Prophylactic efficacy of psychoeducation for mood disorders: review of the evidence and future directions




Francesco CASAMASSIMA, MD
Giovanni Battista CASSANO,
MD, FRCPsych
Division of Psychiatry
University of Pisa
Pisa, ITALY

Prophylactic efficacy of psychoeducation for mood disorders: review of the evidence and future directions

by F. Casamassima and G. B. Cassano ,Italy



Psychoeducation is an easy-to-administer, time-friendly psychotherapeutic technique aiming at increasing knowledge of patients and caregivers about mental illness, improving disease course through early recognition and treatment of symptoms, and suggesting lifestyle adjustments, problem- solving, and stress-management methods to cope with recurrent psychopathologic disturbances. The ultimate goal of psychoeducation is mitigation of symptoms, preventions of relapses, and achievement of better clinical, functional, and vocational outcomes. In this review, we summarize evidence coming from randomized controlled trials supporting efficacy of psychoeducation in mood—mainly bipolar—disorders. Psychoeducated subjects show better compliancewith drug prescriptions, longer time to relapses, fewer recurrences, less time spent ill, and amelioration of functioning when starting from a euthymic state. However, a substantial percentage of subjects may be unwilling or unable to participate in therapeutic sessions, and prophylactic effects of psychoeducation may be more prominent for hypomanic or manic recurrences. Psychoeducation needs to be studied more deeply during acute or subacute mood phases, in standardized and comparable fashion and by independent research groups. Furthermore, given that depression contributes the most to long-term poor outcomes, a specific focus of research on recurrent unipolar and bipolar type II forms of mood disorders is needed. Passive, Web-based psychoeducational approaches have begun to be studied and offer a promising avenue for primary large-scale prevention of affective illnesses.

Medicographia. 2011;33:195-201 (see French abstract on page 201)



Depression is one of themajor causes of disease burden worldwide and a substantial source of long-term disability.1 Though great strides in the management of bipolar disorder and unipolar depression have been made since the last few decades, many subjects still fail to respond to treatments, relapse under maintenance therapy, and spend a large amount of their lifetime in a fully or partially symptomatic status, with depression being the major contributor to these discouraging outcomes.2-5 Furthermore, poor adherence to psychopharmacologic prescriptions is common among patients with bipolar disorder, with figures ranging from 12% to 64%.6 Therefore, there is a clear need for alternative approaches other than pharmacologic ones to treat mood disorders. Many psychotherapeutic techniques have proven helpful for depression and especially for bipolar disorder,7 but they are often not feasible for many individuals due to cost, duration, and the required level of education, self-awareness, and knowledge. Moreover, only in recent years have standardized psychotherapeutic procedures become available for research purposes, allowing clarification of their efficacy in different diagnostic categories, clinical settings, degrees of illness severities, and phases of illness course.

In 1991, Harvey and Peet pioneered a psychoeducational approach8,9 providing 30 patients attending a lithium clinic with educational videotapes and informative handouts. They demonstrated a significant amelioration in knowledge about and attitudes toward lithium in these subjects in comparison with a control group. Since then, an increasing volume of research has come out while therapeutic techniques as well as methods of investigating their effectiveness have been refined.

Psychoeducation is an easy to administer, time-friendly, and relatively inexpensive psychotherapeutic method, hence it offers the important advantage of possible large-scale application in clinical practice. Table I summarizes fundamental aims of psychoeducational programs supported by the scientific literature, including: (i) giving information to patients, families, and caregivers about mood disorders, so as to improve insight into the illness, reduce stigmatization, and build up a supportive environment; (ii) providing clarification about mechanism of action of medications, potential side effects, and therapeutic efficacy to favor adherence to prescribed treatment regimens10,11; (iii) emphasizing the importance of a healthy lifestyle (eg, diet, oversuse of caffeine, nicotine, abuse of street drugs, lifestyle regularity in sleep, work, leisure activities, etc) to stabilize the course of illness; (iv) teaching patients early recognition of prodromal and residual symptoms and small signs of mood instability to prevent relapses, ask for medical advice in a timely way, and allow preventive treatment modifications12; and (v) providing stress-management and problem- solving techniques to correct self-perpetuatingmisbehaviors and cognitive vicious circles.

