Completed Trials

Preventing Recurrence and Suicide in Bipolar Disorder

2007-2010

The objective of this pilot study was to test a novel approach to treating depression and suicidal ideation among bipolar adults. Dr. Miklowitz’s work supported by the Danny Alberts Foundation began when he was in England, in collaboration with Prof. Mark Williams at Oxford. Dr. Williams and his colleagues had designed a suicide prevention method (Mindfulness Based Cognitive Therapy, or MBCT) for persons with depression and suicidality, but had never applied his method to bipolar patients. During Dr. Miklowitz’s year in the U.K., he became immersed in learning this model, and a pilot study was carried out involving bipolar patients who underwent the 8-week MBCT groups. The results showed that bipolar patients responded well to the groups, attended regularly, and reported benefits in terms of their mood and thinking patterns. Thus, the MBCT appeared to be an excellent match for the goals of the Alberts Foundation study: to prevent depressed mood and suicidal ideation in bipolar disorder.

When Dr. Miklowitz returned to Colorado in the Fall 2007, his team began planning a study of MBCT for bipolar patients with suicidal thinking or attempts. A fellow professor at CU-Boulder, Dr. Sona Dimidjian, is an expert trainer in MBCT and was in a position to train others. She trained Monika Hauser, Ph.D., who then ran two consecutive groups of bipolar and unipolar depressed patients in the Spring and Fall of 2008. The results of this study, funded by the Alberts Foundation, are reported below and published in the article,

”A Pilot Study of Mindfulness-Based Cognitive Therapy for Bipolar Disorder,”
in the International Journal of Cognitive Therapy, 2009; 2(4): 373-382.

Tangible Outcomes

2008-2009

With funding from the Alberts Foundation, we hired two staff members for the project, Monika Hauser, Ph.D., and Chris Hawkey, B.A., in the Fall of 2007. After we designed our study, Dr. Hauser prepared a human subjects review application for the University of Colorado’s institutional review board, and submitted it in October 2007. It was approved in December 2007 and reapproved in December 2008.

In this initial study, we offered MBCT to bipolar participants and examined their symptom states before the 8-week course of treatment and again when the 8-week course had finished. We measured mood, anxiety, mania, and suicidal thinking both by interview and questionnaire method.

We have combined our results from the Oxford site and the Colorado site, and can now report on the improvements over 8 weeks experienced by the 21 patients who participated in the groups. Below, we list each outcome measure and the level of improvement we’ve seen in each. “Effect sizes” are measures of how much change has been brought about by a treatment. They are considered small if they are 0.20 or below, and medium if they are between .30-.50.

Measure Pre-treatment Score Post-treatment score Effect Size
Depression (interview) 5.7 3.7 0.39
Mania (interview) 2.2 1.8 0.20
Depression (questionnaire) 16.2 10.6 0.48
Anxiety (questionnaire) 15.9 12.8 0.25
Suicidal Ideation 4.2 1.9 0.46

These results suggest that MBCT is effective in reducing depression, suicidal ideation, and to a lesser extent, mania and anxiety symptoms, with effect sizes in the small to medium range. This study was done in an uncontrolled fashion (there was not a “no-treatment” or “treatment as usual” control group), so we cannot be certain that the effects are due to the treatment itself, as opposed to medications or the simple passage of time. Nonetheless, these results are quite promising and point to the need for future controlled trials with treatments assigned randomly. We will continue to run MBCT groups this year to check on the stability of these findings.

Publication

An article has been published to a peer-reviewed journal reporting our MBCT results. The article describes our findings and reports a case study (see the end of this web page). We have acknowledged the Danny Alberts Foundation as the main source of funding for this study.

Development of a Treatment Manual

Another tangible outcome from the Danny Alberts funding has been the development of a clinicians’ treatment manual for the MBCT for bipolar disorder. This manual is adapted from the original manual of Segal, Williams, & Teasdale (2002) as well as some of the psychoeducational materials used in Miklowitz’s (2008) family-focused treatment. After initial MBCT training, the manual can guide treatment by clinicians who want to apply this method to their bipolar patients. This is the first treatment manual applying MBCT to bipolar disorder, and is a first step in taking the treatment outside of the lab and into community treatment settings.

References

Miklowitz DJ. Bipolar disorder: a family-focused treatment approach. 2nd ed. New York, NY: Guilford Press; 2008.

Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press; 2002.

Williams JM, Alatiq Y, Crane C, Barnhofer T, Fennell MJ, Duggan DS, et al. Mindfulness-based Cognitive Therapy (MBCT) in bipolar disorder: Preliminary evaluation of immediate effects on between-episode functioning. Journal of Affective Disorders. 2007;Sept 18 issue.

Williams JMG, Duggan DS, Crane C, Fennell MJV. Mindfulness-based cognitive therapy for prevention of recurrence of suicidal behavior. Journal of Clinical Psychology, 2006;62:201-10.

Case Study

Sarah, 36 year-old woman with a husband and two children, was diagnosed with bipolar I disorder, with three severe episodes in the past 2 years. She had lost her job and her relationship with her husband and children had become strained. Sarah had had little experience with mindfulness before she started the program. Motivated to try anything that could be helpful beyond her medication regimen and individual therapy, Sarah came to every class and did her homework diligently. She found mindfulness practice to be helpful in dealing with her racing thoughts. When practicing a sitting meditation, she was more and more able to take a decentered, observing stance toward her thoughts, and had a sense that they were slowing down. She used this strategy outside of formal practice when she noticed this symptom returning. Furthermore, Sarah reported that practicing directed awareness helped her to notice earlier when she was becoming upset and angry. As a consequence, she began to use the 3-minute breathing space when she would ordinarily have had an angry outburst. Focusing on breathing distanced her from negative emotions and allowed her to more easily articulate to her husband what had upset her, which ultimately had a positive impact on their relationship.

There were times when Sarah had difficulty finding time for a formal meditation practice. During those times, she practiced present momentary awareness of the activity she was engaged in at the time (e.g., doing the dishes, playing with her children). She reported that this awareness had a calming effect on her and improved the quality of these moments, especially those with her children.

Sarah reported that, prior to the MBCT course, she had had difficulty recognizing the early warning signs of depression and mania. She began to recognize that experiencing everyone else as slow, observing an increased speed of her thinking, and feeling particularly good about herself were early signs of an oncoming manic episode. The reverse symptoms (e.g., experiencing others as too fast; slowing down of her thinking) more typically heralded the beginning of a depressive episode. At the end of the course, Sarah wrote a relapse prevention letter to herself, incorporating the early warning signs of mania and depression and what she hoped to do in the future when she noticed these occurring. Use of mindfulness skills played prominently in her plans.