Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study

Fredrik Holländare, Annsofi Eriksson, Lisa Lövgren, Mats B Humble, Katja Boersma, Fredrik Holländare, Annsofi Eriksson, Lisa Lövgren, Mats B Humble, Katja Boersma

Abstract

Background: Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo)manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment.

Objective: The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful.

Methods: A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually.

Results: Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-Åsberg Depression Rating Scale-Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change-according to the Reliable Change Index-in self-rated symptoms of depression and perseverative thinking.

Conclusions: The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study.

Trial registration: ClinicalTrials.gov NCT01742351; https://ichgcp.net/clinical-trials-registry/NCT01742351 (Archived by WebCite at http://www.webcitation.org/6XnVpv4C3).

Keywords: Internet; behavioral therapy; bipolar disorder; cognitive therapy; pilot projects.

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
An overview of the study design. SCR: initial screening (MADRS-S), PRE: pretest (BDI-II, PTQ, WSAS), Baseline: baseline assessment with weekly ratings (MADRS-S, ISI), Treatment: intervention phase comprising assessment with weekly ratings (MADRS-S, ISI), POST: posttest (BDI-II, PTQ, WSAS, patient evaluation).
Figure 2
Figure 2
Weekly ratings of depressive symptoms (MADRS-S, maximum score is 54 points), symptoms of (hypo)mania (AS-18, maximum score for mania section is 36), and insomnia (ISI, maximum score is 28 points) for patient 1. The vertical line marks the start of the intervention period. Dashed blue lines indicate the mean level of depressive symptoms (MADRS-S) during the baseline period and the treatment phase.
Figure 3
Figure 3
Weekly ratings of depressive symptoms (MADRS-S, maximum score is 54 points), symptoms of (hypo)mania (AS-18, maximum score for mania section is 36), and insomnia (ISI, maximum score is 28 points) for patient 2. The vertical line marks the start of the intervention period. Dashed blue lines indicate the mean level of depressive symptoms (MADRS-S) during the baseline period and the treatment phase.
Figure 4
Figure 4
Weekly ratings of depressive symptoms (MADRS-S, maximum score is 54 points), symptoms of (hypo)mania (AS-18, maximum score for mania section is 36), and insomnia (ISI, maximum score is 28 points) for patient 3. The vertical line marks the start of the intervention period. Dashed blue lines indicate the mean level of depressive symptoms (MADRS-S) during the baseline period and the treatment phase.
Figure 5
Figure 5
Weekly ratings of depressive symptoms (MADRS-S, maximum score is 54 points), symptoms of (hypo)mania (AS-18, maximum score for mania section is 36), and insomnia (ISI, maximum score is 28 points) for patient 4. The vertical line marks the start of the intervention period. Dashed blue lines indicate the mean level of depressive symptoms (MADRS-S) during the baseline period and the treatment phase.

