Status Rating measures , and their symptoms were more likely to worsen at any time than were symptoms in their st and ard-level group counterparts . The first occurrence of subsyndromal symptoms increased the risk of major affective relapse fourfold . Following the onset of subsyndromal symptoms , the patients originally r and omized to receive st and ard-range lithium therapy were still better protected from relapse than were patients r and omized to receive low-range lithium treatment . Patients were two times more likely to develop depressive than hypomanic symptoms between acute episodes of illness . However , onset of hypomanic symptoms predicted subsequent major affective relapse twice as strongly as did depressive symptoms . Seventy-six percent of patients who became hypomanic had a major affective relapse , compared with 39 % of patients who were sub clinical ly depressed BACKGROUND This study reports the outcome of a r and omized controlled trial of cognitive therapy ( CT ) for bipolar disorder . The treatment protocol differed from other published forms of CT for bipolar disorder through the addition of emotive techniques . METHOD Fifty-two patients with DSM-IV bipolar I or II disorder were r and omly allocated to a 6-month trial of either CT or treatment as usual , with both treatment groups also receiving mood stabilizers . Outcome measures included relapse rates , dysfunctional attitudes , psychosocial functioning , hopelessness , self-control , and medication adherence . Patients were assessed during treatment by independent raters blind to the patients ' group status . RESULTS At posttreatment , patients allocated to CT had experienced less severe depression scores ( Beck Depression Inventory and Montgomery-Asberg Depression Rating Scale ) and less dysfunctional attitudes . After controlling for the presence of major depressive episode at baseline , there was a statistical trend toward a greater time to depressive relapse ( p=.06 ) for the CT group . At 12-month follow-up , the CT group showed a trend toward lower Young Mania Rating Scale scores and improved behavioral self-control . The Clinical Global Impressions-Improvement scale , comparing the 18 months prior to treatment to the severity of illness status at follow-up , showed a substantial difference between groups in favor of CT . CONCLUSION Our findings corroborate previous bipolar disorder research in demonstrating the value of CT , particularly immediately post-treatment , and indicate some continuation ( albeit diminishing ) of benefits in the succeeding 12 months . These findings suggest that psychological booster sessions may be crucial for maintaining the beneficial effects of cognitive therapy BACKGROUND Several previous studies have established that low treatment adherence is common among bipolar patients and may explain high rates of recurrence . On the other h and , some patients keep relapsing even when they strictly follow their prescribed somatic treatments . Psychological interventions such as psychoeducation may foster early recognition of prodromal symptoms and minimize the risk of relapse . To date , studies assessing the usefulness of psychoeducation in fully compliant patients are lacking . METHOD This was a single-blind , r and omized , prospect i ve clinical trial on the efficacy of group psychoeducation in remitted fully compliant DSM-IV bipolar I patients ( N = 25 ) who were compared with a group with similar characteristics ( N = 25 ) who did not receive psychoeducation .  All patients received naturalistic pharmacologic treatment . Recruitment began in 1997 and follow-up was completed in January 2002 . The follow-up phase comprised 2 years during which all patients continued receiving naturalistic treatment without psychological intervention and were assessed monthly on several outcome measures . RESULTS At the end of the 2-year follow-up , 23 subjects ( 92 % ) in the control group fulfilled criteria for recurrence versus 15 patients ( 60 % ) in the psychoeducation group ( p < .01 ) . The number of total recurrences and the number of depressive episodes were significantly lower in psychoeducated patients . CONCLUSION Although the present study has the limitation of small sample size , psychoeducation showed its efficacy in preventing relapses in bipolar I patients who were adherent to drug treatment . The action of psychoeducation seems to go beyond compliance enhancement and may support a tripod model composed by lifestyle regularity and healthy habits , early detection of prodromal signs followed by prompt drug intervention , and finally treatment compliance BACKGROUND Bipolar patients are at risk for relapses of their illness even when undergoing optimal pharmacotherapy . This study was performed to determine whether combining family-focused therapy ( FFT ) with pharmacotherapy during a postepisode interval enhances patients ' mood stability during maintenance treatment . METHODS In a r and omized controlled trial , 101 bipolar patients were assigned to FFT and pharmacotherapy or a less intensive crisis management ( CM ) intervention and pharmacotherapy . Outcome assessment s were conducted every 3 to 6 months for 2 years . Participants ( mean + /- SD age , 35.6 + /- 10.2 years ) were referred from inpatient or outpatient clinics after onset of a manic , mixed , or depressed episode .  