Received: 12 February 2017
Revised: 8 June 2017
Accepted: 16 July 2017
DOI: 10.1002/cpp.2124
RESEARCH ARTICLE
Improving functional outcome in bipolar disorder: A pilot study
on metacognitive training
Paula Haffner1
|
Esther Quinlivan1
Elisa Sophie Strasser1
|
|
Jana Fiebig1
|
Steffen Moritz3
Mazda Adli1,2
|
Lene‐Marie Sondergeld1
|
|
Thomas Josef Stamm1,4
1
Department of Psychiatry and
Psychotherapy, Charité Universitätsmedizin
Berlin, Berlin, Germany
2
Fliedner Klinik, Berlin, Germany
3
Department for Psychiatry and
Psychotherapy, University Medical Center
Hamburg‐Eppendorf, Hamburg, Germany
4
Department of Psychiatry and
Psychotherapy, Brandenburg Medical School
Theodor Fontane, Neuruppin, Germany
Correspondence
Paula Haffner, Department of Psychiatry and
Psychotherapy, Charité Universitätsmedizin
Berlin, Chariteplatz 1, Berlin 10117, Germany.
Email: paula.haffner@charite.de
Background:
Effective group psychological interventions in bipolar disorder are rare. In this
study, we present “metacognitive training (MCT) for bipolar disorder”—an adaption of a group
intervention that has proven effective in other severe psychiatric disorders. MCT is a structured,
interactive approach that addresses cognitive biases, social cognition, and self‐esteem. In this
pilot study, we investigated psychosocial functioning as primary outcome measure, as well as
the feasibility of MCT and its acceptance among bipolar patients.
Methods:
Thirty‐four outpatients with bipolar disorder were recruited. Inclusion criteria were
euthymia and psychosocial functioning with a score >11 assessed by the Functional Assessment
Short Test. The subjects received eight weekly MCT sessions. Before and after the intervention,
psychosocial functioning, quality of life (QoL), and patient views were assessed.
Results:
Patients improved significantly in global psychosocial functioning, with a large effect
size from baseline to post‐treatment. Over the intervention period, patient QoL improved significantly in terms of their physical health, however not for other QoL subdomains. Treatment
adherence was 80%, and patients' appraisal of the training was positive.
Limitations:
As this study lacks a control group, it is not possible to ascertain whether the
positive treatment effects are attributable to MCT. Additionally, it is unclear whether gains in
psychosocial functioning would have been maintained long term.
Conclusions:
This pilot trial conclusively shows that MCT is feasible and provides preliminary
evidence for both the acceptance and efficacy of MCT. Further studies with larger samples and
control condition will be necessary to build on these findings.
KEY W ORDS
bipolar disorder, psychotherapy, metacognitive training, psychological intervention, psychosocial
functioning, quality of life
1
|
I N T RO D U CT I O N
psychosocial functioning, and reducing symptoms with small to
medium effect sizes (Miklowitz, 2008; Oud et al., 2016). Although
Bipolar disorder is related to impairment in social and occupational
individual psychotherapy has been studied more thoroughly to date,
functioning throughout all phases of the illness (Judd et al., 2008). An
group interventions also show promise and have been found effective
optimal pharmacotherapy alone does not fully prevent relapses, and
(Oud et al., 2016). Group psychoeducation has shown long‐lasting
even when euthymic, bipolar patients frequently show impaired
prophylactic effects in a 5‐year follow‐up (Colom et al., 2009). For
psychosocial functioning (Rosa et al., 2008; Vieta et al., 2013). Conse-
other group interventions such as functional remediation therapy
quently, there is a need to develop and implement effective psycholog-
(Bonnin et al., 2016), cognitive behavioral group therapy (Gomes
ical treatments for bipolar disorder that can complement the patient's
et al., 2011; Gonzalez Isasi, Echeburua, Liminana, & Gonzalez‐Pinto,
pharmacotherapy and lead to greater functioning overall.
2014), and mindfulness‐based cognitive therapy (Murray et al.,
Adjunctive psychological or psychotherapeutic interventions in
2015; Perich, Manicavasagar, Mitchell, & Ball, 2013; Williams et al.,
bipolar disorder have proven effective in preventing relapse, improving
2008), the initial findings are positive, although to date, studies have
50
Copyright © 2017 John Wiley & Sons, Ltd.
wileyonlinelibrary.com/journal/cpp
Clin Psychol Psychother. 2018;25:50–58.
