Memory for therapy in bipolar disorder and comorbid insomnia.

Memory for medical advice is staggeringly poor. Cancer patients recall 23% to 33% of treatment recommendations (Bober, Hoke, Duda, & Tung, 2007; Jansen et al., 2008). Patients with osteoporosis recall as little as 31% of treatment information (Pickney & Arnason, 2005), and among chronic pain patients, recall is as low as 30% (Lewkovich & Haneline, 2005). Recall is particularly poor for advice regarding health-related behavior change (Flocke & Stange, 2004; Kravitz et al.,1993). These findings are important because poor memory for the content of a doctor's visit has adverse effects on treatment adherence (e.g., Bober et al., 2007; Jansen et al., 2008), leading to the incorrect or incomplete carrying out of recommendations (Vermeire, Hearnshaw, Van Royen, & Denekens, 2001). Although the aforementioned studies have focused on memory for physician recommendations following clinic visits for non-mental health related issues, relatively little is known about the extent to which patients remember the contents of psychotherapy sessions. To the authors’ best knowledge, only one study has examined patient memory for therapy. Chambers (1991) reported that patients with insomnia forget one third of the instructions given during behavioral therapy for insomnia, and for some types of recommendations, recall is as low as 13%. As patient recall in the Chambers (1991) study was measured within the months following treatment, shorter-term memory for therapy has yet to be examined. As such, the first aim of the present study was to establish the extent to which patients recall the contents of therapy from one weekly session to the next. As already highlighted, there is evidence that poor memory for a doctor's visit can have adverse effects on treatment adherence (Bober et al., 2007; Jansen et al., 2008), but the relation between memory for therapy and treatment outcome is yet to be established. On the one hand, baseline memory impairment appears to be a predictor of poor cognitive-behavioral therapy outcome among cocaine-dependent patients (Aharanovic, Nunes, & Hasin, 2003) and individuals with posttraumatic stress disorder (Wild & Gur, 2008). On the other hand, Chambers (1991) found no significant association between recommendations recalled and treatment outcome among patients with insomnia receiving behavioral therapy. However, recall and outcome were measured between 2 to 18 months post treatment. The extent to which memory for therapy during treatment plays a role in treatment outcome remains a critical gap. As such, our second aim was to establish the relation between recall rates and treatment outcome, extending the earlier work pioneered by Chambers (1991). Specifically, we examined the association between patient recall (measured across eight weekly therapy sessions) and associated treatment outcome measured within a week following treatment. The present study examines patient memory for therapy using data from a recent trial of individuals with bipolar disorder and comorbid insomnia. Patients in the present study were randomly allocated to one of two non-pharmacological treatment groups: cognitive behavioral therapy for insomnia (CBTI-BP) or psychoeducation (PE). CBTI-BP is a bipolar-disorder-specific modification of cognitive behavioral therapy for insomnia that integrates elements from cognitive behavioral therapy for insomnia (Morin, Bootzin, Buysse, Edinger, Espie, & Lichstein, 2006), interpersonal and social rhythm therapy (Frank, 2005), and motivational interviewing (Miller & Rollnick, 2002). PE is a treatment in which patients receive general information about sleep and bipolar disorder but no plan for change is discussed. Patients receiving PE are first introduced to a model in which sleep, stress, diet, health, exercise, and mood are all inter-related and have reciprocal effects. They are then provided with information about the etiology, prodromes, and symptoms of bipolar disorder, as well as didactic information about stress management, relaxation, and breathing techniques. Throughout the PE protocol, patients are asked for a detailed description of their experience with each topic covered, but are not encouraged to implement or practice strategies for behavior change. Although memory for medical advice is poor across various patient populations receiving differing forms of treatment, to the best of our knowledge, no study has examined whether memory for therapy varies based on treatment type. As such, an additional objective of the present study was to examine whether patient recall varies based on treatment received (i.e., CBTI-BP vs. PE)—and possible links to differential outcome. To summarize, the present study examined memory for therapy and associated treatment outcome among a sample of individuals with bipolar disorder receiving one of two psychotherapies for insomnia. First, we established the extent to which patients recall the contents of therapy (Aim 1) and determined whether patient recall is associated with treatment outcome (Aim 2). We then examined whether patient recall differs based on the type of treatment received (Aim 3), and whether the relation between patient recall and corresponding treatment outcome varies based on treatment type (i.e., CBTI-BP versus PE; Aim 4). Given the evidence that patients remember about a third or less of physician recommendations following non-mental health related clinic visits, we expected that patients would remember less than a third of therapy contents. We also hypothesized that poorer recall would be associated with worse self-reported ratings of sleep and evaluations of treatment. Given the evidence that memory for medical advice is poor across various treatment types, we predicted that there would be no differences in patient recall rates or associations between patient recall and treatment outcome between the two treatment groups.