Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment

British Medical Journal, Jan 16, 1999 by Alison Perry, Nicholas Tarrier, Richard Morriss, Eilis McCarthy, Kate Limb

(*) One patient died of ischaemic heart disease in first six months.

([dagger]) [chi square] test.

([double dagger]) Mann-Whitney U test.

([sections]) Community psychiatric nurses, mental health social workers, occupational therapists.

([paragraph]) mg equivalents of imipramine per day.

(**) mg equivalents of chlorpromazine per day.

Table 2 also shows that there were few differences in other outcome measures between the experimental and control groups over the 18 months. The experimental group received significantly higher dosages of antidepressants than the control group. There was negligible use of benzodiazepines, valproate, anticholinergic drugs, electroconvulsive therapy, and day hospitals in both groups. Compliance with taking mood stabilising drugs as measured by the latest recorded blood concentration did not significantly differ between the two groups (data not shown).

Table 3 shows that there were significant improvements in overall social functioning and employment[20] in the experimental group compared with the control group 18 months after the baseline assessment.

Table 3 Intention to treat analysis
of social functioning and employment

                       Experimental group   Control group
Mean (SD) score              (n=34)            (n=35)

Social function(*)
Total at baseline          3.74 (2.62)       3.14 (3.03)
Change at:
  6 months                -0.23 (2.60)      -0.20 (2.43)
 12 months                -0.47 (2.67)       0.77 (2.90)
 18 months                -1.03 (2.55)       0.94 (2.68)
Employment([dagger])
Total at baseline          1.68 (1.45)       1.51 (1.46)
Change at:
  6 months                 0.24 (1.16)       0.09 (1.22)
 12 months                -0.44 (1.08)       0.17 (1.65)
 18 months                -0.59 (1.13)       0.11 (1.47)

                          Mean difference
Mean (SD) score              (95% CI)

Social function(*)
Total at baseline               --
Change at:
  6 months             0.44 (-0.78 to 1.65)
 12 months             1.24 (-0.10 to 2.58)
 18 months             1.97 (0.71 to 3.23)
Employment([dagger])
Total at baseline               --
Change at:
  6 months             0.32 (-0.25 to 0.89)
 12 months             0.61 (-0.06 to 1.29)
 18 months             0.70 (0.07 to 1.33)

(*) Maximum range 1-24.

([dagger]) Maximum range 0-3.

Discussion

The experimental treatment was effective in reducing manic but not depressive relapses because manic prodromes are more distinct[11] and longer than depressive prodromes[8 9] and acute mania can be treated more quickly and effectively than acute depression.[22] An increased awareness of depressive symptoms without the skills to cope with them may be wasteful since the experimental group received significantly higher doses of antidepressants. The intervention probably improved social function by increasing confidence in coping with relapse, which confirms the results from cross sectional studies.[10] Cumulative improvements in social function imply a specific treatment effect rather than the non-specific effects of support from an empathic therapist.