HAFFNER
51
ET AL.
been few and mostly involved small sample sizes. The lack of
manualized and easily implemented group interventions other than
KEY PRACTITIONERS MESSAGES
psychoeducation available in German led us to the development of
• This is the first study to apply metacognitive training for
metacognitive training (MCT) for bipolar disorder—a psychological
bipolar disorder.
approach that has shown effectiveness in schizophrenia (Eichner &
• Psychosocial functioning improved significantly with a
Berna, 2016).
large effect size, and treatment adherence was high
1.1
|
(80%).
Metacognitive training for bipolar disorder
• Metacognitive training is a feasible psychological group
Metacognitive training for bipolar disorder (MCT Bipolar) is a novel,
intervention with easy application and represents a
disorder‐specific psychological group training that integrates elements
promising group approach for bipolar patients.
of psychoeducation, cognitive psychotherapy, and mindfulness. The
concept of MCT was first developed by Moritz and Woodward
(2007b) for patients with schizophrenia and is intended to improve
patients' metacognitive abilities (thinking about one's thinking). The
training focuses on typical cognitive patterns and strategies, in partic-
2
METHODS
|
ular cognitive biases, social cognition, and regulation of self‐esteem.
To optimize the appeal and practice of MCT, sessions are highly structured and presented in an enjoyable, playful way (Moritz, Veckenstedt,
2.1
|
Sample
Bohn, Köther, & Woodward, 2013). MCT for schizophrenia is now
Subjects were recruited at the outpatient clinic of the Department of
widely used and was recently investigated in a meta‐analysis that
Psychiatry and Psychotherapy, Campus Charité Mitte in Berlin. The
showed both patient acceptance of the program and its effectiveness
main inclusion criteria were a diagnosis of bipolar disorder type I or II
in reduction of symptoms and cognitive biases (Eichner & Berna,
according to Diagnostic and Statistical Manual of Mental Disorders
2016). MCT has also been developed for other psychiatric disorders,
Fourth Edition (APA, 1994), current euthymia, and impaired psychoso-
such as depression and obsessive–compulsive disorder, and again
cial functioning. Euthymia was defined as a score ≤9 on the 21‐item
shown positive results (Jelinek, Otte, Arlt, & Hauschildt, 2013; Moritz,
Hamilton Depression Rating Scale (Hamilton, 1960) and ≤12 on the
Jelinek, Hauschildt, & Naber, 2010).
Young Mania Rating Scale (YMRS; Young, Biggs, Ziegler, & Meyer,
The concept and contents of MCT Bipolar are based on MCT for
1978) for at least 6 weeks, prospectively assessed after screening.
psychosis (Moritz & Woodward, 2007b) and MCT for depression
Additionally, patients had to be consistently medicated with a mood
(Jelinek et al., 2013), but have been adapted to the specifics of bipolar
stabilizer for at least 6 weeks before and during the intervention. No
disorder. MCT Bipolar targets cognitive vulnerabilities that are
changes of medication were allowed during the intervention. Low
characteristic for many bipolar patients according to current scientific
psychosocial functioning was determined as a score >11 on the
evidence (Fuhr, Hautzinger, & Meyer, 2014; Table 1). Several studies
Functioning Assessment Short Test (FAST; Rosa et al., 2007). This
confirmed specific cognitive biases in bipolar patient samples (e.g.,
cut‐off has been used in studies with euthymic bipolar patients
Alloy et al., 2009; Jabben et al., 2012; Meyer, Barton, Baur, & Jordan,
previously (Lahera et al., 2012; Rosa et al., 2008). Exclusion criteria
2010). Current research revealed an association of risk for mania and
were a diagnosis of schizoaffective disorder, schizophrenia, antisocial
depression and overgeneralization (Eisner, Johnson, & Carver, 2008).
personality disorder, dementia, mild cognitive impairment, or mild
Patients with current depressive or manic symptomatology showed a
intellectual disability according to 10th revision of the International
mood‐congruent attentional bias (Garcia‐Blanco, Perea, & Livianos,
Statistical Classification of Diseases and Related Health Problems
2013; Jabben et al., 2012). Johnson, Meyer, Winett, and Small (2000)
(WHO, 1992). Furthermore, patients were excluded if they had experi-
as well as Pavlickova et al. (2013) highlighted the role of self‐esteem
enced substance abuse, electroconvulsive therapy, or psychotherapy
for the development of manic and depressive symptoms. Additionally,
within the last 6 months.