Table I
Table I. Main domains of psychoeducation.

Stress-diathesis and biopsychosocial models are the theoretical framework underlying psychoeducation and assume that mood disorders arise from different pathogenetic contributions such as genetic susceptibility, dysfunctional family environments, stressful life events (especially early life traumas)13, problems in social interactions, inflexible cognitive styles, and somatic disorders.14,15

In the context of this review we will summarize findings from randomized controlled trials published about individual and group psychoeducation intervention in mood disorders, and discuss current evidence and give hints for future directions of research. Psychoeducation techniques are also implemented in more structured cognitive-behavioral, family or interpersonal psychotherapies. These are beyond the scope of the present work and we refer the interested reader to two recent and thorough reviews.16,17

Randomized controlled trials (RCTs)

Table II lists published RCTs on psychoeducation for mood disorders. To the best of our knowledge Perry et al12 published the first randomized trial addressing the question of whether teaching patients to recognize prodromes of relapse has prophylactic effects on illness course. In their 18-months followup involving 69 bipolar patients—asymptomatic, but with a history of a recent mood episode—the experimental group exhibited a longer time to manic relapses, and fewer of these, as well as better social functioning and employment measures. Yet, the intervention did not affect time to and number of depressive relapses. Possible interpretation of this finding has been provided elsewhere, with for example Lam and collaborators pointing out that patients may find more difficult to recognize and to cope with initial or subtle depressive symptoms.18 A well-designed Spanish study of psychoeducation19 found that psychoeducated patients were more compliant with drug prescriptions, as confirmed by higher lithium plasma levels after 2 years follow-up. The study recruited 120 bipolar I and II outpatients in remission for at least 6 months and randomized them to 21 sessions of group psychoeducation plus standard pharmacologic treatment or to treatment as usual plus unstructured “placebo” group meetings, with age and sex matching. The superiority of this design is mainly based on a fair control condition, but also on frequent monthly assessments during the 21-week intervention phase and during the 2-year follow-up. Besides the cited benefit in terms of compliance with treatment, psychoeducated subjects concluded assessments with a significant benefit with regard to number of relapses, time spent without depressive, manic, hypomanic and mixed symptomatology, and number and length of hospitalizations.

The same research group also sought to clarify the efficacy of psychoeducation beyond the improvement of compliance with prescribed medication.20 Hence, they focused on fully compliant bipolar I patients being euthymic for at least 6months and compared 25 patients receiving standard psychiatric care with 25 patients randomized to adjunctive psychoeducation. The intervention group fared better than the control sample both during the 20-week treatment phase (16% of individuals vs 56% fulfilled criteria for any polarity recurrence) and during the 2-year follow-up phase (60% vs 92%) with a significantly longer time to relapse and fewer hospitalization needed (0% vs 16% of subjects).

Table II
Table II. Randomized controlled trial of individual or group psychoeducation for affective disorders.

Abbreviations: AD, antidepressant; BD, Bipolar Disorder; CG, control group; EC, exclusion criteria; EG, experimental group; HAM-D, Hamilton Depression Rating
Scale; MS, mood stabilizer; N, number; PC, placebo-controlled; pts, patients SB, single blind; YMRS, Young Mania Rating Scale.

Colom et al21 subsequently analyzed a subset of the described sample to study the efficacy of psychoeducation in patients suffering from bipolar disorder comorbid with personality disorders. The psychoeducation group consisted of 15 subjects, the majority of whom were diagnosed with a cluster B personality disorder (PD) (ie, 29.7% Borderline PD and 22.7% Histrionic PD) and was compared with 22 control individuals.