References

    1. Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, Viana MC, Andrade LH, Hu C, Karam EG, Ladea M, Medina-Mora ME, Ono Y, Posada-Villa J, Sagar R, Wells JE, Zarkov Z. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011 Mar;68(3):241–251. doi: 10.1001/archgenpsychiatry.2011.12.
    1. Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RM, Petukhova M, Kessler RC. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007 May;64(5):543–552. doi: 10.1001/archpsyc.64.5.543.
    1. Fagiolini A, Forgione R, Maccari M, Cuomo A, Morana B, Dell'Osso MC, Pellegrini F, Rossi A. Prevalence, chronicity, burden and borders of bipolar disorder. J Affect Disord. 2013 Jun;148(2-3):161–169. doi: 10.1016/j.jad.2013.02.001.
    1. Gardner HH, Kleinman NL, Brook RA, Rajagopalan K, Brizee TJ, Smeeding JE. The economic impact of bipolar disorder in an employed population from an employer perspective. J Clin Psychiatry. 2006 Aug;67(8):1209–1218.
    1. Judd LL, Akiskal HS, Schettler PJ, Coryell W, Endicott J, Maser JD, Solomon DA, Leon AC, Keller MB. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry. 2003 Mar;60(3):261–269.
    1. Altshuler LL, Post RM, Black DO, Keck PE, Nolen WA, Frye MA, Suppes T, Grunze H, Kupka RW, Leverich GS, McElroy SL, Walden J, Mintz J. Subsyndromal depressive symptoms are associated with functional impairment in patients with bipolar disorder: results of a large, multisite study. J Clin Psychiatry. 2006 Oct;67(10):1551–1560.
    1. De Dios C, Ezquiaga E, Agud JL, Vieta E, Soler B, García-López A. Subthreshold symptoms and time to relapse/recurrence in a community cohort of bipolar disorder outpatients. J Affect Disord. 2012 Dec 20;143(1-3):160–165. doi: 10.1016/j.jad.2012.05.047.
    1. Judd LL, Schettler PJ, Akiskal HS, Coryell W, Leon AC, Maser JD, Solomon DA. Residual symptom recovery from major affective episodes in bipolar disorders and rapid episode relapse/recurrence. Arch Gen Psychiatry. 2008 Apr;65(4):386–394. doi: 10.1001/archpsyc.65.4.386.
    1. Reinares M, Sánchez-Moreno J, Fountoulakis KN. Psychosocial interventions in bipolar disorder: what, for whom, and when. J Affect Disord. 2014 Mar;156:46–55. doi: 10.1016/j.jad.2013.12.017.
    1. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognit Ther Res. 2012 Oct 1;36(5):427–440. doi: 10.1007/s10608-012-9476-1.
    1. Lam DH, Burbeck R, Wright K, Pilling St. Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention - a systematic review. Bipolar Disord. 2009 Aug;11(5):474–482. doi: 10.1111/j.1399-5618.2009.00724.x.
    1. Johansson R, Andersson G. Internet-based psychological treatments for depression. Expert Rev Neurother. 2012 Jul;12(7):861–869; quiz 870. doi: 10.1586/ern.12.63.
    1. Richards D, Richardson T. Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clin Psychol Rev. 2012 Jun;32(4):329–342. doi: 10.1016/j.cpr.2012.02.004.
    1. Smith DJ, Griffiths E, Poole R, di Florio A, Barnes E, Kelly MJ, Craddock N, Hood K, Simpson S. Beating Bipolar: exploratory trial of a novel Internet-based psychoeducational treatment for bipolar disorder. Bipolar Disord. 2011;13(5-6):571–577. doi: 10.1111/j.1399-5618.2011.00949.x.
    1. Proudfoot J, Parker G, Manicavasagar V, Hadzi-Pavlovic D, Whitton A, Nicholas J, Smith M, Burckhardt R. Effects of adjunctive peer support on perceptions of illness control and understanding in an online psychoeducation program for bipolar disorder: a randomised controlled trial. J Affect Disord. 2012 Dec 15;142(1-3):98–105. doi: 10.1016/j.jad.2012.04.007.
    1. Lauder S, Chester A, Castle D, Dodd S, Berk L, Klein B, Austin D, Gilbert M, Chamberlain JA, Murray G, White C, Piterman L, Berk M. Development of an online intervention for bipolar disorder. . Psychol Health Med. 2013;18(2):155–165. doi: 10.1080/13548506.2012.689840.
    1. Todd NJ, Solis-Trapala I, Jones SH, Lobban FA. An online randomised controlled trial to assess the feasibility, acceptability and potential effectiveness of 'Living with Bipolar': a web-based self-management intervention for bipolar disorder: trial design and protocol. Contemp Clin Trials. 2012 Jul;33(4):679–688. doi: 10.1016/j.cct.2012.02.011.
    1. Barnes C, Harvey R, Mitchell P, Smith M, Wilhelm K. Evaluation of an online relapse prevention program for bipolar disorder. Disease Management & Health Outcomes. 2007;15(4):215–224. doi: 10.2165/00115677-200715040-00003.
    1. Svanborg P, Asberg M. A new self-rating scale for depression and anxiety states based on the Comprehensive Psychopathological Rating Scale. Acta Psychiatr Scand. 1994 Jan;89(1):21–28.
