Functional remediation for patients with bipolar II disorder: Improvement of functioning and subsyndromal symptoms

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Abstract

Recently, Functional Remediation (FR) has proven to be effective in improving the functional outcome of euthymic bipolar patients. The aim of this study was to test the efficacy of the FR program in a subsample of euthymic bipolar II patients (BPII). A post-hoc analyses were undertaken using data of 53 BPII outpatients who had participated in a multicenter, rater-blind, randomized, controlled trial exploring the efficacy of FR (n=17) as compared with a Psychoeducation group (PSY) (n=19) and a treatment as usual control group (TAU n=17). The primary outcome variable was the functional improvement defined as the mean change in the Functioning Assessment Short Test (FAST) from baseline to endpoint after the intervention. Regarding the treatment effect, data reveal a significant functional improvement from baseline to endpoint, suggestive for an interaction between program pertinence and time (pre-post). Nevertheless, Tukey׳s post-hoc test only revealed a trend in favor of a better outcome for FR when compared to the other two groups. We also found an interaction between program pertinence and time when analysing the subdepressive symptoms, with BPII patients in FR showing a significant reduction when compared to the PSY group. Our results suggest that the FR appears to be effective in improving the overall functional outcome in BPII, as well as in reducing subdepressive symptoms.

Introduction

Bipolar disorder type II (BPII) has been often considered as a mild form of bipolar disorder type I (BPI). However, nowadays it is known that BPII is not a less impairing variant of bipolar disorder. The disease burden in BPII does not differ from that observed in BPI regarding clinical severity, impairment, patterns of comorbidity, suicide attempts, family history and treatment patterns (Merikangas et al., 2007). Moreover, a recent report has demonstrated that BPII patients are as functionally impaired as BPI (Rosa et al., 2010). Similarly, evidence from recent reviews focused on neurocognition suggests that both subtypes of bipolar disorders present with similar neurocognitive deficits, with BPII only showing subtle differences when compared to BPI (Sole et al., 2011, Bora et al., 2011). Furthermore, there exists also a link between neurocognitive deficits and daily functioning in bipolar disorder, similarly to that found in schizophrenia (Depp et al., 2012, Tabares-Seisdedos et al., 2008, Iosifescu, 2012). In fact, a study with a sample of BPII patients reported that impairment in executive functions as well as the presence of subthreshold depressive symptoms were the best predictors of psychosocial outcome (Sole et al., 2012).

Taking all these data into account, it seems necessary to implement therapies focused on enhancing functional outcome in bipolar disorder. In addition to cognitive remediation programs (Deckersbach et al., 2010), recently some psychological interventions, including mindfulness, have been used in order to improve cognition and functioning in bipolar disorder (Stange et al., 2011, Lahera et al., 2013). However, there is still a need for further innovative treatment approaches (Fuentes-Dura et al., 2012, Anaya et al., 2012), especially concerning to BPII population. In this sense, Martinez-Aran and colleagues proposed a new therapeutic intervention named Functional Remediation (FR), designed exclusively for bipolar patients, aimed at improving neurocognition in order to achieve a functional recovery (Martinez-Aran et al., 2011). The efficacy of this new intervention has been recently tested in a randomized controlled trial (RCT), suggesting that the FR program is a promising tool to ameliorate daily functioning in bipolar patients (Torrent et al., 2013). Nevertheless, RCTs devoted to analyze the impact of psychological therapies on BPII patients are scarce (Colom et al., 2009a). In fact, most available therapies targeting BP, derive from studies carried out with BPI or mixed samples of BPI and BPII patients. Therefore, it cannot be concluded whether therapies for BPII patients require adjustments to meet the specific needs showed by this group of patients or not.

Hence, the present subanalysis was aimed to assess the efficacy of the Functional Remediation program specifically in a sample of bipolar II patients concerning global psychosocial functioning, assessed by changes in the means of the Functioning Assessment Short Test (FAST). We hypothesized that bipolar II patients in the Functional Remediation group would experience greater improvement in global psychosocial functioning compared with the other two intervention groups (Psychoeducation and TAU).

