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Outcome of group psychoeducation for stabilised bipolar disorders: needs further clarification
- Navendu Gaur, Sandeep Grover, Assistant Professor, Department of Psychiatry, PGIMER, Chandigarh, India (7 April 2009)
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Outcome of group psychoeducation for stabilised bipolar disorders: everything is quite clear (now)
- Francesc Colom, Eduard Vieta (13 May 2009)
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Navendu Gaur, Senior Resident, Department of Psychiatry, PGIMER, Chandigarh, India , Sandeep Grover, Assistant Professor, Department of Psychiatry, PGIMER, Chandigarh, India
Send letter to journal:
drsandeepg2002{at}yahoo.com Navendu Gaur, et al.
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The article by Colom et al.1 further enhanced our understanding about the role of psychoeducation in the management of bipolar disorders. The study draws its strengths from the fact that it included an active control group, included subjects of bipolar disorder with axis-II comorbidity, follow-up rates were excellent and the authors assessed the outcome in the form of number and type of recurrences, time to recurrence, time spent ill and number of hospitalizations at 5 years. However, some of the issues require further clarification. When one looks at the article reporting 2 year follow-up of the same cohort2, there the authors report that subjects with Axis-I comorbidity were excluded, but at 5 year follow-up the authors report that only those with severe axis-I diagnosis were excluded. Further the authors don’t define “severe”. Subjects with bipolar disorders can have high rate of comorbidity, hence clarification of this fact is very important from the perspective of generalizability of the findings of the study. Further, authors don’t provide details of status and/or type of Axis-I/II comorbidities and whether the drop out and completers had any difference with regard to clinical and demographic features. Another important aspect is the way the authors defined recurrence based on rating scale scores. This kind of definition in true sense doesn’t include the subsyndromal symptoms and can influence almost all the outcome measures like time spent ill, time to recurrence and also the number of recurrences, especially when the cohort is being followed up at a frequency of every 2 weeks. Similarly, although the study included number and duration of hospitalization as an outcome measure the author have not discussed the criteria for hospitalization. Another important aspect which needs clarification is the analysis of data. At many places the authors have used parametric test to compare the numerical variables although the standard deviation is more than the mean. Similarly, mean values are given for number of recurrence without standard deviations while comparison statistics are given as F values. In the Table 2, again the authors have compared the mean values using Fisher F statistics and have presented that there was significant difference in number of days spent in each episode for all types of episodes. However when one looks at the data, it is difficult to understand this contention. In the same table when one adds the mean number of days spent in each episode for the control group the data regarding each episode and the total duration do tally, but same is not the case for the psychoeducation group. References: 1. Colom F, Vieta E, Sánchez-Moreno J, Palomino-Otiniano R, Reinares M, Goikolea JM, Benabarre A, Martínez-Arán A. Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial. Br J Psychiatry 2009; 194:260-5. 2. Colom F, Vieta E, Martinez-Aran A, Reinares M, Goikolea JM, Benabarre A, Torrent C, Comes M, Corbella B, Parramon G, Corominas J. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Arch Gen Psychiatry 2003; 60: 402-7. |
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Francesc Colom, Senior Researcher Bipolar Disorders Program, IDIBAPS, CIBERSAM, Barcelona , Spain, Eduard Vieta
Send letter to journal:
fcolom{at}clinic.ub.es Francesc Colom, et al.
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Dear Sir, In response to Dr Navendu Gaur kind queries on our article “Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial” (Colom et al., The British Journal of Psychiatry 2009; 194: 260-265), we would like to provide some clarifications: 1. Only those patients with “severe” axis I comorbidity diagnoses were excluded. This means that patients were excluded in the case that they presented with a coexisting axis-I condition that might have a major impact on their ability to effectively participate in the groups, such as severe social phobia or obsessive compulsive disorder, for instance. 2. Regarding details of status and/or type of Axis-I/II comorbidities, we would like to point out that this was already covered for the 2-year follow-up in a previous paper (Colom et al., 2004). 3. We defined recurrence both based on severity ratings AND DSM-IV criteria; these are narrow criteria which are much more reliable than just asking for diagnostic criteria alone OR rating scale scores. We disregarded the possibility of using a life-chart method to catch subsyndromal fluctuations because this method has not shown good reliability and would likely capture a lot of noise. 4. Criteria for hospitalization were those used at the Barcelona Bipolar Disorders Program; any patient presenting an episode that due to its severity can not be managed in an outpatient setting and/or any patient presenting suicide risk or representing a risk for third persons. 5. As clearly explained in our manuscript, the primary outcome of the trial was time to recurrence. Secondary outcomes included time spent ill and number of recurrences. Our original submission included a full data report on those secondary variables, which had to be condensed due to space constraints. The analysis of number of recurrences was, as explained in methods, perfomed by means of ANCOVA and therefore the mean values for each group are just orientative. 6. We acknowledge a typo mistake on table 2 referring to the number of days spent in depression. The right values should be: Control group 398.55 (364.16), Psychoeducation group 93,28 (165,46). Apparently, the standard deviation for the control group was mistakenly repeated replacing the mean number of days spent in depression for the Psychoeducation group. After correcting this error, data regarding mean number of days spent in each episode tally with the total duration for both groups. As this was only a typo mistake, it does not change any statistics. We have been informed of this mistake by other readers and have already proceeded to issue the corresponding erratum. We would like to thank Dr Gaur for his comments and British Journal of Psychiatry for giving us the opportunity to further clarify them. |
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