significant impairments in theory of mind and social cognition could
Seventy‐two subjects were screened, and 34 subjects participated
be observed in bipolar patients even when euthymic (Bora,
in the study (see Figure1 for a study flow diagram). Of these, four
Bartholomeusz, & Pantelis, 2016; Lahera et al., 2012). Consequently,
patients were excluded from the analyses post hoc having emerged
all of these characteristics of bipolar patients were considered in the
to meet exclusion criteria (viz., current alcohol abuse, mild intellectual
MCT Bipolar (see Table 1). Additionally, MCT Bipolar includes a
disability, or not fulfilling criteria of euthymia).
Table 2 shows the sociodemographic and clinical characteristics of
stronger emphasis on mindfulness due to the encouraging results of
mindfulness‐based cognitive therapy in bipolar patients (Deckersbach
the study sample at baseline.
et al., 2012; Weber et al., 2017).
The present pilot study is the first to use MCT Bipolar and aimed
at investigating its feasibility, acceptance, and potential efficacy in a
2.2
|
Metacognitive training
sample of euthymic patients with impairment in psychosocial
MCT Bipolar is a psychological intervention for a group of 3–10
functioning. We hypothesized that MCT would improve psychosocial
participants and conducted by a psychologist, psychiatrist, or trained
functioning, and as a secondary outcome, quality of life (QOL).
psychiatric nurse. The eight sessions each last 60–90 min and are
52
HAFFNER
TABLE 1
ET AL.
Summary of the metacognitive training modules
Module
Target domain
Description of contents
Relevant evidence
(1) Introduction into
mindfulness;
brooding and
thought racing
Rumination versus
racing thoughts in
depression and
(hypo‐) mania
Patients are familiarized with the concept of mindfulness and a first
exercise is performed. Next, brooding and thought racing are
defined. Advantages and disadvantages are explicated. As an
exercise, the participants are then asked to explicitly “brood” or let
their thoughts race loudly. In the next exercise, how difficult it is to
suppress thoughts is illustrated, and strategies to deal with brooding
and thought racing are introduced.
Alloy et al. (2009)
and Ghaznavi and
Deckersbach
(2012)
(2) Attributional style
Attributional biases:
monocausal
attribution, self‐
blaming, and self‐
serving bias
A general definition of cognitive biases is given. Participants are asked
for different attributions (oneself, others, and situation/coincidence)
of everyday situations. Balanced attributions that take several
different causes into account are then worked out. Consequences of
monocausal attributions and their link to mood states are discussed.
In the following exercises, possible depressive, manic, and neutral
attributions for different situations are gathered.
Lex, Hautzinger, and
Meyer (2011),
Meyer et al.
(2010), and
Pavlickova et al.
(2013)
(3) Thinking and
reasoning I
Filtering and
overgeneralization
The effect of cognitive biases on mood and their emergence as possible
warning signs for upcoming episodes is highlighted. For cognitive
filtering, consequences and alternative thoughts are discussed with
multiple examples. Overgeneralization is then addressed similarly. At
the end of the session, strategies to correct cognitive biases are
proposed (e.g., examining alternative explanations by getting
feedback from third parties, or asking oneself what would they tell a
friend in that situation).
Eisner et al. (2008)
and Johnson and
Jones (2009)
(4) Thinking and
reasoning II
Perfectionism and
disqualifying the
positive/the negative
In the first section, self‐demanding statements are presented, and the
participants are encouraged to practice verbalizing self‐tolerant
statements. In the following exercise, patients identify their
respective “inner drivers.” Following this, the characteristics,
advantages, and consequences of perfectionism are discussed. The
particular importance for bipolar patients to balance demands
towards oneself is highlighted. In the second section, disqualifying
the positive, or respectively, the negative, is addressed with multiple
examples. At the end, strategies to achieve a balanced estimation of
oneself are conveyed.
Garcia‐Blanco et al.
