The mainstay of treatment for bipolar disorder for the past 50 years has been pharmacotherapy. There has been increasing development of ‘third-wave behavioural therapy’ and there is a growing evidence base for its role in the treatment of depression as previously discussed in this elf blog by Chris Sampson: “Is third-wave CBT good value?“.
Mindfulness-based cognitive therapy has been found to have comparable efficacy to antidepressant medication with regards decreasing the rate of relapse of major depressive disorder (Kuyken et al., 2016) and has also been shown to have positive effects for anxiety symptoms (Hoge et al., 2013).
It has therefore been proposed, from a symptomatic perspective, that mindfulness-based cognitive therapy could also have a positive role to play in the treatment of patients with bipolar disorder and potentially reduce the use of medications given the concerns around side-effects of mood-stabilisers such as lithium. Consequently it would be beneficial to review the literature to assess if this hypothesis holds stable.
A new systematic literature review (Lovas et al. July 2018) was carried out to identify studies reporting clinical and/or neurocognitive findings for mindfulness-based cognitive therapy for bipolar disorder and evaluate their findings. This systematic review began by doing a literature search to identify relevant studies (both Pubmed and PsycINFO databases were searched). Studies were deemed eligible if they met two topic criteria:
- first they included participants with DSM-IV or DSM-5 bipolar disorder,
- and secondly the participants were treated with mindfulness-based cognitive therapy (MBCT).
Only English language papers were included.
An initial screen was made based on titles and abstracts. They initially identified 65 studies from database searches and 3 studies through other sources. Once duplicates were removed this left 45 studies which was further reduced to 15 articles that underwent full-text assessment for eligibility after studies that did not meet the topic criteria, had not been peer-reviewed or were review articles were removed. Following assessment of the full text of articles for eligibility two further articles were removed, leaving a total of 13 studies included in the qualitative synthesis.
A robust evaluation of articles was carried out to determine if they were suitable for inclusion, and an independent assessment of the quality of the selected studies was carried out using the Downs and Black checklist.
Overall this systematic review looked at 13 articles. They found that most studies were either underpowered or did not present power calculations. The Downs and Black assessed quality was generally low-medium, so there is definitely room for improvement when it comes to the quality of research in this field.
- The main finding was that MBCT did not appear to precipitate mania.
- There is some preliminary evidence to support a positive effect on anxiety, residual depression, mood regulation, and broad attentional and frontal-executive control.
- All of the studies involved patients in remission from manic, meaning there was a floor effect on mania scores (e.g. Young Mania Rating Scale) and so the studies could not show an improvement on already low to non-existent manic symptoms. However, there was no significant increase in manic symptoms in any of the studies over the course of MBCT, suggesting that it was not destabilising.
- Three trials had a clinically significant level of residual depression at baseline, and of these two found a significant positive effect on depressive symptoms.
- With regards to anxiety symptoms, 3 RCTs found some beneficial effects of MBCT over waitlist control on anxiety measures.
- One study looked at suicidality using self-report, and did not find any significant change during the trial (Miklowitz et al., 2009).
- One study looked at a population that were largely off medication (due to pregnancy) and thus receiving only MBCT. In this population the results were negative, with worsening depression rating scale scores over time (Miklowitz et al., 2005). In all other studies the participants remained on mood-stabilising medication.
The authors of this systematic review found a potential role for MBCT as an adjunct to psychotropic treatment, but in one article that looked at the role of MBCT alone the results were notably negative, suggesting that MBCT will not be able to replace medication therapy.
The authors highlight that MBCT may have more of a role to play in preventing the development of bipolar disorder in high-risk youth by targeting children with anxiety disorder and at least one parent with bipolar disorder, however further research will be needed to assess this.
Strengths and limitations
There were a number of strengths to this review:
- As well as doing an initial search for articles in 2016 they did a secondary search in 2018, ensuring they included the most up to date research.
- They highlighted the potential role of MBCT as an adjunct to pharmacotherapy and explained that modifications will be needed to ensure participants with bipolar disorder are able to fully learn the techniques.
- The systematic review revealed a lack of randomised controlled trials, highlighting an area for future research.
- The authors followed PRISMA guidelines and used the Downs and Black checklist to independently check the quality of papers identified for the review.
There were several weaknesses too:
- Most (11) of the studies selected for review had a quality score of between 10-16 (maximum score 28). These were low quality studies and so would not be a sufficient evident base to impact clinical practice at present. There were not enough high quality studies to justify carrying out a meta-analysis.