A larger percentage of control subjects relapsed during the treatment phase (77% vs 46.7%) and this finding was confirmed at the end of the 2-year follow-up period (100% of controls relapsed vs 66.7% of cases). Survival analyses also showed a longer time-to-relapse for patients receiving psychoeducation. Finally, the latter had a lower number of total, manic, and depressive relapses even if no differences were detected as regards the number of patients hospitalized during follow-up. Although this study shows a significant advantage of psychoeducation plus treatment-as-usual over pharmacologic treatment alone, results were quite discouraging given that all controls and a high percentage of cases relapsed. Yet, authors notice that this was a sample characterized by great overall illness severity, and intervention was not focused on Axis I-Axis II comorbidity. Adjunctive modules of psychoeducation addressing personality disorder issues might further improve outcomes. Recently, Colom and collaborators22 provided data from the same sample as described above, but with a longer 5-year follow-up, and confirmed previous results. In fact, patients receiving pscyhoeducation exhibited longer time to any recurrence, fewer recurrences, less time spent ill, lower median number of days of hospitalization, and effect sizes did not decrease in comparison with the 2- year assessments.

A further analysis of collected data23 provided preliminary evidence that psychoeducation may be useful in subjects diagnosed with bipolar disorder type II. Actually, prior work on mixed bipolar samples did not provide distinct analyses of bipolar type II subgroups. The psychoeducated group (N=7), compared with the control sample (N=10), showed significantly better outcomes in terms of number of any type of recurrences, time spent in mood episodes, and achieved level of global functioning. No differences were found in the number of patients needing hospitalization during follow-up. As usual in bipolar II disorder, at baseline assessment patients presented high rates (40%-50%) of comorbid psychiatric disorders.

However, a study with negative results has been recently published.24 In this trial, 80 and 84 bipolar I and II patients, respectively, were randomized to a standardized adjunctive psychoeducation program or to treatment as usual. Intervention consisted of 6-weekly interactive group sessions plus optional monthly sessions during a 12-month follow-up phase. Overall, at the beginning of the study, subjects were moderately depressed (mean Hamilton Rating Scale for Depression [HAM-D] score = 18.6±11.3), whereas mean score on the Young Mania Rating Scale (YMRS) was 7.4±5.4, but 32% of patients met criteria for current manic or hypomanic episode. Moreover, a high rate of current or lifetime substance abuse comorbidity was recorded (ie, 87%). The two randomized samples were similar at all follow-up assessments on the majority of outcomes considered: compliance with treatment, psychopathologic measures, and functional status. In contrast, it should be noted that only 49%of patients randomized to psychoeducation participated in 4 to 6 phase I group sessions and fewer than 10%continued attendingmonthly optional sessions. Secondary analyses restricted to the subgroup effectively receiving the psychotherapeutic intervention demonstrated a significant improvement in attitudes toward medication. This is a partially satisfactory finding, because it highlights the intuitive conviction that compliance with psychotherapy is related to compliance with pharmacologic treatments.

Further to the aforementioned studies of simple psychoeducation that indicate it is a useful treatment in conjunction with pharmacotherapy, other research teams have focused their attention on systematic disease management programs, involving more than a single intervention. These programs have also proved effective in the context of primary care.25 Below, we summarize results from two of the most interesting trials of multicomponent interventions conducted in bipolar disorder.

