Staging bipolar disorder: what data and what models are needed?

Although bipolar disorder is increasingly recognised as a spectrum of multisystem disorders (ie, bipolar disorders), proposed staging models and theories of bipolar disease progression often fail to incorporate longitudinal data or data from multiple domains of dysfunction. We propose that bipolar disorders are best thought of as syndromes, with different trajectories of development and progression for various symptoms and demographic groups. This inherent complexity might be better suited to non-traditional modelling techniques, potentially derived from chaos theory. In this Personal View, we propose an allostatic load framework to account for biomarkers of physiological symptom progression. We then suggest integration of two potential domains of biobehavioural markers: sleep and wake and circadian rhythm regulation and the behavioural activation system. A satisfactory model should account for the effects of developmental stage as well as demographic characteristics, including but not limited to sex, culture, ethnicity, and socioeconomic status. The ultimate goal of a staging model has to be to inform the development of targeted, stage-appropriate interventions to reduce the substantial burden of bipolar disorders on individuals and societies.

An Integrated Risk Reduction Intervention can reduce body mass index in individuals being treated for bipolar I disorder: results from a randomized trial.

OBJECTIVES: We conducted a randomized, controlled trial comparing the efficacy of an Integrated Risk Reduction Intervention (IRRI) to a control condition with the objective of improving mood stability and psychosocial functioning by reducing cardiometabolic risk factors in overweight/obese patients with bipolar I disorder. METHODS: A total of 122 patients were recruited from our outpatient services and randomly allocated to IRRI (n = 61) or psychiatric care with medical monitoring (n = 61). Individuals allocated to IRRI received psychiatric treatment and assessment, medical monitoring by a nurse, and a healthy lifestyle program from a lifestyle coach. Those allocated to the control condition received psychiatric treatment and assessment and referral, if indicated, for medical problems. A mixed-effects model was used to examine the impact of the interventions on body mass index (BMI). Exploratory moderator analyses were used to characterize those individuals likely to benefit from each treatment approach. RESULTS: Analyses were conducted on data for the IRRI (n = 58) and control (n = 56) participants with ≥ 1 study visit. IRRI was associated with a significantly greater rate of decrease in BMI (d = -0.51, 95% confidence interval: -0.91 to -0.14). Three variables (C-reactive protein, total cholesterol, and instability of total sleep time) contributed to a combined moderator of faster decrease in BMI with IRRI treatment. CONCLUSIONS: Overweight/obese patients with bipolar disorder can make modest improvements in BMI, even when taking medications with known potential for weight gain. Our finding that a combination of three baseline variables provides a profile of patients likely to benefit from IRRI will need to be tested further to evaluate its utility in clinical practice.

Is Interpersonal Psychotherapy Infinitely Adaptable? A Compendium of the Multiple Modifications of IPT.

We employed standard literature search techniques and surveyed participants on the International Society for Interpersonal Psychotherapy listserve (isiptlist@googlegroups.com) to catalogue the multiple and highly creative ways in which Klerman's and Weissman's original concept of interpersonal psychotherapy (IPT) has been modified to meet the needs of a vast range of patient populations. Focusing first on adaptations of the individual treatment model for subgroups of adult patients, we next describe further adaptations of four major off-shoots of IPT: interpersonal counseling (IPC), IPT for adolescents (IPT-A), group IPT (IPT-G) and most recently, brief IPT (IPT-B). We then discuss IPT "in-laws," those treatments that have married IPT with of other forms of psychotherapy for patients with bipolar disorder, panic symptomatology, and substance abuse. We conclude with that although there have been myriad successful adaptations of IPT, there remain some conditions for which IPT adaptations have not been found to be efficacious.