(2013), Jabben
et al. (2012), and
Reilly‐Harrington,
Alloy, Fresco, and
Whitehouse
(1999)
(5) To empathize I
Theory of mind: first
order
Different categories contributing to the ability to infer mental states
are presented. First, emotional theory of mind is explained, and the
limitations of emotion recognition are highlighted. In the second
section, cognitive theory of mind is practiced using incomplete
cartoon stories. Probable motifs of the cartoon characters are
discussed, and subsequently, more information is added to the story.
From this, the participants experience how knowledge about
situations and people can increase the validity of our evaluations.
Bora et al. (2016)
and Lahera et al.
(2012)
(6) To empathize II
Theory of mind: second
order
The influence of current mood on one's ability to analyze social
situations is explained. Using cartoon stories, patients are trained to
infer mental states in complex social situations. Equally, care is taken
to discuss the limitations of people's ability to infer mental states and
how this can potentially result in misunderstandings or negative
social interactions, particularly when we have limited knowledge of a
situation.
See Module 5
(7) Changing beliefs
Confirmation bias
Causes, advantages, and consequences of the confirmation bias are
discussed. The tendency to select information according to one's
mood, both during mania and during depression, is illustrated with
examples. Patients are trained to re‐evaluate decisions and integrate
new information into their thoughts using cartoon pictures that are
sequenced in reverse order.
In line with findings
for schizophrenia
(Speechley,
Whitman, &
Woodward,
2010) and clinical
observation in
bipolar disorder
(8) Self‐esteem
Balanced self‐esteem
How it may be particularly challenging for patients with bipolar
disorder to regulate and appropriately balance their self‐esteem is
explained. Different sources of self‐esteem (e.g., hobbies, traits,
talents, friends, and leisure time) are presented, and the participants
are asked to identify their own personal strengths across various
areas of their life.
Johnson et al. (2000),
Pavlickova et al.
(2013), and Van
der Gucht,
Morriss, Lancaster,
Kinderman, and
Bentall (2009)
structured by slides that makes the training easy to deliver. The
this, the group orientates to the session's topic. This includes topics
atmosphere of the sessions should be enjoyable and interactive.
such as cognitive biases and thinking patterns, social cognition, and
At the beginning of each session, a mindfulness exercise lasting
self‐esteem. Patients are coached on how to become aware of their
from 10 to 20 min is performed to orientate and ground participants
cognitive patterns, illustrated by examples from daily life and cartoons
(e.g., mindful breathing, mindful listening, and body scan). Following
(see Table 1 for a summary of the different modules). All of the topics
HAFFNER
53
ET AL.
FIGURE 1 Study flow chart.
FAST = Functioning Assessment Short Test
TABLE 2
Demographics and clinical characteristics (n = 30).
Variable
M (SD)
Diagnosis (bipolar I in %)
50.0
Sex (% female)
46.7
Age (years)
48.1 (13.5)
Depressive symptoms (HAMD‐21)
5.6 (2.8)
Manic symptoms (YMRS)
1.4 (2.2)
Duration of illness
22.4 (11.1)
Number of episodes
22.1 (12.6)
Number of hospitalizations
2.9 (2.8)
Rapid cycling lifetime (%)
10.0
Number of different psychotropic substance groups
1.9 (0.8)
Treatment with lithium (%)
43.3
Treatment with antipsychotics (%)
40.0
Treatment with anticonvulsants (%)
63.3
Treatment with antidepressants (%)
43.3
Completed psychotherapy in the past (%)
70
Years of education
15.4 (2.6)
Premorbid intellectual ability (MWT‐B)
30.3 (3.5)
Fluid reasoning (LPS3)
27.1 (6.2)
Note. HAMD‐21 = 21‐item Hamilton Depression Rating Scale; LPS3 = subtest of a German intellectual functioning test battery; MWT‐B = multiple‐
choice vocabulary test; YMRS = Young Mania Rating Scale.
are discussed and considered from the perspective of both manic and
depressive mood. A hallmark of the treatment is that knowledge of
the topics and their relevance in bipolar disorder are presented to
participants in an understandable way.
To avoid stigmatization, the relevance of cognitive distortions in
everyday life for people with and without a mental illness is emphasized. Further, how cognitive distortions may differ among participants
is stressed. Changes in the individual's way of thinking are highlighted
as possible warning signs for upcoming episodes. Finally, more
appropriate cognitive patterns and strategies are developed and
trained exhaustively using multiple, diverse examples. At the end of
the sessions, worksheets and mindfulness exercises are distributed
to the participants to bring home, to enhance, and to consolidate
their learning.
