Psychosocial Management of Bipolar Disorder: Methodology of Performing a Systematic Review

By Dr Eden Fazel 

This article is deliberately divided in to subsections to discuss the topic thoroughly and systematically.

Methodology

In this article the author details how a researcher should conduct a systematic review of bipolar disorder. This will help future reviewers to conduct their reviews according to the most scientific standards of the day.

Review Methods

In contrast to a narrative review, the author provides a summary of randomized controlled trials on the specific and focused clinical question of the review, using explicit methods to search, critically appraise, and synthesized the literature systematically. He brings together a number of separately conducted studies, regardless of their findings, and synthesis their results.

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The reviewer is well aware of the needed rigor in the preparation of a systematic review and conducts a formal process for this purpose. This includes a comprehensive and systematic search for primary studies on the focused question, followed by selection of studies using clear and reproducible eligibility criteria, critical quality appraisal of primary studies, and finally synthesis of results according to predetermined and explicit methods.

Aims and objectives

The author endeavors to examine the effectiveness of various types of adjunct psychosocial interventions in management of bipolar affective disorder, using an explicit a priori methodology according to a standard review protocol.

A protocol was developed to minimize bias, by taking all key methodological decisions clearly and systematically, before going to the literature. The protocol aimed to set out the tasks and clear and explicit methods to be followed in this systematic review and to ensure that results are reproducible.

Focused question: Are different methods of adjunct psychosocial management for people with bipolar disorder useful, effective and superior to standard medical treatment solo, in relapse prevention, functional improvement, and reduction of severity and duration of bipolar episodes?

Definition of psychosocial management for the purpose of conducting a systematic review: Psychosocial management is an umbrella term used to cover various forms of psychological therapies used in the management of bipolar disorder. This includes cognitive therapy, family focused therapy, interpersonal and social rhythm therapy, psycho-education, and relapse prevention. The author includes studies where some of the following elements were considered:

1) Education about the illness: All forms of studies included should have offered general education to the subjects of the study intervention arm, in order to improve the individual’s awareness and understanding of bipolar disorder.

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2) Monitoring and self regulation: Monitoring, vigilance, identification and management of acute symptoms and relapse prevention should have been part of
the agenda for the intervention arm. Individual’s ability to recognize and manage the relapse prodromes or the internal and external stressors that may increase their vulnerability to future relapse should have been discussed.

3) Enhancement of adherence to pharmacotherapy: Among the included studies, forming a therapeutic alliance with the psychiatrist and importance of adherence to pharmacotherapy should have been discussed to the therapy group. Management of side effects, and pros and cons of medical treatment and dangers of abrupt treatment withdrawal should have been discussed.

4) Cognitive processes in bipolar disorder should have been discussed with the intervention arm of included studies. This might include education on techniques to monitor, examine and change dysfunctional habits and behavior associated with undesirable mood consequences.

5) Studies included should have described the content and duration of the psychological therapy for the intervention arm, and have a follow up period of at least two years.

6) A minimum total of 6 sessions should have been delivered to the study participants included in each study.

The above mentioned elements are considered to be integral parts of psychosocial management of bipolar disorder. Different treatment regimes, might give more weight and emphasis on one or the other, but it is deemed necessary for some of the above elements to be introduced, no matter how briefly through the course of therapy provided.

Eligibility criteria with rationales

Type of studies

Randomized controlled trials, Nonrandomised and quasi-randomized trials should not included.

Rationale: The reviewers only includes RCTs, for the reason that randomized trials are the gold standard of examination of effectiveness, they ensure random allocation to intervention and control arms of the studies, help eliminate selection bias, and ensure the similarity in characteristics and treatments of both groups in the long run, except for the intervention under study.

Participants

1) In all included studies, all patients had a diagnosis of bipolar disorder I or bipolar disorder II, according to explicit diagnostic criteria, identified by structured clinical interviews.

Rationale: To avoid bias resulting from different definitions between studies the author restricts the review to studies using DSM IV criteria as the reference standard for mental disorders.

2) Studies should had not solely recruited patients who were suffering from acute mania or patients who were hospitalized in acute wards at the point of recruitment. Studies should have not recruited patients with only depressive or manic episodes.

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