Comparing the Efficacy of Pharmacotherapy Versus Combined Treatment of Cognitive Emotional Regulation Group Therapy and Pharmacotherapy on Manic and Depressive Symptoms, and Suicidal Thoughts in Patients With Bipolar Disorder Type I

Montazer , Samaneh; Karbalaee Mohammad Meigouni , Ahmad; Seirafi , Mohammad Reza

Volume 15 - Articles-1404 MEJDS (2025) 15: 90 | Back to browse issues page

Ethics code: IR.IAU.K.REC.1403.200

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Montazer S, Karbalaee Mohammad Meigouni A, Seirafi M R. Comparing the Efficacy of Pharmacotherapy Versus Combined Treatment of Cognitive Emotional Regulation Group Therapy and Pharmacotherapy on Manic and Depressive Symptoms, and Suicidal Thoughts in Patients With Bipolar Disorder Type I. MEJDS 2025; 15 (0) :90-90
URL: http://jdisabilstud.org/article-1-3621-en.html

Comparing the Efficacy of Pharmacotherapy Versus Combined Treatment of Cognitive Emotional Regulation Group Therapy and Pharmacotherapy on Manic and Depressive Symptoms, and Suicidal Thoughts in Patients With Bipolar Disorder Type I

Samaneh Montazer¹

, Ahmad Karbalaee Mohammad Meigouni ^*²

, Mohammad Reza Seirafi²

1- PhD Student in General Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran
2- Assistant Professor, Department of Psychology, Karaj Branch, Islamic Azad University, Karaj, Iran

Abstract: (789 Views)

Abstract
Background & Objectives: Bipolar disorder can have profound effects on various aspects of patients' lives. Among the different types of bipolar disorder, type I bipolar disorder is associated with greater vulnerability. If depressive and manic symptoms remain uncontrolled in individuals with bipolar disorder, the patients may exhibit isolative behaviors, including self–harming ones such as suicide. Given the significance of manic symptoms, depression, and suicidal ideation in individuals with bipolar disorder, identifying effective therapeutic approaches is crucial. The dominant approach for treating bipolar disorder is pharmacotherapy, primarily involving mood stabilizers.
Additionally, considering the prominent role of mood fluctuations in bipolar disorder, intervention programs focusing on emotion regulation appear to be beneficial. One widely used emotion regulation therapy is the Cognitive Emotion Regulation Program (CERP), which helps individuals better understand and manage their moods and emotions. Given that the cost–effectiveness of treatment programs is very important, this study aims to compare the effectiveness of pharmacotherapy versus combined group–based cognitive emotion regulation therapy with pharmacotherapy on manic and depressive symptoms and suicidal ideation in patients diagnosed with type I bipolar disorder.
Methods: This quasi–experimental research employed a pretest–posttest and follow–up design. The study population consisted of all patients diagnosed with bipolar disorder inpatients at Payambarān Hospital in Tehran City, Iran, in 2024. Thirty eligible individuals voluntarily participated in the study and were randomly assigned to either pharmacotherapy (n = 15) or combined treatment (n = 15) groups. The following inclusion criteria were considered for participants: 1) having a diagnosis of type I bipolar disorder, 2) age range of 20–40 years, 3) being hospitalized and receiving pharmacotherapy, and 4) not receiving electroconvulsive therapy. Additionally, the following exclusion criteria were applied: 1) missing more than two sessions and 2) having a history of participation in other individual or group therapy programs concurrently with the present study. To prevent sample loss or attrition, a briefing session was held with patients and their families, during which detailed explanations were provided about the importance of the study and the impact of their participation on the results, to increase their sense of responsibility and commitment. Telephone or text messages were also kept with participants and their families throughout the study.
Additionally, an effort was made to establish a strong therapeutic relationship, aiming to build trust between participants and the research team and increase their commitment to attending the sessions. Additionally, the session times were tailored to the participants' schedules. After evaluating the inclusion/exclusion criteria, eligible individuals participated in the study. Data collection was performed using structured diagnostic interviews, the Mania Rating Scale (Young et al., 1978), the Beck Depression Inventory–II (Beck et al., 1996), and the Beck Suicidal Ideation Scale (Beck et al., 1979). One experimental group received pharmacotherapy, and the second experimental group received Gross's Cognitive Emotion Regulation Protocol (2014) in addition to pharmacotherapy. Data were analyzed using the Student's t test, Chi–square test, repeated measures analysis of variance, and Bonferroni post hoc test at a significance level of 0.05 in SPSS software version 26.
Results: Results showed that the within–group time effect was significant for manic symptoms (p<0.001), death wish (p<0.001), suicidal preparedness (p<0.001), active suicidal ideation (p=0.011), and total suicide score (p<0.001). The group effect was significant for manic symptoms (p=0.009), depressive symptoms (p<0.001), death wish (p<0.001), suicidal preparedness (p=0.002), and actual suicidal tendencies (p<0.001), indicating there were significant differences between the two interventions and combined treatment was more effective than pharmacotherapy.
Conclusion: According to the research findings, it is recommended to develop structured treatment programs that incorporate both pharmacotherapy and group–based cognitive emotion regulation therapy as a primary approach for patients with type I bipolar disorder. Therefore, treatment teams should consider designing structured therapeutic protocols that integrate pharmacotherapy with cognitive emotion regulation group therapy as a first–line intervention for type I bipolar disorder.