The manual of the MCT Bipolar has been published recently
(Sondergeld et al., 2016). The contents of MCT Bipolar will be achievable free of charge online: www.uke.de/mct.
2.3
|
Measures
Psychosocial functioning was measured using the FAST, an interviewer‐administered instrument specifically developed for bipolar
disorder and used to assess impairment of psychosocial functioning.
54
HAFFNER
On the FAST, a summary score is computed, along with six different
subdomains: independency, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time.
High scores imply more difficulties and lower psychosocial functioning
(Rosa et al., 2007). Assessment of FAST was performed by a trained
psychiatrist with >5 years of experience with FAST who was not
involved in the MCT as therapist.
As a subjective measure of global well‐being QoL was assessed
with the brief version of the World Health Organization Quality of Life
questionnaire (WHOQOL‐BREF; WHO, 1998) that has been applied in
previous studies with bipolar patients (Demant, Vinberg, Kessing, &
Miskowiak, 2015; Smith et al., 2011). The WHOQOL‐BREF is a self‐
rating that comprises four domains: Physical health, psychological
2.5
|
ET AL.
Data analysis
Changes from pre‐ to post‐intervention were examined with paired sample t tests, or using the Wilcoxon signed rank tests in cases where the
assumptions for parametric tests were violated. Cohen's d and r
for nonparametric measures according to Rosenthal (1994) were
calculated and used as effect sizes. To examine differences between
completers and non‐completers, the Mann–Whitney U test and Fisher's
exact test were performed. Completion was defined as attendance to
the final measurement appointment post‐intervention and to at least five
of the eight sessions. Spearman's rho was used to examine correlations
between the treatment outcome and other variables. All analyses were
conducted using IBM SPSS version 22.
health, social relationships, and environment. Two further items
concerning overall QoL and physical health constitute the facet
global QoL.
3
RESULTS
|
To assess the patients' perception and views of the training,
inspired by a scale previously used in studies on MCT for schizophrenia
3.1
(Aghotor, Pfueller, Moritz, Weisbrod, & Roesch‐Ely, 2010; Moritz &
Overall, the sample showed high treatment adherence with an average
Woodward, 2007a), a 6‐point Likert scale with statements concerning
attendance of 77.5% (SD = 15.2) or respectively on average 6.2
the appraisal of MCT (e.g., “The sessions were fun.” or “I would recom-
(range = 3–8) attended sessions. For study completers, this figure was
mend the training.”) and changes in some life domains (e.g., “The
even higher with 80.3% (SD = 11.3) and on average 6.4 (range = 5–8)
perception of myself has changed.” or “In my working life something
attended sessions. In order to ensure a better training effect, those
has changed for me.”) was administered. Additionally, the participants
who missed three of the eight sessions were offered an intensive indi-
were encouraged to give written feedback.
vidual session to compensate for content missed.
|
Preliminary analyses
Premorbid intellectual functioning was estimated with a multiple‐
Four out of 30 subjects (11.8%) did not complete the study. Two
choice vocabulary test (Lehrl, 1999), and fluid reasoning was measured
participants could not continue to attend the sessions due to onset of
with the subtest LPS3 of a German intellectual functioning test battery
either a depressive or manic episode. Two other participants chose to
(Leistungsprüfungssystem; Horn, 1983).
quit the sessions, reporting that they found the training too easy. The
four non‐completers (Mdn = 18.0) had significantly more years of education than the 26 completers (Mdn = 15.0); U = 86.0, z = 2.18, p = .04.
2.4
|
Procedure
Completers and non‐completers did not differ in age, sex, number of
The study procedures were approved by the ethics committee of the
episodes, or baseline scores on any of the measures (all p values ≥.15).