Simon et al26 randomly assigned 441 bipolar I and II patients, in all possible phases of the disease course (ie, remission, threshold, or subthreshold symptomatology), to usual care or to a systematic care program provided by nurse care managers and involving: (i) a collaborative treatment plan (ie, follow- up visits, warning signs of disease worsening or relapse, management of medication side effects, and other coping strategies, identification of a principal care-giver at home); (ii) monthly telephone calls to administer rating scales, checkup on compliance with treatments and tolerability issues; (iii) feedback to treating clinicians and psychotherapists; (iv) 5- weekly psychoeducation group sessions followed by biweekly meetings up to a total of 48 sessions; and (v) crisis management, as-needed support, and coordination with family members. The majority of enrolled subjects (59%) completed at least the first-phase weekly group sessions and 84.9% of individuals agreed to receive at least 12 phone calls. A significant positive effect of the intervention was detected throughout the 24-month follow-up regarding mean mania severity ratings. No differences in depression scores emerged be tween randomized samples, with even a worsening of depressive symptoms during the initial 6 months. The major shortcoming of the trial is the lack of a true placebo condition, making difficult to interpret the specificity of the findings. Furthermore, a mixed sample of remitted, syndromic, and symptomatic states provides poor guidance for an effective implementation of psychoeducation. For example, teaching patients early symptom recognition may be helpful in preventing hypomania or mania, but, and this is probably the case, may render depressed subjects more worried of their clinical condition and discouraged by their inability for selfmanagement. Therefore, prophylaxis of depression should be initiated during euthymic intervals or before disease onset in at-risk populations.

Table III
Table III. Heterogeneity of trials of psychoeducation for mood disorders: variables involved.

In a 3-year multisite single-blind trial, Bauer et al27 randomized 330 subjects to usual care or to a complex intervention including group psychoeducation and reorganization of services to improve access to, continuity of, and monitoring of care. This effectiveness study enrolled, during acute hospitalization, severely ill bipolar I and II patients with few exclusion criteria to best reflect real-word mental health services. In fact, descriptive data at start of study show high rates of anxiety and substance use comorbidity, history of suicide attempts, psychosis, hospitalization, and functional impairment (eg, 54% of subjects were classified as unemployable, 28% were given a disability pension, and 13% were homeless). At 3-year follow-up, the most notable result was a significant reduction in percentage of weeks spent in any episode (ie, –6.2 weeks), as assessed with the Longitudinal Interval Follow- Up Examination (LIFE), mainly attributable to a decrease in weeks spent manic or hypomanic. With regard to functional outcomes, the overall finding was positive and specific improvements were reported in work and parental and extended family measures of functioning. Of note, the intervention was shown to be cost-neutral.

Discussion

Randomized controlled trials are an irreplaceable means of determining the efficacy of an intervention under ideal conditions and there is a clear need for more and well-powered studies of psychoeducation in mood disorders. Yet we still lack an unequivocal literature on psychotherapeutic strategies, if only because they are not easily studied in randomized controlled designs. For example, it is difficult to distinguish between specific therapeutic effects attributable to psychoeducation and nonspecific improvements of subjects receiving closer observation, assistance, and support. Therefore, control groups randomized to treatment-as-usual, waiting list, or even to short-term crisis management programs would bias results in favor of any more structured intervention. Psychoeducation should be contrasted with a “psycho-placebo” similar at least in terms of time involved, setting of administration, and schedule of sessions.28 Other factors contribute to a substantial heterogeneity in psychoeducation trials design such as diagnosis (eg, bipolar disorder type I, type II, recurrent depression, comorbidity, etc), type of intervention (eg, individual, group, family, psychoeducation alone, or complex chronic care, etc), time of delivering (eg, acute manic or depressive phase, residual symptoms, maintenance phase), stage of the disorder (eg, first episode, early recurrences, chronic stage, rehabilitation) and so on. Table III summarizes variables that should be taken into consideration when planning a trial, but also when interpreting findings from published trials. Psychoeducation seems to be more effective when administered in the context of a euthymic state. Negative results were reported by Sajatovic et al24 who randomized patients experiencing acute or subacute episodes. Subjects suffering from prominent symptoms may not profit from psychoeducational aids due to cognitive symptoms, psychomotor disturbances, and/ or distorted insight into illness.

Future studies should address more specific questions to distinguish the effectiveness of psychotherapeutic intervention during/after moderate-to-severe depression, mania, hypomania, or subsyndromal states with residual or prodromal symptoms. Moreover, the content of adjunctive modules need to be flexible and appropriate for mood disorders with or without anxiety, substance abuse, eating disorders, and Axis II and medical comorbidities. For example, in a small 2009 randomized trial (N=50), Pibernik-Okanovic and coauthors29 reported that psychoeducation benefited subjects with mildto- moderate depression and suffering from diabetes. At 6-month and 1-year assessments, patients improved both in terms of psychopathologic measures and indicators of glycemic control, but no significant differences were detected in comparison with a control group merely receiving support and explanations about laboratory monitoring.

