Substance abuse compounds the problems of people with bipolar disorder. Individuals with this comorbidity get less benefit from their mood disorder treatment, recover more slowly from mood swings, spend more time in hospitals, and are more prone to committing suicide. They also are less responsive to drug abuse treatment than noncomorbid individuals, but a new psychosocial intervention may partially alleviate this disadvantage. The intervention, called integrated group therapy (IGT), simultaneously focuses on substance abuse and bipolar disorder. In a recent NIDA-funded clinical trial, IGT reduced patients' substance use more than standard substance abuse group counseling did.
"People with these disorders often feel hopeless about ever getting better," says Dr. Roger D. Weiss, professor of psychiatry at Harvard Medical School and chief of the Division of Alcohol and Drug Abuse at McLean Hospital in Belmont, Massachusetts. "They often feel that no matter what they do, it doesn't help; so they may stop trying." Dr. Weiss and colleagues developed and tested IGT with support from NIDA's Behavioral and Integrative Treatment Development Program.
Testing the Approach
All of the study's 62 participants had both bipolar disorder and substance dependence, and all were taking mood-stabilizing prescription medications. The majority had both alcohol and drug disorders; the most common primary drugs of abuse, in order of prevalence, were marijuana, cocaine, sedatives, and opioids. The researchers randomly assigned them to receive either IGT or standard, manual-based substance abuse counseling once per week in groups of six to eight. The two treatment groups did not differ in terms of patients' diagnostic categories, mood-stabilizer regimens, baseline substance use problems, or concurrent participation in individual counseling and 12-step programs.
|Average days of substance use per month||IGT*||Drug Counseling|
|Before group therapy||10.2||13.3|
|During group therapy||5.3||10.0|
|During the 3 months after group therapy||6.0||12.0|
|Average days of alcohol use per month||IGT*||Drug Counseling|
|Before group therapy||9.3||7.8|
|During group therapy||4.4||6.5|
|During the 3 months after group therapy||4.5||7.8|
|Average days of illicit use per month||IGT*||Drug Counseling|
|Before group therapy||6.7||9.7|
|During group therapy||2.1||5.2|
|During the 3 months after group therapy||3.4||6.5|
*Integrated Group Therapy
The IGT intervention is based on a cognitive-behavioral therapy model for relapse prevention. In each session, patients reported on their previous week's substance use, mood swings, medication adherence, and high-risk situations. Clinicians addressed the connections between bipolar disorders and substance abuse, covering topics such as methods to deal with depression without using alcohol or illicit drugs.
In the standard group drug counseling format, sessions began with patients' reports on substance use and craving. These groups focused primarily on substance use without providing explicit references to bipolar disorder signs or symptoms. When patients raised mood-related issues, counselors responded briefly and referred them to the physicians who had prescribed their mood-stabilizing medications. Counselors responded to mood-related emergencies, however, with clinically appropriate interventions.
During the 20-week trial, recipients of both therapies reduced their alcohol and illicit drug use as assessed by urine toxicology and self-reports (see table above). The IGT group showed greater reductions, and those in the group who achieved a month-long period of abstinence did so earlier than participants in the standard counseling group. In the 3 months following the therapy, substance use remained lower in the IGT group but returned to baseline levels in the standard counseling group.
Community-Friendly Version of Integrated Group Therapy Shows Promise
Although their research demonstrated that integrated group therapy (IGT) can foster recovery in abusers with bipolar disorder, a group of Massachusetts scientists recognized barriers that might prevent community programs from adopting the treatment. Now, they report that during a 12-week study, patients who received a modified IGT therapy, designed especially for delivery in community addiction treatment programs, were nearly twice as likely as those in standard drug counseling to attain 1 month of abstinence from illicit drugs and alcohol and nearly three times as likely to abstain for the entire period.
Dr. Roger D. Weiss, professor of psychiatry at Harvard Medical School and chief of the Division of Alcohol and Drug Abuse at McLean Hospital in Belmont, Massachusetts, and colleagues made three major changes in their IGT treatment:
- To increase the likelihood of insurance reimbursement, they decreased therapy from 20 to 12 group sessions.
- Rather than using counselors with experience in both substance abuse and psychiatric disorder treatment, the modified IGT program was delivered by addiction counselors who had received general information on bipolar disorder and the cognitive-behavioral therapeutic approach but who had little experience in these areas.