Charité Universitätsmedizin Berlin, and written informed consent was
obtained from all subjects. The MCT took place weekly over 8 weeks
and was facilitated by a clinical psychologist with an expertise in
3.2
|
Psychosocial functioning
bipolar disorder. The measures were administered within a week of
The results of our primary outcome measure, psychosocial functioning,
the first and last MCT session. All subjects received full medical care
are presented in Table 3. The analyses revealed a significant improve-
as appropriate during and after the intervention. Subjects were asked
ment in psychosocial functioning, indicated by a significant change in
to contact the study team during and after the intervention if they
the FAST general score with a large effect size. Significant treatment
required additional psychological or medical supports.
effects with moderate to large effect sizes were also observed on the
TABLE 3
FAST scores at baseline and post‐treatment and global QoL (n = 26).
Outcome
Baseline
Post‐treatment
Test statistic
p value
Effect size
r = .52
FAST general Mdn (IQR)
24.5 (18.0)
18.0 (13.5)
z = −3.77
0.001
FAST autonomy Mdn (IQR)
2.0 (3.0)
1.0 (2.3)
z = −2.75
0.01
r = .38
FAST occupational M (SD)
7.0 (4.0)
5.6 (3.9)
t = 3.04
0.01
d = .35
FAST cognitive M (SD)
6.0 (3.1)
4.3 (2.8)
t = 3.48
0.01
d = .58
FAST financial Mdn (IQR)
0.0 (2.0)
0.0 (2.0)
z = 0.00
1.00
r = .0
FAST interpersonal Mdn (IQR)
7.5 (5.0)
5.5 (4.3)
z = −2.16
0.03
r = .30
FAST leisure time Mdn (IQR)
2.0 (3.0)
1.5 (3.3)
z = −1.29
0.20
r = .18
Global QoL Mdn (IQR)
50.0 (37.5)
56.3 (37.5)
z = 0.12
0.91
r = .02
Note. When assumptions for parametric testing were violated, nonparametric tests were performed, and r for nonparametric measures according to
Rosenthal (1994) was used. FAST = Functioning Assessment Short Test; QoL = quality of life.
HAFFNER
55
ET AL.
FAST domains of autonomy, occupational functioning, cognitive func-
direction of some thoughts or to question them.” or “I benefited from
tioning, and interpersonal functioning.
the training and was already able to apply something [I learned].”).
Depressive symptoms measured by the HAMD, respectively,
manic symptoms measured by the YMRS did not differ significantly
over the interventional period (HAMD: pre‐M (SD) = 5.9 (2.7), post‐M
4
|
DISCUSSION
(SD) = 6.7 (5.0), t = −.84, p = .41; YMRS: pre‐Mdn (IQR) = 0.5 (2.0),
post‐Mdn (IQR) = 1.7 (4.0), z = 0.25, p = .8).
The present pilot study is the first to examine MCT Bipolar and
Next, we examined variables that had the potential to influence
confirms the feasibility of this novel group intervention that has been
the training effect. Improvements in the FAST general score correlated
tailored for individuals with bipolar disorder. Moreover, this study
significantly with the FAST baseline score (rs = .50, p = .01) and HAMD
provides preliminary evidence for the efficacy of MCT in a sample of
score at baseline (rs = .45, p = .02), indicating that lower psychosocial
patients with impaired psychosocial functioning. Overall, we found
functioning and greater depressive symptoms were related to a greater
an improvement of global psychosocial functioning with a large effect
gains from the training. More years of education was negatively corre-
size. This effect was underpinned by significant improvements in
lated with improvements in psychosocial functioning, with a trend
different domains of functioning, such as independence, and cognitive,
towards significance (rs = −.34, p = .09). Subjects who completed any
occupational, and interpersonal functioning. Further analyses revealed
kind of psychotherapy in the past showed higher improvements in
that greater levels of functional impairment at baseline were
general psychosocial functioning (Mdn = 8.0) than those who had
strongly correlated with gains in functioning over the course of the
never previously completed a course of psychotherapy (Mdn = 0.0),
intervention.
again, with a trend towards significance (U = 96.0, z = 1.72, p = .09).
Our study sample had a mean age of 48.3 years, and on average,
Regarding improvement in psychosocial functioning over the interven-
22.1 past mood episodes. The study's inclusion criteria of impaired
tional period, no significant group differences were observed for sex or
psychosocial functioning most likely accounted for this. It is notewor-
significant correlations for age, number of episodes, fluid reasoning,
thy that despite our participant group being comprised of patients with
crystallized intellectual functioning, YMRS at baseline, and HAMD or
a long history of bipolar illness and many episodic relapses, this group
YMRS post‐intervention were found (all p values >.33).
emerged to benefit from the MCT intervention. This is positively
surprising in light of previous research findings that indicated that
psychotherapy might be more effective in patients with fewer
3.3
|
Quality of life
Changes in QoL were assessed using the WHOQOL‐BREF questionnaire. For global QoL, there were no significant differences between
baseline and post‐treatment (see Table 3).
episodes (Scott, Colom, & Vieta, 2007).