Section snippets

Experimental procedures

This was a post-hoc, exploratory subanalysis of data obtained from a larger study focused on the efficacy of FR in the psychosocial functioning improvement in euthymic bipolar patients (Torrent et al., 2013). BPI and BPII patients were hereby randomized by means of a computer-generated sequence to either a structured group of FR, a manual-based group psychoeducative intervention (PSY), or to join a group of patients only following pharmacological treatment as usual (TAU). It was designed as a

Results

Although diagnostic subtype was not matter of stratification at the randomization phase, allocation was balanced in the three groups: FR (n=17; 32.1%); PSY (n=19; 35.8%) and TAU (n=17; 32.1%). At baseline, there were no statistically significant differences between groups in neither demographic characteristics nor clinical variables (data summarized in Table 1). The average age was around 40 years and BPII participants had suffered a mean of 5 depressive episodes and 3 hypomanic episodes from

Discussion

This manuscript provides preliminary evidence that FR may be an effective tool in improving overall functional outcome and reducing subclinical depressive symptoms in a sample of BPII patients. These results are in line with the recent RCT that showed the efficacy of FR in improving functioning in a larger sample of bipolar I and II patients. However, in the original study the authors did not find a decrease in subclinical depressive symptomatology (Torrent et al., 2013).

This subanalysis shows

Role of funding source

Supported by an ETS grant from the Spanish Ministry of Economy and Competitiveness (PI080180 and PI08/90825, PI08/90327, PI08/90675, PI08/90224, PI08/90654, PI08/90189, PI08/90916, PI08/90416, PI08/90094) PN 2008–2011, Instituto de Salud Carlos III, Subdirección General de Evaluación y Fomento de la Investigación; Fondo Europeo de Desarrollo Regional. Unión Europea, “Una manera de hacer Europa”; CIBERSAM; and the Comissionat per a Universitats i Recerca del DIUE de la Generalitat de Catalunya

Contributors

All the authors have been sufficiently involved in the submitted study and have approved the final paper.

Conflict of interest

Dr. Amann has served as a speaker for Bristol-Myers Squibb/Otsuka.

Dr. González-Pinto has received grants from or served as consultant, adviser, or CME speaker for Almirall, AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, GlaxoSmithKline, Janssen-Cilag, Lundbeck, Merck, Novartis, Otsuka, Pfizer, Sanofi-Aventis, Schering-Plough, and the Spanish Ministry of Science and Innovation (CIBERSAM).

Dr. Crespo has served as a consultant or speaker for AstraZeneca, Bristol-Myers Squibb, Janssen, Eli

Acknowledgments

The authors thank the support of the Esther Koplowitz Centre (CEK) and of the Spanish Ministry of Economy and Competitiveness, Instituto de Salud Carlos III, CIBERSAM, the Spanish Ministry of Education and the Comissionat per a Universitats i Recerca del DIUE de la Generalitat de Catalunya to the Bipolar Disorders Group (2009 SGR 1022), the postdoctoral fellowship Beatriu de Pinós of the Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement de la Generalitat de Catalunya

References (43)

  • E. Vieta

    Tertiarism in psychiatry: the barcelona clinic bipolar disorders programme

    Rev. Psiquiatr. Salud. Ment.

    (2011)
  • L.M. Weinstock et al.

    Psychosocial predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder

    Compr. Psychiatry

    (2010)
  • F. Benazzi

    Prevalence and clinical correlates of residual depressive symptoms in bipolar II disorder

    Psychother. Psychosom.

    (2001)
  • A.L. Benton et al.

    Multilingual Aphasia Examination

    (1976)
  • E. Bora et al.

    Meta-analytic review of neurocognition in bipolar II disorder

    Acta. Psychiatr. Scand.

    (2011)
  • K.E. Burdick et al.

    Neurocognitive dysfunction and psychosocial outcome in patients with bipolar I disorder at 15-year follow-up

    Acta. Psychiatr Scand.

    (2010)
  • F. Colom et al.

    Psychoeducation Manual for Bipolar Disorder

    (2006)
  • F. Colom et al.

    Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial

    Br. J. Psychiatry.

    (2009)
  • T. Deckersbach et al.

    RESEARCH: Cognitive rehabilitation for bipolar disorder: an open trial for employed patients with residual depressive symptoms

    CNS Neurosci. Ther.

    (2010)
  • Delis,D.C., Kramer,J.H., Kaplan,E. and Ober,B., 1987. California Verbal Learning Test Psychological Corporation, New...
  • C.A. Depp et al.

    Meta-analysis of the association between cognitive abilities and everyday functioning in bipolar disorder

    Bipolar Disord.

    (2012)
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