Keywords: Pharmacotherapy, Cognitive emotional regulation, Mania, Depression, Suicide, Bipolar disorder type I

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Type of Study: Original Research Article | Subject: Psychology

References

1. Harvey D, Lobban F, Rayson P, Warner A, Jones S. Natural language processing methods and bipolar disorder: scoping review. JMIR Ment Health. 2022;9(4):e35928. [DOI]

2. Carvalho AF, Hsu C-W, Vieta E, Solmi M, Marx W, Berk M, et al. Mortality and lithium-protective effects after first-episode mania diagnosis in bipolar disorder: a nationwide retrospective cohort study in Taiwan. Psychother Psychosom. 2024;93(1):36-45. [DOI]

3. Verdolini N, Hidalgo‐Mazzei D, Del Matto L, Muscas M, Pacchiarotti I, Murru A, et al. Long‐term treatment of bipolar disorder type I: a systematic and critical review of clinical guidelines with derived practice algorithms. Bipolar Disord. 2021;23(4):324-40. [DOI]

4. Bartoli F, Callovini T, Cavaleri D, Cioni RM, Bachi B, Calabrese A, et al. Clinical correlates of comorbid attention deficit hyperactivity disorder in adults suffering from bipolar disorder: a meta-analysis. Aust N Z J Psychiatry. 2023;57(1):34-48. [DOI]

5. Fornaro M, Carvalho AF, Fusco A, Anastasia A, Solmi M, Berk M, et al. The concept and management of acute episodes of treatment-resistant bipolar disorder: a systematic review and exploratory meta-analysis of randomized controlled trials. J Affect Disord. 2020;276:970-83. [DOI]

6. Tsuboi T, Suzuki T, Azekawa T, Adachi N, Ueda H, Edagawa K, et al. Factors associated with non-remission in bipolar disorder: the multicenter treatment survey for bipolar disorder in psychiatric outpatient clinics (MUSUBI). Neuropsychiatr Dis Treat. 2020:881-90. [DOI]

7. Rantala MJ, Luoto S, Borráz-León JI, Krams I. Bipolar disorder: an evolutionary psychoneuroimmunological approach. Neurosci Biobehav Rev. 2021;122:28-37. [DOI]

8. Tsapekos D, Seccomandi B, Mantingh T, Cella M, Wykes T, Young AH. Cognitive enhancement interventions for people with bipolar disorder: A systematic review of methodological quality, treatment approaches, and outcomes. Bipolar Disord. 2020;22(3):216-30. [DOI]

9. Nestsiarovich A, Gaudiot CE, Baldessarini RJ, Vieta E, Zhu Y, Tohen M. Preventing new episodes of bipolar disorder in adults: systematic review and meta-analysis of randomized controlled trials. Eur Neuropsychopharmacol. 2022;54:75-89. [DOI]

10. Zakowicz P, Skibińska M, Wasicka-Przewoźna K, Skulimowski B, Waśniewski F, Chorzepa A, et al. Impulsivity as a risk factor for suicide in bipolar disorder. Front Psychiatry. 2021;12:706933. [DOI]

11. Hu F-H, Jia Y-J, Zhao D-Y, Fu X-L, Zhang W-Q, Tang W, et al. Gender differences in suicide among patients with bipolar disorder: a systematic review and meta-analysis. J Affect Disord. 2023;339:601-14. [DOI]

12. Nierenberg AA, Agustini B, Köhler-Forsberg O, Cusin C, Katz D, Sylvia LG, et al. Diagnosis and treatment of bipolar disorder: a review. JAMA. 2023;330(14):1370-80. [DOI]

