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BACKGROUND: Bipolar disorder (BD) is commonly associated with cognitive and functional impairments even during remission periods, and although a growing number of studies have demonstrated the benefits of psychotherapy as an add-on to pharmacological treatment, its effectiveness appears to be less compelling in severe presentations of the disorder. New interventions have attempted to improve cognitive functioning in BD patients, but results have been mixed. METHODS: The study consists of a clinical trial comparing a new structured group intervention, called "Cognitive-Behavioral Rehabilitation," with treatment as usual (TAU) for bipolar patients. The new approach is a combination of cognitive behavioral strategies and cognitive remediation exercises, consisting of 12 weekly group sessions of 90 min each. To be included in the study, patients must be diagnosed with BD type I or II, aged 18-55 years, in full or partial remission, and have an IQ of at least 80. A comprehensive neuropsychological battery, followed by mood, social functioning, and quality of life assessments will occur in three moments: pre and post intervention and 12 months later. The primary outcome of the study is to compare the time, in weeks, that the first full mood episode appears in patients who participated in either group of the study. Secondary outcome will include improvement in cognitive functions. DISCUSSION: This is the first controlled trial assessing the validity and effectiveness of the new "Cognitive-Behavioral Rehabilitation" intervention in preventing new mood episodes and improving cognitive and functional impairments. TRIAL REGISTRATION: Clinicaltrial.gov, NCT02766361 . Registered on 2 May 2016.

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OBJECTIVE: Children of parents with bipolar disorder (BD) are at heightened risk for developing mood and other psychiatric disorders. We proposed to evaluate the environment of families with at least one parent with BD type I (BDF) with affected offspring (aBDF) and unaffected offspring (uBDF) compared with control families without a history of DSM-IV Axis I disorder (CF). METHOD: We used the Family Environment Scale (FES) to evaluate 47 BDF (aBDF + uBDF) and 30 CF. Parents were assessed through the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Diagnosis of the offspring was determined through the Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL) interview. RESULTS: There were statistically significant differences between aBDF, uBDF and CF in cohesion (p = 0.003), intellectual-cultural orientation (p = 0.01), active-recreational orientation (p = 0.007), conflict (p = 0.001), control (p = 0.01), moral-religious emphasis (p = 0.01) and organization (p = 0.001). The aBDF showed higher levels of control (p = 0.02) when compared to the uBDF. CONCLUSIONS: Families with a BD parent presented more dysfunctional interactions among members. Moreover, the presence of BD or other psychiatric disorders in the offspring of parents with BD is associated with higher levels of control. These results highlight the relevance of psychosocial interventions to improve resilience and family interactions.

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BACKGROUND: Children and adolescents with bipolar disorder (BD) live in family environments with high levels of expressed emotion (EE), conflict, and tension; as well as low maternal warmth and cohesion. These family characteristics have been evaluated in research settings using different scales. Nonetheless, empirically supported assessment instruments are not always feasible to be used in clinical settings. Our aim was to identify the best characteristics that discriminate BD families from control by building a classifier with the main characteristics found from different scales. We also built a classifier based on the adjective check-list scale (ACL) because this scale would be the most feasible one to be used in clinical setting. METHODS: We evaluated 33 families of pediatric BD patients and 29 control families. Two self-report scales, ACL and the Family Environment Scale (FES), and a direct interview scale, the Psychosocial Schedule for School Age Children-Revised (PSS-R), were administered. RESULTS: BD families presented lower positive EE and higher negative EE, less cohesion, organization, greater conflict and control; lower rate of intact family, higher maternal and paternal tension compared to control families. Both classifiers demonstrated high accuracy. The offspring's EE toward the mother was the family characteristic that best discriminated BD from control families. LIMITATIONS: Small sample size and cross-sectional design. CONCLUSIONS: Families of BD children presented altered communication and functioning. The high accuracy of the ACL-based classifier highlights a feasible scale to be used in clinical settings. Further studies assessing prognosis associated with the patterns of communication in such families are needed.