From the perspective of Berk's et al. (2007) model of stages in
bipolar disorder, our sample represented a group in the advanced stage
of illness. Our intervention fits with recent calls for more stage‐specific
interventions and for a stronger focus on functional recovery as well as
syndromic recovery (Reinares, Sanchez‐Moreno, & Fountoulakis,
3.4
|
Participant feedback
2014; Rosa et al., 2008). On these grounds, MCT may be a promising
psychological intervention, particularly for patients whose illness has
Feedback was measured by a 6‐point Likert scale ranging from 1
been characterized by a severe course of persistent impairment in
(strongly agree) to 6 (strongly disagree) after completion of the training.
different domains of life, even when in remission.
On average, participants agreed that there was subjective learning
Subthreshold depressive symptoms during clinical remission have
success (M = 2.2, SD = 1.0) and that the contents of the training were
been described as an important factor that may contribute to impair-
relevant for their daily life (M = 2.3, SD = 0.9). Furthermore, the group
ment in psychosocial functioning (Bonnin et al., 2012). In our study, a
(slightly) agreed that the atmosphere was pleasant (M = 2.2, SD = 1.3)
significant correlation between depressive symptoms at baseline and
and that sessions were fun (M = 2.5, SD = 1.0). Finally, participants
functional outcome was found. Thus, in future studies, it may be
agreed that they would recommend the training to others (M = 1.9,
important to consider subthreshold depressive symptoms as possible
SD = 1.0).
confounders of gains in functional outcome.
When asked if the perception of themselves had changed by the
Although this study did not observe immediate gains in global QoL
training the participants slightly agreed (M = 3.1, SD = 3.1). However,
post‐intervention, it remains unclear whether gains could be observed
on a whole participants slightly disagreed that the training had led to
long term. Moritz et al. (2014) completed a randomized control trial on
changes in their friendships, family, or occupational life (M = 3.8,
MCT for psychosis and found QoL to improve at the 3‐year follow‐up,
SD = 1.2; M = 3.6, SD = 1.3; n = 23, M = 3.8, SD = 1.3).
despite gains not being observed prior to this time point. Thus, the
The subjects were also invited to make comments on the training.
potential for gains to be observed in the long‐term cannot be ruled out.
Subjects offered their appraisal of the MCT and reported that the
Adherence to the MCT treatment was good, with 80% attendance
exercises were easy to understand, in particular, the cartoon stories.
at sessions and 12% drop‐out rate. The interactive and playful style of
Moreover, most of the participants appreciated the mindfulness exer-
the training was positively appraised by the patients. Patients also
cises and the pleasant group atmosphere. Most patients highlighted
reported that they would recommend the training to others. Taking
that they had benefited from the training (e.g., “Certain thoughts are
into account that subjects of a lower‐level educational background
like an alarm signal now. I'm now paying attention to change the
tended to achieve greater improvements, we can infer that the content
56
HAFFNER
ET AL.
of the intervention was accessible to participants. However, in con-
patients. As the approach combines and integrates elements of
trast, two subjects who were both of a high‐level educational back-
psychoeducation, cognitive behavioral therapy, and mindfulness,
ground quit the training, which may indicate that the MCT is less
patients can enjoy the benefits of and explore working with these
well‐suited for patients who prefer a challenging intervention. As is
different psychological treatments. Indeed, knowing what works well
the case in all psychological interventions, deterioration of mood,
for patients has therapeutic value as it can inform the clinician's future
stress, or a general disturbance during the course of or after the inter-
treatment recommendations (Holtforth, Krieger, Bochsler, & Mauler,
vention is always possible. To address these clinical needs and ensure
2011). With this in mind, it is possible that MCT Bipolar may represent
no adverse effects, as per routine practice, we offered support and
a useful component of a broader, stepwise psychological care
assistance to the patients as appropriate. Over the course of the inter-
approach. This could for example include short group interventions
vention, two patients experienced relapse. Based on statistical proba-
as the first port of call, followed by more specific and intensive
bility for relapse in a group of participants with the aforementioned
interventions for those whose needs are not addressed by the initial,
characteristics, this rate of relapse is within reasonable expectation.
lower‐resource interventions (as previously suggested by Swartz &
However, in further studies, it would be important to give careful
Swanson, 2014). In such an integrative psychosocial care concept,
attention to potential adverse effects of MCT.
