Preliminary communication
A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder

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Abstract

Background

Bipolar disorder (BD) is a chronic and disabling psychiatric disorder characterized by recurrent episodes of mania/hypomania and depression. Dialectical behavior therapy (DBT) techniques have been shown to effectively treat borderline personality disorder, a condition also marked by prominent affective disturbances. The utility of DBT techniques in treating BD has been largely unexplored. The purpose of this research was to conduct a pilot study of a DBT-based psychoeducational group (BDG) in treating euthymic, depressed, or hypomanic Bipolar I or II patients.

Methods

In this experiment, 26 adults with bipolar I or II were randomized to intervention or wait-list control groups and completed the Beck depression inventory II, mindfulness-based self-efficacy scale, and affective control scale at baseline and 12 weeks. The BDG intervention consisted of 12 weekly 90-min sessions which taught DBT skills, mindfulness techniques, and general BD psychoeducation.

Results

Using RM-ANOVA, subjects in BDG demonstrated a trend toward reduced depressive symptoms, and significant improvement in several MSES subscales indicating greater mindful awareness, and less fear toward and more control of emotional states (ACS). These findings were supported with a larger sample of patients who completed the BDG. Furthermore, group attendees had reduced emergency room visits and mental health related admissions in the six months following BDG.

Limitations

The small sample size in RCT affects power to detect between group differences. How well improvements after the12-week BDG were maintained is unknown.

Conclusions

There is preliminary evidence that DBT skills reduce depressive symptoms, improve affective control, and improve mindfulness self-efficacy in BD. Its application warrants further evaluation in larger studies.

Introduction

Bipolar disorder (BD) is a highly recurrent and disabling condition, marked by major depression and manic/hypomanic episodes. According to the CANMAT guidelines (Yatham et al., 2009), the lifetime prevalence of bipolar I is 1.0%; bipolar II is 1.1%; and sub-threshold bipolar is 2.4%. The impact of this illness is considerable, including reduced opportunities for education and work (Leahy, 2007); increased rates of substance abuse and dependence, making the illness more difficult to treat (Altman et al., 2006); and increased rates of divorce (Leahy, 2007). In addition, for those with BD, the rate of suicide attempts has been documented to be as high as 50% (Rizvi and Zaretsky, 2007), with lifetime rates for completed suicide reported to be 60 times higher than for the general population (Leahy, 2007).

Although mood-stabilizing medication is the corner-stone of treatment for BD, most patients are not fully stabilized on drug therapies alone: even when patients remain on medication, rates of recurrence average 40% to 60% (Gitlin et al., 1995). As well, a large number of patients experience residual symptoms or on-going mood cycling, so that full functional recovery is uncommon (Treuer and Tohen, 2010). An additional problem is the fact that 50% of people with BD have at least one episode of medication non-adherence (Zaretsky et al., 2007); and that polypharmacy is the rule rather than the exception in BD, and mood stabilizing medications are associated with a host of side-effects that can affect adherence to treatment.

Group psychoeducation and psychotherapy, such as cognitive-behavioural therapy (CBT) and interpersonal social rhythm therapy (IPSRT) are recommended treatments to complement medication management in BD (Rizvi and Zaretsky, 2007). Studies have shown CBT to be effective in treating depressive episodes, but efficacy in treating manic episodes and acutely ill patients is questionable (Rizvi & Zaretsky, 2007). One study by Scott and colleagues (2001) concluded that CBT may be most suited to patients in the early stages of the illness, or to those with a less recurrent course of BD.

IPSRT, on the other hand, when delivered in the acute treatment phase, has been shown to delay recurrences of bipolar episodes (Frank, 2007). However, in an article reviewing efficacy of psychotherapies for BD, Miklowitz (2008) concluded that “…(BD) is a highly chronic, disabling, and recurrent illness, and our existing treatment options are inadequate for maintaining long-term stability. Even with optimal psychotherapy and pharmacotherapy, recurrences occurred in 50–75% of patients in 1 year” (2008, p. 1417).

Therefore, it is imperative that we continue to look for more effective psychotherapies that will be helpful to our patients with BD. Dialectical behavior therapy (DBT) techniques have not yet been studied or routinely applied in BD, but there are reasons to believe they may be helpful.

Studies have demonstrated that DBT is the most effective treatment for borderline personality disorder (Bohus et al., 2000, Linehan et al., 1991, Linehan et al., 1993). Given the similarities between these two illnesses (e.g., emotion dysregulation, suicidality, impulsivity, interpersonal difficulties and treatment non-adherence), it is reasonable to hypothesize that DBT would also be an effective treatment for BD.

DBT is a treatment originally designed to help individuals primarily with problems in regulating their emotions, and the subsequent difficulties this creates. Mindfulness, which is one component of DBT, has been studied as a treatment for many different mental illnesses such as depression and depression relapse (Teasdale et al., 2000); generalized anxiety disorder (Kutz et al., 1985, Miller et al., 1995); and panic disorder (Kabat-Zinn et al., 1992). Only two small studies have looked at the use of mindfulness-based cognitive therapy (MBCT) for BD, the first found some improvement in symptoms of anxiety and mania, as well as a reduction in suicidal ideation (Williams et al., 2008). The second found no improvement in symptoms, but the authors reported that clients subjectively noted an improvement in their ability to cope with emotions (Weber et al., 2010).

In light of this research, the investigators in the present study further believed that the mindfulness practice involved in DBT would be particularly beneficial to individuals with BD given the fact that depression is a large component of BD, as well as the high co-morbidity rate of BD with anxiety disorders. The purpose of this pilot study was to evaluate the feasibility and effectiveness of the bipolar disorder group (BDG), a DBT skills-based psychoeducational group with emphasis on mindfulness practice, in euthymic, depressed, or hypomanic bipolar patients.

Section snippets

Methods

This study was a randomized control trial (RCT) in which the control group was a wait condition. All patients who were eligible to participate in the DBT group were randomized to enter the group immediately (intervention group) or to wait 12 weeks until the next group (wait-list control). In this way, all patients had the opportunity to participate in the group intervention. Given the small number of patients (13 assigned per group; 12 per group completed questionnaires and completed the

Description of sample

Twenty-six patients were recruited for the RCT, 13 were randomly assigned to the intervention and wait-list control groups; 12 of each group completed the study. The majority of subjects were female (75%), with an average age of 42.3 years; about one third (38%) were married. Average age of diagnosis of BD was 36.1 years, one was diagnosed before the age of 18 years, with first depressive episode typically as teenagers/young adults and first manic episode some time later. Most (75%) had been

Discussion

This study reports data from a pilot randomized controlled trial using DBT skills to treat BD in a psychoeducational group. The sample in this study was typical in that subjects showed a long length of illness and multiple comorbidities. As far as we know, it is the first study to look at the use of DBT skills to treat BD in adults. The results suggest significant effects of DBT skills on reducing depressive symptoms, and increasing emotional control and self-efficacy. While current findings

Conclusion

While psychopharmacological treatment remains the corner-stone of managing BD, the lives of many patients with this illness could be improved further through adjunctive psychotherapy. Further trials evaluating the efficacy of using DBT skills to treat BD are needed, especially given the small sample in this study. Studies comparing the use of DBT skills to other treatments already proven effective in the treatment of BD (e.g., CBT, IPSRT) would be beneficial, as would trials with a follow-up to

Role of funding source

This study was unfunded.

Conflict of interest

There is no actual or potential conflict of interest including any financial, personal, or other relationships with other people or organizations.

Acknowledgements

We have no acknowledgements to include with this submission.

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