Background: The unique recovery process and treatment needs of persons with bipolar II disorder (BD II) has been subject of limited research. BD II is associated with high rates of disability worldwide and people with BD II are among the highest risk of suicide of all populations. Research of psychotherapy for bipolar disorders (BDs) in general has focused on clinical outcomes (i.e., reducing mood symptoms, remission of mood episodes) rather than functional outcomes, suicide risk, or co-occurring problems. This dissertation addresses these gaps in three quantitative studies, which investigate the recovery process of individuals with BDs and what treatment (i.e., psychotherapy alone or in combination with medication) works for whom (i.e., individuals with childhood trauma, anxiety, and various stages of illness progression) to improve symptoms, reduce suicidal thoughts, and restore functioning to all major life areas. The goal of these studies is to inform treatment considerations for BD II to decrease the high rates of mortality and disability associated with BD II. These studies are guided by kindling theory and social rhythms disruption therapy, which emphasize stressful life events and disruption of social and biological rhythms, in combination with genetic predisposition to explain the etiology and ongoing expression of BDs.
Methods: Study design consisted of a randomized, double blind, controlled trial (ClinicalTrials.gov identifier: NCT01133821) testing the efficacy of interpersonal social rhythms therapy (IPSRT) plus placebo compared to IPSRT plus medication (i.e., quetiapine) for adults with BD II depression (n = 92). Study 1 used multilevel logistic regression with growth curve modeling to examine (1) the comparative effectiveness of IPSRT plus placebo compared to IPSRT plus medication on suicidal ideation outcomes, and (2) whether higher levels of childhood trauma and anxiety predicted change in suicidal ideation. Study 2 used multilevel modeling with growth curve modeling to examine (1) the comparative effectiveness of IPSRT plus placebo compared to IPSRT plus medication on specific domains of functioning, and (2) whether stage of illness progression predicted functional outcomes. Study 3 used Kaplan Meir survival analysis to calculate recovery rates (i.e., symptomatic, syndromal, and functional recovery) at 8, 12, and 20 weeks. Log rank tests examined effect between treatment groups and z-tests examined differences between the different types of recovery rates.
Results: Study one’s results demonstrated a significant decrease in suicidal ideation with each additional week of treatment. There was no significant difference in the decrease in suicidal ideation over time between those receiving IPSRT alone v. IPSRT plus quetiapine. Childhood trauma and anxiety did not predict worse functional outcomes. Study two’s results demonstrated improvement in functioning in all areas (i.e., autonomy, occupational, cognitive, financial, interpersonal, and leisure) with no significant difference over time between those receiving IPSRT alone ad IPSRT + quetiapine. However, despite improvement the majority of participants remained impaired in all areas of functioning at the end of acute treatment other than leisure time. Stage of illness progression did not predict functional outcomes, except those with those most advanced stage of illness had the worst occupational functioning at baseline, but showed the most improvement over the course of the 20-week treatment period. Study three’s results demonstrated participants reached each type of recovery (i.e., symptomatic, syndromal, and functional) at comparable rates between the two treatment groups. Significantly more participants recovered syndromally than functionally or symptomatically.
Conclusions: Results suggest individuals with BD II can improve in suicidal ideation, all areas of functioning, and achieve all forms recovery whether or not they receive medication in addition to psychotherapy. Functional recovery required longer time than reduction of active symptoms and half of participants did not reach remission, indicating longer, more intensive or combination treatments may be needed for half of individuals with BD II. However, psychotherapy independent of medication may be a reasonable treatment option for some individuals with BD II. Replication with larger sample size and additional comparator conditions is needed before forming treatment recommendations. Limitations include small sample size with limited racial diversity, high attrition, and lack of a standard of care psychotherapy group or medication only group.