- Rather than participating as a single group for a predefined 12-week period, patients could join ongoing group therapy at any time, which is the usual practice in most community treatment programs.
All of the new study's 61 participants were taking mood-stabilizing medications. They were randomly assigned to one of two treatment groups and further divided into groups of six to eight members led by clinicians who provided either the modified IGT or standard, manual-based substance abuse counseling.
Both treatments helped patients reduce their days of substance use. Comparing results from the month before treatment began to the last month of treatment, drug use dropped from 18.6 days to 4.4 days in the modified IGT group and from 17.9 days to 6.5 days in the group receiving standard drug counseling. Of the patients who received modified IGT, 71 percent attained at least 1 month of abstinence from both drugs and alcohol during treatment, compared with 40 percent of those in standard group drug counseling. Modified-IGT patients also achieved their first month of abstinence sooner than those in group drug counseling. Moreover, 36 percent of the men and women who participated in modified IGT were abstinent throughout all 3 months of treatment, compared with only 13 percent of the patients in standard counseling.
About 70 percent of patients reported depression, mania, or a mixture of the two during treatment. Patients receiving modified IGT, however, were more than twice as likely as those in group drug counseling to be abstinent and to report no mood disorder episode during the final month of treatment.
"If the findings are borne out in future studies with larger numbers of patients, community addiction treatment programs could benefit from adding modified IGT to mood-stabilizing pharmacotherapies for people with co-occurring substance abuse and bipolar disorders," says Dr. Lisa Onken, chief of NIDA's Behaviorial and Integrated Treatment Branch. "This approach might not only improve outcomes in this difficult-to-treat group but also do so in a community-friendly way," she adds.
Weiss, R.D., et al. A "community-friendly" version of integrated group therapy for patients with bipolar disorder and substance dependence: A randomized controlled trial. Drug and Alcohol Dependence 104(3):212-219, 2009. [Abstract]
Alcohol use dropped more than illicit drug use in both groups. This result may reflect the greater severity of the patients' alcohol problems. "There was more room for improvement and perhaps greater motivation among patients to address their drinking," Dr. Weiss says.
Although IGT focuses on mood disorders as well as substance abuse, IGT group members experienced mood disorder episodes as frequently during and after treatment as they had before. In fact, they also received higher scores on two measures of mood symptoms than did members of the drug counseling groups. "It is unclear whether this reflects true mood differences or an increased awareness among IGT participants of mood symptoms more subtle than those that cause a bipolar episode," Dr. Weiss says. He notes that IGT encourages early recognition of mood changes, and he suggests that reduced substance use may temporarily worsen mood in people with bipolar disorder.
Appreciation and Engagement
According to Dr. Weiss, the participants in the IGT group appreciated having a treatment program tailored to their needs. "Many of our people had bounced back and forth between specialty programs for substance abuse and bipolar disorder, and in each program they felt that only some of their issues were being addressed," Dr. Weiss says.
Twelve study participants dropped out of therapy. When Dr. Weiss and colleagues analyzed the characteristics of these 12 dropouts, they were surprised to find that 11 were smokers. (Of the 49 participants who completed the study, 24 were smokers.) The researchers say that smokers with bipolar disorder may represent a subgroup that requires special efforts to engage in substance abuse treatment.
"IGT shows a lot of promise," says Dr. Lisa Onken, chief of NIDA's Behavioral and Integrative Treatment Branch. "Before Dr. Weiss and his colleagues began their work, we had many questions about how to treat people with bipolar and substance use disorders. The finding that IGT reduces days of substance use disorder indicates that this program is a meaningful step in the right direction.
"In addition, because IGT is group therapy, it's more likely to be used in community drug treatment centers, providing more individuals with comorbid bipolar and substance use disorders access to an evidence-based treatment that was designed specifically for their needs," Dr. Onken adds.
Weiss, R.D., et al. A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence. American Journal of Psychiatry 164(1):100-107, 2007. [Full Text]
Graff, F.S., Griffin, M.L., and Weiss, R.D. Predictors of dropout from group therapy among patients with bipolar and substance use disorders. Drug and Alcohol Dependence 94(1-3):272-275, 2008. [Full Text (PDF, 299KB)]