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Interventions for helping people recognise early signs of recurrence in bipolar disorder

  • Review
  • Intervention




Recurrence rates for bipolar disorder are high despite effective treatments with mood stabiliser drugs. Self-help treatments and psychological treatments that teach patients to recognise and manage early warning symptoms and signs (EWS) of impending manic or depressive episodes are popular with patients. The main aim of such interventions is to intervene early and prevent bipolar episodes, thereby increasing the time to the next recurrence and preventing hospitalisation.


To compare the effectiveness of an EWS intervention plus treatment as usual (TAU ) versus TAU (involving and not involving a psychological therapy) on time to manic, depressive and all bipolar episodes (the primary outcome), hospitalisation, functioning, depressive and manic symptoms.

Search methods

Relevant studies identified by searching Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers (CCDANCTR-Studies and CCDANCTR-References - searched on 20/10/2005), supplemented with hand searching the journal Bipolar Disorders, searching the UK National Research Register, checking reference lists of included studies and contacting authors.

Selection criteria

Only randomised controlled trials (RCTs) were included. Participants were adults with a diagnosis of bipolar disorder based on standardised psychiatric criteria.

Data collection and analysis

Two reviewers independently rated trials for inclusion. Data were extracted from included trials by reviewers using a data extraction sheet. Authors of all the included studies were contacted for any additional information required. Time to recurrence data was summarised as log hazard ratios, dichotomous data as relative risk and continuous data as weighted mean difference, using random effects models to calculate effect size only when there was heterogeneity in the data.

Main results

Eleven RCTs were identified, but only six provided primary outcome data. All six RCTs were of high quality. Time to first recurrence of any type (RE, hazards ratio 0.57, 95% CI 0.39 to 0.82), time to manic/hypomanic episode, time to depressive episode, and percentage of people hospitalised and functioning favoured the intervention group. Neither depressive nor hypomanic symptoms differed between intervention and control groups.

Authors' conclusions

This review shows a beneficial effect of EWS in time to recurrence, percentage of people hospitalised and functioning in people with bipolar disorder. However, the absence of data on the primary outcome measure in so many included studies is a source of concern and a potential source of bias. Mental health services should consider routinely providing EWS interventions to adults with bipolar disorder, as they appear to reduce hospitalisation and therefore may be cost-effective.




雙極性情感性疾病的復發率是很高的,即使在有效的情緒穩定劑控制下。那些教育病人辨識並處理早期鬱期或躁期預警症狀和跡象(EWS)的自我協助(self help)治療和心理治療是十分受歡迎的。此介入的主要目的在於早期介入,預防復發,因而延後下次復發的時間以及避免住院。




相關的試驗都是從搜尋Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Registers(CCDANCTRStudies and CCDANCTRReferences  searched on 20/10/2005),和人工搜尋 journal Bipolar Disorders, the UK National Research Register而來,並確認所有納入試驗的相關清單和作者。




兩位評論者獨立地評價納入的試驗。評論者以data extraction sheet從納入試驗來摘錄資料。所有納入研究的作者被聯繫以提供任何額外的資訊。復發時間的資料被摘要為log hazard ratios,歧異性資料為relative risk而連續性資料為weighted mean difference,當資料存在異質性時使用random effects models來計算effect size。


11個RCTs被找出來,但只有六個提供了初步結果的資料。所有六個RCTs都是高品質的。任何形式第一次復發的時間(RE, hazards ratio 0.57, 95% CI 0.39 to 0.82),躁期/輕躁期發作的時間,鬱期發作的時間,病人住院的比例以及功能方面都偏好接受介入這個族群。憂鬱症狀和輕躁症狀在接受介入和對照組並無不同。





此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。


介入可以幫助人們分辨雙極性疾病復發的早期跡象。雙極性疾病(BPD)或是躁鬱精神病是一個非常嚴重的精神疾病,終生盛行率1∼2 %。BPD的特徵是躁期和鬱期兩種形式的反覆發作。即使在有效的治療範圍下,高復發率以及相關不良的影響仍會發生。早期預警跡象(EWS)的介入,目的在改善狂躁和憂鬱症狀的辨識以及自我處理,並想要訓練復發的雙極性情感性患者去辨識復發的早期預警跡象和避開不良的結果。這篇回顧顯示,在常態的治療方式(TAU)如藥物或是和專業人員的規則預約之外,這些介入對於復發的時間和住院是有幫助的。只和TAU比較,EWS介入也產生18個月的功能改善,雖然這些資料很稀少而且其發現需要小心地解讀。EWS介入對憂鬱或狂躁症狀似乎沒有效果,但再一次,這些發現是根據少數可能被選到的緩解病人。應該注意的是,EWS和其他心理介入一起使用,使得不完全清楚有助益效果的那個部分是因為單獨EWS介入的關係。

Plain language summary

Interventions for helping people recognise early signs of recurrence in bipolar disorder

Bipolar disorder (BPD), or manic-depressive psychosis, is a common and severe mental illness, with a lifetime prevalence of 1-2%. BPD is characterised by two types of recurrence, mania and depression. High rates of recurrence and associated adverse consequences occur in spite of a range of effective treatments. Early warning signs (EWS) interventions, targeted at improving the recognition and self-management of manic and depressive symptoms, are intended to train people with recurrent bipolar affective disorder to recognise early warning signs of recurrence and to avert adverse outcomes. This review demonstrated that these interventions, in addition to treatment as usual (TAU), including medication and regular appointments with health professionals, have benefits on time to recurrence and hospitalisation. Compared with TAU only, EWS interventions also resulted in improved functioning at eighteen months, although these data were sparse and the findings should be interpreted with caution. EWS interventions did not appear to have any effect on depressive or manic symptoms, although again, these findings were based on small numbers of potentially selected patients in remission. It should be noted that EWS was used along with other psychological interventions, and it is not entirely clear what proportion of the beneficial effect was due to the EWS intervention alone.