Expand the applicability and acceptability of CBT approaches in mood disorders

Thase et al (1) succinctly describe the benefits of cognitive behavior therapy (CBT) in both unipolar and bipolar mood disorder. Concerning the former, it should be noticed that the STAR*D study had an enriched design, open only to patients still depressed after three-month treatment with citalopram (2). Less than a third of the eligible patients agreed to participate. Those who received CBT as an adjunct to citalopram had outcomes similar to those receiving pharmacotherapy alone. A second study showed clear advantages for the CBT group, but the benefitting group constituted less than half of the sample (3). The complexity of the design of the third study reviewed (4) contributes to the ambiguous state of the evidence. The bipolar depressed patient studies are of particular interest, since some clinically significant risk of illness course worsening is associated with treatment employing the most commonly prescribed antidepressants, selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (5). Some indications of benefit were seen with each of the six CBT studies summarized by Thase et al. The large study in STEP-BD showed benefits sustained for a one-year follow-up period (6). Importantly, outcomes were similar for CBT and two quite different other forms of psychotherapy: family focused therapy with first-degree relatives participating, and interpersonal-social rhythms therapy. Three studies reviewed yielded generally negative results, but one (7) indicated significant adjunctive benefit among patients with fewer lifetime bipolar episodes, whereas patients with more episodes actually underperformed bipolar medications alone. Thase comments on the importance of determining which patients should not receive CBT. There may also be merit in addressing ways that CBT can be adapted to the complex psychopathology of bipolar disorders. Most bipolar patients will have sleep disorders and anxiety disorders (or, equally relevant as a focus of treatment, anxiety symptomatology) that are not benefitted by primary bipolar drugs. Medications commonly used for anxiety and sleep disturbances, i.e., benzodiazepines and drugs such as zolpidem, often impair memory and judgment. Anxiety is the most consistent predictor of poor treatment response in bipolar studies and is highly associated with suicidality, poor function and greater health services utilization (8). No drug is approved for treatment of anxiety in bipolar disorder. CBT for bipolar disorder could include a focus on such domains as anxiety and sleep/circadian disturbances, and outcome measures to assess changes in such domains. Some variants of CBT are presented as adjunctive group psychotherapy (9). These have been reported as superior to unstructured support groups in reducing relapse into syndromal bipolar states. Some evidence indicates that benefits may be greater for manic relapses. Whereas most studies have been technique driven, there are several features that are common. These include attention to medication compliance, identifying early signs of episodes, improving coping skills, involvement of significant others, and provision of information about the features, course and treatment of bipolar disorder. An underlying assumption of these approaches is that identifying situations that could precipitate relapse coupled with teaching about cognitive and behavioral skills to reduce such risks could benefit long-term wellness. However, these approaches tend to place little emphasis on individual needs, values and issues contributing to poor function. Mindfulness training has in recent years increasingly complemented relapse prevention techniques to better deal with a variety of medical disorders, including depression. Mindfulness aids patients staying in contact with diverse emotional states, both desirable and undesirable, recognizing reasons for associated maladaptive behaviors. A usual component of mindfulness is developing skills in stress recognition and stress reduction. Both emotional and cognitive experiences are utilized to deal more effectively with individual specific issues in achieving and maintaining a state of wellness. Mindfulness as a component of CBT could strengthen self-instituted steps to monitor emotional and thought characteristics, thereby contributing to reduce or limit problematic behaviors or emotional states (10).