Some authors have already suggested that severity and duration of illness, number of episodes, and even sex of participants— with females being more willing to participate—are important variables to take in account when designing a psychotherapy trial.23-24,30-31 In order to ensure an adequate cooperation of subjects, practical issues such as scheduling of sessions and frequency, individual vs group formats, intervention limited to patients or extended to family members should be considered as well. In this connection, so far only two studies with negative32 and positive33 findings, respectively, have been published, which raise the interesting idea of educating the partners of bipolar manic patients.

Bipolar II patients are particularly prone to depressive relapses and spend much of their lifetime in a full-blown or partial depressive state.3 Despite a limited sample size, findings published by Colom et al23 are very promising and warrant larger studies to explore the usefulness of psychoeducation sessions in bipolar II disorder and recurrent unipolar depression. Finally, a particular field of application of psychoeducation techniques is early diagnosis of bipolar disorder, given that depression is the most frequent first presentation of mood disorders. For example, patients could be taught to recognize the early signs of hypomanic/manic activation, particularly if external indicators of bipolarity are present (eg, early onset, family history of bipolar disorder).34

Prevention of mood disorder onset

Innovative interactive Web-based sessions have been proposed.35 If they prove helpful, a larger number of patients could be treated in a cost-effective fashion. Indeed, Donker et al36 have recently carried out a meta-analysis of 5 studies implementing passive psychoeducation approaches (ie, education Web site, weekly telephone calls, personalized mailed feedback or leaflets) for potentially wide populations (ie, community residents, college students, primary care attendees, factory workers). Their findings confirm that psychoeducation has a therapeutic role even as a standalone intervention for subthreshold- to-moderate affective symptoms. Furthermore, its techniques may help prevent severe mood episodes, reduce perceived social stigma, encourage individuals to seek help, integrate different therapies, and teach family members, caregivers, and friends to build up a positive environment around people suffering from psychiatric diseases.

We believe that psychoeducation holds particular promise for the early stages of mood disorders. Given that social, family, environment problems, as well as negative events, contribute in a significant way to the pathogenesis of psychiatric diseases, psychoeducation is probably the only intervention with a potential primary and tertiary prophylactic effect regarding risk of relapse and improvement in functioning, respectively. In 2008, Mackinnon et al37 reported findings from a large trial (N=525) showing that at the 12-month assessment, both an Internet-based cognitive behavioral therapy and a depression information Web site were superior to a control condition in relieving depression, as measured by the Center for Epidemiologic Studies–Depression Scale. Through the Web site, participants from the community with high depression scores as main inclusion criterion were provided evidencebased information about symptoms, diagnosis, pharmacologic, psychological, alternative, and lifestyle interventions, as well as contacts to seek mental health aids. The possibility of delivering psychoeducation on the Internet has growing appeal, as it allows mental health providers to exert a positive influence on subjects suffering from initial symptoms of depression and living in environments at risk for depression.

Conclusions

Psychoeducation is a patient-centered approach. It offers a significant opportunity to improve mood disorder care and tailor therapies to individual needs. It has shown efficacy in preventing relapses, particularly manic relapses, improving compliance with treatment, and reducing social stigma. Psychoeducated patients develop constructive conflict resolution strategies, learn to assert their needs, and to modulate their affective states, by recognizing worrisome clues of disease reexacerbation and dysfunctional attitudes. More trials from independent research groups and with well-defined designs are warranted. Preliminary evidence is available that psychoeducation may be useful in the early stages of mood disorders. Unfortunately, studies targeting at-risk populations are still scant. _

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Keywords: mood disorder; unipolar depression; bipolar disorder; psychoeducation; primary prevention; lifestyle; relapse; recurrence; compliance