FFT consisted of 21 sessions of psychoeducation , communication training , and problem-solving skills training . Crisis management consisted of 2 sessions of family education plus crisis intervention sessions as needed . Both protocol s lasted 9 months . Patients received pharmacotherapy for 2 study years . Main outcome measures included time to relapse , depressive and manic symptoms , and medication adherence . RESULTS Rates of study completion did not differ across the FFT ( 22/31 , 71 % ) and CM groups ( 43/70 , 61 % ) . Patients undergoing FFT had fewer relapses ( 11/31 , 35 % ) and longer survival intervals ( mean + /- SD , 73.5 + /- 28.8 weeks ) than patients undergoing CM ( 38/70 , 54 % ; mean + /- SD , 53.2 + /- 39.6 weeks ; hazard ratio , 0.38 ; 95 % confidence interval , 0.20 - 0.75 ; P = .003 ; intent to treat ) . Patients undergoing FFT showed greater reductions in mood disorder symptoms and better medication adherence during the 2 years than patients undergoing CM . CONCLUSION Combining family psychoeducation with pharmacotherapy enhances the postepisode symptomatic adjustment and drug adherence of bipolar patients OBJECTIVE The purpose of this study was to evaluate the outcome of bipolar disorder in the context of maintenance pharmacotherapy . METHOD Eighty-two bipolar out patients were followed prospect ively for a mean of 4.3 years ( minimum of 2 years ) ; symptom rating and psychosocial outcome scales were used , and pharmacotherapy was rated on a 5-point scale . RESULTS Despite continual maintenance treatment , survival analysis indicated a 5-year risk of relapse into mania or depression of 73 % . Of those who relapsed , two-thirds had multiple relapses . Relapse could not be attributed to inadequate medication . Even for those who did not relapse , considerable affective morbidity was observed . A measure of cumulative affective morbidity appeared to be a more sensitive correlate of psychosocial functioning than was the number of relapses . Poor psychosocial outcome paralleled poor syndromal course . Poor psychosocial functioning , especially occupational disruption , predicted a shorter time to relapse . Depressions were most strongly related to social and family dysfunction . CONCLUSIONS Even aggressive pharmacological maintenance treatment does not prevent relatively poor outcome in a significant number of bipolar patients CONTEXT Numerous studies have pointed to the failure of prophylaxis with pharmacotherapy alone in the treatment of bipolar I disorder . Recent investigations have demonstrated benefits from the addition of psychoeducation or psychotherapy to pharmacotherapy in this population . OBJECTIVE To compare 2 psychosocial interventions : interpersonal and social rhythm therapy ( IPSRT ) and an intensive clinical management ( ICM ) approach in the treatment of bipolar I disorder . DESIGN R and omized controlled trial involving 4 treatment strategies : acute and maintenance IPSRT ( IPSRT/IPSRT ) , acute and maintenance ICM ( ICM/ICM ) , acute IPSRT followed by maintenance ICM ( IPSRT/ICM ) , or acute ICM followed by maintenance IPSRT ( ICM/IPSRT ) . The preventive maintenance phase lasted 2 years . SETTING Research clinic in a university medical center . PARTICIPANTS One hundred seventy-five acutely ill individuals with bipolar I disorder recruited from inpatient and outpatient setting s , clinical referral , public presentations about bipolar disorder , and other public information activities . INTERVENTIONS Interpersonal and social rhythm therapy , an adaptation of Klerman and Weissman 's interpersonal psychotherapy to which a social rhythm regulation component has been added , and ICM . MAIN OUTCOME MEASURES Time to stabilization in the acute phase and time to recurrence in the maintenance phase . RESULTS We observed no difference between the treatment strategies in time to stabilization . After controlling for covariates of survival time , we found that participants assigned to IPSRT in the acute treatment phase survived longer without a new affective episode ( P = .01 ) , irrespective of maintenance treatment assignment . Participants in the IPSRT group had higher regularity of social rhythms at the end of acute treatment ( P<.001 ) . Ability to increase regularity of social rhythms during acute treatment was associated with reduced likelihood of recurrence during the maintenance phase ( P = .05 ) . CONCLUSION Interpersonal and social rhythm therapy appears to add to the clinical armamentarium for the management of bipolar I disorder , particularly with respect to prophylaxis of new episodes OBJECTIVE To test whether the statistically significant results of a r and omized clinical trial of an inpatient family intervention were clinical ly significant for hospital practice , the authors reanalyzed outcome data using a measure of clinical significance based on the extent to which patients had recovered during the course of the intervention . METHODS A total of 169 hospitalized subjects and their families were r and omly assigned to a psychoeducational inpatient family intervention or to a comparison group . Patient and family outcome measures were assessed at admission , discharge , and six and 18 months after admission . Analyses of statistically significant differences in outcome suggested that inpatient family intervention was effective for certain patient subgroups identified by gender and diagnosis . Global Assessment Scale scores two or more st and ard deviations above the pretreatment ( admission ) mean were used as indicators for clinical ly