MCT could represent an important element to make bipolar‐specific
psychological interventions accessible for a high number of patients.
4.1
|
Limitations
The primary limitation of this pilot study is the lack of a control group,
which implies that the treatment effects cannot definitively be attributed to the intervention. Similarly, a regression to the mean in terms
of the stronger improvement in functioning of those subjects with
lower functioning at baseline cannot be excluded in the context of
our study's design. Moreover, we introduced mindfulness as a promising addition to MCT Bipolar. Still, there might be interferences of
mindfulness exercises and MCT contents possibly influencing the
positive effects of MCT. It is, therefore, assumable, that the mindfulness exercises contributed to the outcome. However, within our
design, it was possible to rule out a number of potential confounding
5
|
CO NC LUSIO NS
This study presents preliminary evidence for the efficacy of MCT Bipolar, particularly for patients with more impaired functioning. The findings of this study also indicate that MCT Bipolar is a feasible
intervention. Next, it will be important to confirm the efficacy of
MCT in further studies with larger sample sizes, a control condition
and long‐term outcome parameters such as time until relapse and
number of episodes. A multicentered trial addressing these shortcomings is currently in preparation.
ACKNOWLEDGMENT
factors; such as a current psychotherapy or medication changes prior
to or during the intervention. Furthermore, raters were not blind due
to the design of the study. Additionally, without a follow‐up of functional outcome, it is not possible to establish whether these treatment
effects were lasting. On the other hand, a follow‐up might have
We thank Grace O'Malley for proofreading the manuscript and for
guidance on the overall readability.
CONFLICTS OF INTERES T
revealed new treatment effects that were not observed immediately
Mazda Adli has received grant/research support from the German
post‐intervention. Lastly, a high proportion of patients could not be
Federal Ministry of Education and Research, German Federal Ministry
included in our study after screening, mostly because of little psycho-
of Health, the Volkswagen Foundation, Lundbeck, esparma, and
social impairment (FAST <11) or not achieving stability even over a
Bristol‐Myers Squibb. He has received speaker honoraria from Astra
longer period of time, mostly because of rapid cycling. Other reasons
Zeneca, Eli Lilly & Company, Lundbeck, Bristol‐Myers Squibb,
were current individual psychotherapy or lack of interest in a group
GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Sanofi, esparma, Wyeth
intervention. Nevertheless, the remaining study population could be
Pharmaceuticals, Gilead, and Deutsche Bank. He has been a consultant
described as representative of a currently stable, but psychosocially
to Bristol‐Myers Squibb, esparma, and Lundbeck.
impaired bipolar sample.
Steffen Moritz is the developer of MCT.
Thomas Stamm has received grant/research support from the
German Federal Ministry of Education and Research and speaker
4.2
|
Clinical implications and perspectives
The most important advantages of MCT are its ease of application for
those delivering the intervention and its accessibility for patients, who
honoraria from Lundbeck and Bristol‐Myers Squibb. He is a consultant
to Servier.
All other authors declare that they have no conflicts of interest.
may benefit from the skills‐based approach. Needless to say, it should
be clear to clinicians that MCT is not comparable to or seen as an
FUNDING INFORMATION
alternative to individual psychotherapy. Instead, MCT as a treatment
This research did not receive any specific grant from funding agencies
option should be construed as a first step towards individual interven-
in the public, commercial, or not‐for‐profit sectors.
tions or as an adjunct therapy to other treatments (see also Moritz &
Woodward, 2007b). The style of the intervention—which is interactive,
ORCID
non‐stigmatizing, and makes use of everyday life examples to help
Paula Haffner
http://orcid.org/0000-0002-4416-6438
patients apply their learning—makes the intervention attractive to
Steffen Moritz
http://orcid.org/0000-0001-8601-0143
HAFFNER
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