    1. Snaith RP, Harrop FM, Newby DA, Teale C. Grade scores of the Montgomery-Asberg Depression and the Clinical Anxiety Scales. Br J Psychiatry. 1986 May;148:599–601.
    1. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva, Switzerland: World Health Organization; 1992. [2015-04-20]. .
    1. Fantino B, Moore N. The self-reported Montgomery-Asberg Depression Rating Scale is a useful evaluative tool in major depressive disorder. BMC Psychiatry. 2009;9:26. doi: 10.1186/1471-244X-9-26.
    1. Holländare F, Andersson G, Engström I. A comparison of psychometric properties between internet and paper versions of two depression instruments (BDI-II and MADRS-S) administered to clinic patients. J Med Internet Res. 2010;12(5):e49. doi: 10.2196/jmir.1392.
    1. Beck AT, Steer RA, Brown GK. Beck Depression Inventory-2nd edition (BDI-II): manual. Swedish version. Sandviken, Sweden: Psykologiförlaget; 2006.
    1. Storch EA, Roberti JW, Roth DA. Factor structure, concurrent validity, and internal consistency of the Beck Depression Inventory-Second Edition in a sample of college students. Depress Anxiety. 2004;19(3):187–189. doi: 10.1002/da.20002.
    1. Morin CM. Insomnia: Psychological Assessment and Management. New York, NY: The Guilford Press; 1993.
    1. Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011 May;34(5):601–608.
    1. Mundt JC, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry. 2002 May;180:461–464.
    1. Ehring T, Zetsche U, Weidacker K, Wahl K, Schönfeld S, Ehlers A. The Perseverative Thinking Questionnaire (PTQ): validation of a content-independent measure of repetitive negative thinking. J Behav Ther Exp Psychiatry. 2011 Jun;42(2):225–232. doi: 10.1016/j.jbtep.2010.12.003.
    1. Adler M, Liberg B, Andersson S, Isacsson G, Hetta J. Development and validation of the Affective Self Rating Scale for manic, depressive, and mixed affective states. Nord J Psychiatry. 2008;62(2):130–135. doi: 10.1080/08039480801960354.
    1. Mohr DC, Cuijpers P, Lehman K. Supportive accountability: a model for providing human support to enhance adherence to eHealth interventions. J Med Internet Res. 2011;13(1):e30. doi: 10.2196/jmir.1602.
    1. Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol. 1991 Feb;59(1):12–19.
    1. Beck AT, Steer RA, Brown GK. Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996.
    1. Kazdin AE. Single-Case Research Designs: Methods for Clinical and Applied Settings. 2nd edition. New York, NY: Oxford University Press; 2010.
    1. González IA, Echeburúa E, Limiñana JM, González-Pinto A. Psychoeducation and cognitive-behavioral therapy for patients with refractory bipolar disorder: a 5-year controlled clinical trial. Eur Psychiatry. 2014 Mar;29(3):134–141. doi: 10.1016/j.eurpsy.2012.11.002.
    1. Lauder S, Chester A, Castle D, Dodd S, Gliddon E, Berk L, Chamberlain J, Klein B, Gilbert M, Austin DW, Berk M. A randomized head to head trial of : an Internet based self-help program for bipolar disorder. J Affect Disord. 2015 Jan 15;171:13–21. doi: 10.1016/j.jad.2014.08.008.
    1. Todd NJ, Jones SH, Lobban FA. What do service users with bipolar disorder want from a web-based self-management intervention? A qualitative focus group study. Clin Psychol Psychother. 2013;20(6):531–543. doi: 10.1002/cpp.1804.
    1. van Straten A, Emmelkamp J, de Wit J, Lancee J, Andersson G, van Someren EJ, Cuijpers P. Guided Internet-delivered cognitive behavioural treatment for insomnia: a randomized trial. Psychol Med. 2014 May;44(7):1521–1532. doi: 10.1017/S0033291713002249.
    1. Andersson G, Hesser H, Veilord A, Svedling L, Andersson F, Sleman O, Mauritzson L, Sarkohi A, Claesson E, Zetterqvist V, Lamminen M, Eriksson T, Carlbring P. Randomised controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression. J Affect Disord. 2013 Dec;151(3):986–994. doi: 10.1016/j.jad.2013.08.022.
    1. Hedman E, Ljótsson B, Lindefors N. Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost-effectiveness. Expert Rev Pharmacoecon Outcomes Res. 2012 Dec;12(6):745–764. doi: 10.1586/erp.12.67.
    1. Latalova K, Prasko J, Kamaradova D, Jelenova D, Ociskova M, Sedlackova Z. Internet psychoeducation for bipolar affective disorder: basis for preparation and first experiences. Psychiatr Q. 2014 Jun;85(2):241–255. doi: 10.1007/s11126-013-9286-y.
    1. Eysenbach G, CONSORT-EHEALTH Group CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res. 2011;13(4):e126.

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