13. Lane NM, Smith DJ. Bipolar disorder: diagnosis, treatment and future directions. R Coll Physicians Edinb. 2023;53(3):192-6. [DOI]

14. Hsu CW, Carvalho AF, Tsai SY, Wang LJ, Tseng PT, Lin PY, et al. Lithium concentration and recurrence risk during maintenance treatment of bipolar disorder: Multicenter cohort and meta‐analysis. Acta Psychiatr Scand. 2021;144(4):368-78. [DOI]

15. Dodd A, Lockwood E, Mansell W, Palmier-Claus J. Emotion regulation strategies in bipolar disorder: a systematic and critical review. J Affect Disord. 2019;246:262-84. [DOI]

16. Mennin DS, Fresco DM. Emotion regulation therapy. In: Gross JJ, editor. Handbook of emotion regulation. 2nd edition. New York: Guilford Press; 2014. pp. 469–90.

17. McRae K. Cognitive emotion regulation: a review of theory and scientific findings. Curr Opin Behav Sci. 2016;10:119-24. [DOI]

18. Renna ME, Quintero JM, Fresco DM, Mennin DS. Emotion regulation therapy: a mechanism-targeted treatment for disorders of distress. Front Psychol. 2017;8:98. [DOI]

19. Park DY, Do D, Chang L, Shah S, Yuen LD, Hooshmand F, et al. Episode accumulation associated with hastened recurrence and delayed recovery in bipolar disorder. J Affect Disord. 2018;227:657-64. [DOI]

20. Kadkhodaei M. The effectiveness of group training in cognitive emotion regulation on reducing suicidal thoughts and emotional schemas of individuals with suicide attempts. Journal of New Achievements in Humanities Studies. 2014;5(50):95-104. [Persian] [Article]

21. Young RC, Biggs JT, Ziegler VE, Meyer DA. A Rating Scale for Mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133(5):429-35. [DOI]

22. Barakatin M, Tavakoli M, Molavi H, Maroufi M, Salehi M. Normative assessment, reliability and validity of Young's Mania Assessment Scale. Journal of Psychology. 2007;42:150-66. [Persian]

23. Beck AT, Steer RA, Brown G. Beck Depression Inventory–II. Psychol Assess; 1996. [DOI]

24. Lien IA, Bolstad I, Lien L, Bramness JG. Screening for depression in patients in treatment for alcohol use disorder using the Beck Depression Inventory-II and the Hopkins Symptom Checklist-10. Psychiatry Research. 2022;308:114363. [DOI]

25. Taheri Tanjani P, Hamidi R, Fekrizadeh Z, Azadbakht M, Garmaroudi G, Fathizadeh S, et al. Validity and reliability Beck Depression Inventory-II among the Iranian elderly Population. Journal of Sabzevar University of Medical Sciences. 2015;22(1):189-98. [Persian] [Article]

26. Beck AT, Kovacs M, Weissman A. Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol. 1979;47(2):343. [DOI]

27. Anisi J, Fathi Ashtiani A, Salimi H, Ahmadi K. Evaluation of the reliability and validity of the Beck Suicidal Ideation Scale in soldiers. Journal of Military Medicine. 2005;7(1):37-54. [Persian] [Article]

28. Gross JJ. Emotion regulation: conceptual and empirical foundations. In: Gross JJ, editor. Handbook of emotion regulation. 2nd edition. New York: Guilford Press; 2014. pp. 3–20.

29. Mirsepasi Z. Rehabilitation in bipolar disorder. In: The First Congress on Mood Disorders. Iran University of Medical Sciences, Tehran, Iran; 2016. [Persian] [Article]

30. Semnani Y. Early therapeutic interventions in bipolar disorder. In: The First Congress on Mood Disorders. Iran University of Medical Sciences, Tehran, Iran; 2016. [Persian] [Article]

31. Aiff H, Attman P-O, Ramsauer B, Schön S, Svedlund J. Cardiovascular comorbidity increases the risk for renal failure during prophylactic lithium treatment. J Affect Disord. 2019;243:416-20. [DOI]

32. Rajabi F. The importance of perinatal management of bipolar disorder. In: The First Congress on Mood Disorders. Iran University of Medical Sciences, Tehran, Iran; 2016. [Persian] [Article]

33. Sedighi G. Treatment of bipolar depression. In: The 28th Annual Conference of the Iranian Psychiatric Association. Tehran, Iran; 2011. [Persian] [Article]