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BACKGROUND: The association between suicidal behavior and quality of life (QoL) in bipolar disorder (BD) is poorly understood. Worse QoL has been associated with suicide attempts and suicidal ideation in schizophrenic patients, but this relationship has not been investigated in BD. This study tested whether a history of suicide attempts was associated with poor QoL in a well-characterized sample of patients with BD, as has been observed in other psychiatric disorders and in the general population. METHODS: One hundred eight patients with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BD type I (44 with previous suicide attempts, 64 without previous suicide attempts) were studied. Quality of life was assessed using the World Health Organization's Quality of Life Instrument-Short Version. Depressive and manic symptoms were assessed using the Hamilton Depression Rating Scale-17 items and the Young Mania Rating Scale. RESULTS: Patients with BD and previous suicide attempts had significantly lower scores in all the 4 domains of the World Health Organization's Quality of Life Instrument-Short Version scale than did patients with BD but no previous suicide attempts (physical domain P = .001; psychological domain P < .0001; social domain P = .001, and environmental domain P = .039). In the euthymic subgroup (n = 70), patients with previous suicide attempts had significantly lower scores only in the psychological and social domains (P = .020 and P = .004). LIMITATIONS: This was a cross-sectional study, and no causal associations can be assumed. CONCLUSIONS: Patients with BD and a history of previous suicide attempts seem to have a worse QoL than did patients who never attempted suicide. Poorer QoL might be a marker of poor copying skills and inadequate social support and be a risk factor for suicidal behavior in BD. Alternatively, poorer QoL and suicidal behavior might be different expressions of more severe BD.

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CONTEXTO: Vem crescendo nos últimos anos o número de estudos com abordagens psicoterápicas no tratamento de pacientes com transtorno afetivo bipolar. Contudo, pouco ainda se sabe sobre o efeito que tem estas abordagens nestes pacientes. OBJETIVO: Avaliar a efetividade da terapia de grupo no tratamento do transtorno afetivo bipolar. MÉTODO: Levantamento bibliográfico no Medline, Lilacs, PubMed e ISI de artigos publicados em língua inglesa no período de 1975 a 2005 e busca manual com base na bibliografia dos artigos selecionados. Foram incluídos apenas os estudos que utilizaram grupo controle, randomizados, com casuística superior a 20 pacientes. RESULTADOS: Foram encontrados somente cinco trabalhos, três deles publicados nos últimos cinco anos. Três utilizaram modelos de psicoeducação, encontrando aumento na adesão ao tratamento farmacológico. Um destes verificou redução no número de hospitalizações e recaídas. Dois estudos combinaram psicoeducação e abordagens psicoterápicas variadas. Destes, um mostrou aumento no período de remissão e redução de sintomas para episódios maníacos. CONCLUSÕES: O interesse por intervenções psicoterápicas baseadas em evidência, no tratamento do TAB, vem aumentando nos últimos anos. Este fato contrasta com o baixo número de estudos dedicados à modalidade de atendimento em grupo, que poderia ser muito útil em instituições onde grande número de pacientes é atendido. A complexidade clínica dessa doença, a presença de diversas comorbidades e os diferentes graus de adesão à farmacoterapia demandam a criação de opções terapêuticas variadas que atendam às necessidades de cada indivíduo. Os estudos indicam que a terapia de grupo pode ser uma opção eficaz de tratamento que merece ser mais bem investigado para permitir sua aplicação na prática clínica.

BACKGROUND: In the last years there has been a growing number of studies using psychotherapy approaches in the treatment of bipolar patients. However, little is known about the effects of these approaches. OBJECTIVE: Evaluate the effectiveness of Group Therapy in the treatment of bipolar affective disorder. METHOD: Review of the literature using Medline, Lilacs, PubMed e ISI, selecting English language articles published between the years of 1975 and 2005. The reference sections of the selected articles, review articles and specialized books were also consulted. Only randomized controlled trails, with more than twenty subjects, were selected. RESULTS: Five published studies were identified; three of them have been published in the last five years. In three of the selected studies, models of Psychoeducation were used, showing an increase in the adherence to the pharmacological treatment. One showed reduction in the number of relapses and hospital admissions. The other two studies combined psychoeducation with some other form of psychotherapeutic approach. In one of them, not only an increase in the remission period but also symptom reduction was identified, concerning manic episodes. DISCUSSION: There has been a growing interest in evidence based psychotherapy interventions for the treatment of bipolar affective disorder over the last years. This fact contrasts with the low number of studies dedicated to group therapy, which could be very useful in institutions where a great number of patients are assisted. The clinical complexities of this disease, the presence of several comorbidities and the different levels of adherence to pharmacotherapy demand the development of diverse therapeutic options, in order to meet the needs of each individual. The studies show that group therapy could be an effective treatment option that deserves better investigations so that it can be used in clinical practice.

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