Bipolar disorder is a term applied to conditions that are characterised by extreme mood swings.  These swings in mood range from periods of overactive excited behaviour (known as mania) to deep depression. Some people also see or hear things that others around them don’t (known as having visual or auditory hallucinations) or have strange, unshared, beliefs (known as delusions).

Treatment of bipolar disorder usually involves medication aimed at controlling mania (lithium, antipsychotics, sodium valproate) or treating the depressive mood (antidepressants). Psychological treatments include: education (learning about the condition and how to control it); mood monitoring (learning to notice when mood is starting to change); strategies (to stop moods becoming out of control); and Cognitive Behavioural Therapy (CBT) for depression. Bipolar disorder affects about 1:100 people.

Most recently attention has been given to developing therapies which attempt to treat neurocognitive impairment (a decline in brain functioning performance, affecting: attention and concentration; executive function; information processing speed; language; visuospatial skill; psychomotor ability; learning; and memory), which is experienced by about half of those with bipolar disorder.

As neurocognitive impairment impacts on daily functioning, it seems logical that treatments that address such deficiencies would improve everyday functioning in bipolar disorder patients.

Functional remediation has been shown to be effective with schizophrenia (Wykes et al. 2011) and an open label study has suggested it might be of benefit for bipolar disorder patients (Deckersbach et al. 2010).

Functional remediation involves psychoeducation about cognitive dysfunctions (thinking errors) and their impact on the general functioning (life coping skills).

The context

The findings of a Spanish multicentre (Torrent el al. 2013), randomised, rater-blind, clinical trial have recently been published. The authors attempted to demonstrate the efficacy of functional remediation on patients with bipolar disorder who were in remission.

Methods

The study compared three treatments in 239 patients with bipolar I or II disorder:

• Functional Remediation (n=77)
• Psychoeducation (n=82)
• Treatment as usual (n=80)

Functional remediation addresses:

Attention

Memory

Executive functions

Enhancing functioning in daily routine

Functional remediation treatment comprised a 21 weekly session intervention that addressed neurocognitive issues (see box).

Psychoeducation consisted 21 weekly sessions aimed at improving: illness awareness; treatment adherence; early detection and lifestyle regularity.

Treatment as usual patients received prescribed pharmacological treatment without any additional psychosocial therapy.

All patients were evaluated pre- and post- treatment:

• Functional assessment: using a 24-item scale for assessing disability in patients with bipolar disorder
• Clinical and sociodemographic assessment: diagnosis (DSM-IV); standard demographic data; symptom history; treatment history
• Neuropsychological assessment: Testing for (i) estimated IQ; (ii) processing speed; (iii) executive functioning; (iv) visual memory and verbal learning/memory; (v) working memory index and (vi) attention

Data were analysed using SPSS.

Results

A total of 183 out of 239 patients completed their treatment. Functional impairment (measured with the Functional Assessment Short Test) was statistically significantly reduced in patients treated in the Functional Remediation when compared to those in the treatment as usual group (p=0.001) but not when compared to psychoeducation (p=0.056).

Conclusions

The authors conclude that functional remediation showed efficacy in improving the functional outcome of a sample of euthymic (in remission) bipolar disorder patients as compared with standard pharmacological treatments. Functional remediation was not statistically different from Psychoeducation intervention tested and Psychoeducation was not better than treatment as usual.

The results show significantly greater improvements for the functional remediation group on functioning…

To sum up

Bipolar disorder is a term given to a spectrum of mood swing disorders. The disorder has profound and far-reaching impact on the sufferer and on those in contact with people with bipolar disorder. In addition, bipolar disorder is the 6^th leading cause of disability worldwide, with concomitant global financial burden implications. Any treatment that helps those with the better function is therefore of great importance. This study shows some promise for the use of functional remediation in the treatment of euthymic bipolar disorder patients.

The study does however have its limitations. The inclusion of patients with bipolar I disorder (characterised by manic episodes) and bipolar II disorder (characterised by severe depressive episodes) pools two somewhat different variations of the disorder; the lack of detail as to the use of medication (type and dose) in the three treatment groups; the observation that functioning remediation was no better than Psychoeducation; the fact that the patients were in remission (at least 3 months) and the lack of long-term follow-up.

These shortcomings notwithstanding, functional remediation shows promise for enhancing functioning in patients with bipolar disorder and may, as the authors suggest:

…ultimately improve the outcome of patients suffering from bipolar disorder.

Links

Torrent C, del Mar Bonnin C, Martinez-Aran A, et al. Efficacy of functional remediation in bipolar disorder: a multicenter randomized controlled study. Am J Psychiatry 2013; published online March 20. DOI:10.1176/appi.ajp.2012.12070971 [PubMed abstract]

Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry. 2011 May;168(5):472-85. doi: 10.1176/appi.ajp.2010.10060855. Epub 2011 Mar 15. [PubMed abstract]

Deckersbach T, Nierenberg AA, Kessler R, Lund HG, Ametrano RM, Sachs G, Rauch SL, Dougherty D. Cognitive rehabilitation for bipolar disorder: An open trial for employed patients with residual depressive symptoms. CNS Neurosci Ther. 2010 Oct;16(5):298-307. doi: 10.1111/j.1755-5949.2009.00110.x.

Martínez-Arán A, Torrent C, Solé B, Bonnín CM, Rosa AR, Sánchez-Moreno J, Vieta E. Functional remediation for bipolar disorder. Clin Pract Epidemiol Ment Health. 2011;7:112-6. doi: 10.2174/1745017901107010112. Epub 2011 Jun 6.