significant improvement . RESULTS The re analysis confirmed that inpatient family intervention was associated with clinical ly significant improvement at discharge , especially for female patients and patients with chronic schizophrenia and bipolar disorder . These effects were maintained six months after admission before attenuating at 18 months . CONCLUSIONS Inpatient family intervention results in clinical ly meaningful outcomes for certain subgroups of patients and their families Prospect ively collected data on 19 recently hospitalized patients with bipolar disorder were examined for prodromal changes preceding relapse . The 4-month periods before six manic and six depressive relapses were compared with each other and with a comparable period for seven patients who did not relapse . The  Brief Psychiatric Rating Scale  was used to assess symptoms . Significant elevations in unusual thought content were found 1 month before manic relapse . Depressive relapsers evidence d higher levels of conceptual disorganization throughout the prerelapse period . Nonrelapsers showed very stable symptom profiles Objective : The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder . It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning , disability and satisfaction with services . Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates . Method : Clients referred for case management were r and omly allocated to one of three groups :  st and ard case management  ( n = 35 ) ,  client-focused case management  ( n = 39 ) , or  client-focused case management plus consumer advocacy  ( n = 45 ) . Measures of functioning , disability , quality of life , burden of care and service satisfaction were measured at baseline and 12 months . Outcome data were collected concerning number and duration of hospital readmission , crisis intervention and compliance with treatment and services . Results : While there were no differences between the groups on quantitative measures of functioning , disability , quality of life , service satisfaction and burden of care , there were significant between-group differences on qualitative measures of satisfaction with services . Conclusions : Several method ological difficulties hampered interpretation of the findings . Although clients did not differ on outcome measures of functioning and disability , the group receiving client-focused case management reported greater satisfaction with service delivery Data from a clinical trial of consumer-delivered case management services were used to construct an explanatory model for attitudes toward medication compliance , focusing on psychosocial factors . A regression model explaining attitudes toward medication compliance shows that more positive attitudes toward compliance are related to older age , fewer symptoms , and a broader array of daily activities involving social relations . Participation in  social activities is a practical goal of psychosocial rehabilitation services that support compliance with medication regimens and psychiatric treatment BACKGROUND Studies on individual psychotherapy indicate that some interventions may reduce the number of recurrences in bipolar patients . However , there has been a lack of structured , well- design ed , blinded , controlled studies demonstrating the efficacy of group psychoeducation to prevent recurrences in patients with bipolar I and II disorder . METHODS One hundred twenty bipolar I and II out patients in remission ( Young Mania Rating Scale score < 6 , Hamilton Depression Rating Scale-17 score < 8) for at least 6 months prior to inclusion in the study , who were receiving st and ard pharmacologic treatment , were included in a controlled trial . Subjects were matched for age and sex and r and omized to receive , in addition to st and ard psychiatric care , 21 sessions of group psychoeducation or 21 sessions of nonstructured group meetings . Subjects were assessed monthly during the 21-week treatment period and throughout the 2-year follow-up . RESULTS Group psychoeducation significantly reduced the number of relapsed patients and the number of recurrences per patient , and increased the time to depressive , manic , hypomanic , and mixed recurrences . The number and length of hospitalizations per patient were also lower in patients who received psychoeducation . CONCLUSION Group psychoeducation is an efficacious intervention to prevent recurrence in pharmacologically treated patients with bipolar I and II disorder
target: This review shows a beneficial effect of EWS in time to recurrence , percentage of people hospitalised and functioning in people with bipolar disorder .
background: BACKGROUND Recurrence rates for bipolar disorder are high despite effective treatments with mood stabiliser drugs .
  Self-help treatments and psychological treatments that teach patients to recognise and manage early warning symptoms and signs ( EWS ) of impending manic or depressive episodes are popular with patients .
  The main aim of such interventions is to intervene early and prevent bipolar episodes , thereby increasing the time to the next recurrence and preventing hospitalisation .
  OBJECTIVES To compare the effectiveness of an EWS intervention plus treatment as usual ( TAU ) versus TAU ( involving and not involving a psychological therapy ) on time to manic , depressive and all bipolar episodes ( the primary outcome ) , hospitalisation , functioning , depressive and manic symptoms .