- Of note a separate systematic review and meta-analysis was carried out in 2018 (Chu, CS et al., 2018) which looked at 12 trials (3 of which were randomised controlled trials) and it found significantly beneficial effects on depressive and anxiety symptoms of bipolar disorder patients in within-group analysis. However, this significance was not observed in comparison with the control groups.
- Another major weakness is that the studies involved in this review all involved patients who were in remission from manic/hypomanic/mixed episodes, and so was unable to show if MBCT had an improving impact on manic symptoms, only that it was not destabilising.
- While this review looked at 13 studies, the data for those studies came from 8 clinical trials, meaning that several papers analysed the same sample/trial, but focused on different neurocognitive processes.
- The reviewers only searched Pubmed and PsycINFO and excluded non-English language papers, so it’s likely that they missed a significant quantity of published research. They don’t seem to have made any efforts to find unpublished research.
- The PRISMA diagram indicates 3 articles were found through additional sources outside of the database searching, but no reference is made as to how these papers were identified. Given that three articles were identified through other sources it is possible there could have been other articles missed by the database search.
Implications for practice
This systemic review raises the prospect of the potential role mindfulness-based cognitive therapy could play in the treatment of bipolar disorder. However there is a need to gather a larger evidence base for the safety and efficacy of MBCT in this patient group through further randomised controlled trials.
Significantly, all the research to date has been done with patients in remission. Questions still remain as to what is the optimal dosage for patients to receive. Additionally, due to neurocognitive deficits involving the attentional system in patients with bipolar disorder it can be difficult for patients to engage with MBCT.
It is clear that patients with bipolar disorder can experience difficulties in engaging with psychotherapies, and the authors made several helpful suggestions as to modifications that could be made to tailor MBCT to this population in order to help them receive an adequate dosage. These modifications include:
- shorter practices,
- more emphasis on informal daily mindfulness,
- mindfulness movement practices,
- modifying the mindfulness practice based on energy/mood (i.e sitting when high, movement when low),
- the use of reminder technologies to practice formally or informally throughout the day,
- and more, shorter sessions.
Further research into the effectiveness of these changes to help engagement with MBCT in patients with bipolar disorder is warranted.
This review has also highlighted the need for further well-powered, randomised controlled trials in order to fully ascertain the efficacy of the use of MBCT in patients suffering from Bipolar Disorder.
MBCT appears to be beneficial as an adjunct to pharmacological treatment, but has not been shown to be beneficial as monotherapy. Further RCTs are needed to fully assess the effectiveness of MBCT as an adjunct to medication before it can be recommended in clinical practice.
Conflicts of interest
None to declare.
Lovas DA, Schuman-Olivier Z. (2018) Mindfulness-based cognitive therapy for bipolar disorder: A systematic review. J Affect Disord. 2018 Nov;240:247-261. doi: 10.1016/j.jad.2018.06.017. Epub 2018 Jul 6.
Che-Sheng Chu, Brendon Stubbs, Tien-Yu Chen, Chia-Hung Tang, Dian-Jeng Li, Wei-Cheng Yang, Ching-Kuan Wu, André F. Carvalho, Eduard Vieta, David J. Miklowitz, Ping-Tao Tseng, Pao-Yen Lin. (2018) The effectiveness of adjunct mindfulness-based intervention in treatment of bipolar disorder: A systematic review and meta-analysis. Journal of Affective Disorders, Volume 225, 234-245. [Abstract]
Kuyken W, Warren FC, Taylor RS, Whalley B, Crane C, Bondolfi G, Hayes R, Huijbers M, Ma H, Schweizer S, Segal Z, Speckens A, Teasdale JD, Van Heeringen K, Williams M, Byford S, Byng R, Dalgleish T. (2016) Efficacy and moderators of mindfulness-based cognitive therapy (MBCT) in prevention of depressive relapse: An individual patient data meta-analysis from randomized trials. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.0076 Published online April 27, 2016.
Miklowitz, D.J., Alatiq, Y., Goodwin, G.M., Geddes, J.R., Fennell, M.J.V, Dimidijian, S., Hauser, M., Williams, J.M.G. (2009) A pilot study of mindfulness-based cognitive therapy for bipolar disorder. Int. J. Cogn. Ther. 2, 373-382 [Abstract]
Miklowitz, D.J., Semple, R.J., Hauser, M., Elknun, D., Weintraub, M.J., Dimidjian, S., 2015. Mindfulness-based cognitive therapy for perinatal women with depression or bipolar spectrum disorder. Cognit. Ther. Res. 590-600. [Abstract]