34. Eisner L, Eddie D, Harley R, Jacobo M, Nierenberg AA, Deckersbach T. Dialectical behavior therapy group skills training for bipolar disorder. Behavior Therapy. 2017;48(4):557-66. [DOI]

35. Pacchiarotti I, Anmella G, Colomer L, Vieta E. How to treat mania. Acta Psychiatr Scand. 2020;142(3):173-92. [DOI]

36. Yolken R, Adamos M, Katsafanas E, Khushalani S, Origoni A, Savage C, et al. Individuals hospitalized with acute mania have increased exposure to antimicrobial medications. Bipolar Disord. 2016;18(5):404-9. [DOI]

37. Zhang J, Wang G, Yang X, Gao K. Efficacy and safety of electroconvulsive therapy plus medication versus medication alone in acute mania: a meta-analysis of randomized controlled trials. Psychiatry Research. 2021;302:114019. [DOI]

38. Hassas O, Mashhadi A, Shamloo ZS, Bordbar MRF. Emotional schema therapy for bipolar disorder: Improving emotional schemas, quality of life, cognitive emotion regulation, and symptom management. Int J Cogn Behav Ther. 2024;17(3):347-68. [DOI]

39. McGrogan CL, Dodd AL, Smith MA. Emotion regulation strategies in mania risk: a systematic review. Journal of clinical psychology. 2019;75(12):2106-18. [DOI]

40. Kurtz M, Mohring P, Förster K, Bauer M, Kanske P. Deficits in explicit emotion regulation in bipolar disorder: a systematic review. Int J Bipolar Disord. 2021;9:1-23. [DOI]

41. Meyer K, Attar CH, Fiebig J, Stamm T, Bassett TR, Bauer M, et al. Daring to feel: emotion-focused psychotherapy increases amygdala activation and connectivity in euthymic bipolar disorder—a randomized controlled trial. Biol Psychiatry Cogn Neurosci Neuroimaging. 2023;8(7):750-9. [DOI]

42. Van Rheenen TE, Murray G, Rossell SL. Emotion regulation in bipolar disorder: profile and utility in predicting trait mania and depression propensity. Psychiatry Research. 2015;225(3):425-32. [DOI]

43. Mahmoud Alilou M, Esmailpour K, Farzi A. The effectiveness of emotional regulation and mindfulness techniques based on dialectical behavior therapy in improving negative emotions (Depression, Anxiety, Anger) in borderline personality disorder. Journal of School of Public Health and Institute of Public Health Research (SJSPH ). 2023;21(1):101-22. [Persian] [Article]

44. Goldstein CM, Gathright EC, Garcia S. Relationship between depression and medication adherence in cardiovascular disease: the perfect challenge for the integrated care team. Patient Prefer Adherence. 2017:547-59. [DOI]

45. Davis AM, Graham TB, Zhu Y, McPheeters ML. Depression and medication nonadherence in childhood-onset systemic lupus erythematosus. Lupus. 2018;27(9):1532-41. [DOI]

46. Warwar S. The use of homework in emotion‐focused therapy for depression. Journal of Clinical Psychology. 2024;80(4):744-61. [DOI]

47. Alder MC, Dyer WJ, Sandberg JG, Davis SY, Holt-Lunstad J. Emotionally-focused therapy and treatment as usual comparison groups in decreasing depression: a clinical pilot study. Am J Fam Ther. 2018;46(5):541-55. [DOI]

48. Esmaeili A. Studying the level of suicidal tendencies in people diagnosed with bipolar disorder. Iranian Psychiatric Scientific Yearbook. 2017;28:16-8. [Persian]

49. Dodds TJ. Prescribed benzodiazepines and suicide risk: a review of the literature. Prim Care Companion CNS Disord. 2017;19(2):22746. [DOI]

50. D'Anci KE, Uhl S, Giradi G, Martin C. Treatments for the prevention and management of suicide: a systematic review. Annals of Internal Medicine. 2019;171(5):334-42. [DOI]

51. Schade LC. Non-suicidal self-injury (NSSI): a case for using emotionally focused family therapy. Contemp Fam Ther. 2013;35:568-82. [DOI]

52. Colmenero-Navarrete L, García-Sancho E, Salguero JM. Relationship between emotion regulation and suicide ideation and attempt in adults and adolescents: a systematic review. Arch Suicide Res. 2022;26(4):1702-35. [DOI]