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Psychoeducation in bipolar disorder: A systematic review

BACKGROUND Bipolar disorder (BD) is a severe psychiatric disorder characterized by mood swings. Psychosocial interventions, such as psychoeducation, play an essential role in promoting social rehabilitation and improving pharmacological treatment. AIM To investigate the role of psychoeducation in BD. METHODS A systematic review of original studies regarding psychoeducation interventions in patients with BD and their relatives was developed. A systematic literature search was performed using the Medline, Scopus, and Lilacs databases. No review articles or qualitative studies were included in the analysis. There were no date restriction criteria, and studies published up to April 2021 were included. RESULTS A total of forty-seven studies were selected for this review. Thirty-eight studies included patients, and nine included family members. Psychoeducation of patients and family members was associated with a lower number of new mood episodes and a reduction in number and length of stay of hospitalizations. Psychoeducational interventions with patients are associated with improved adherence to drug treatment. The strategies studied in patients and family members do not interfere with the severity of symptoms of mania or depression or with the patient's quality of life or functionality. Psychoeducational interventions with family members do not alter patients' adherence to pharmacotherapy. CONCLUSION Psychoeducation as an adjunct strategy to pharmacotherapy in the treatment of BD leads to a reduction in the frequency of new mood episodes, length of hospital stay and adherence to drug therapy.


INTRODUCTION
Bipolar disorder (BD) is a chronic mental health illness characterized by mood swings [1]. It is estimated that more than 1% of the world population is affected by BD[2,3]. The prevalence rates for each BD subtype, I and II, in community-based samples are 0.6% and 1.4%, respectively, and the mean age of onset of the disease is approximately 20 years [2,3]. Poor treatment adherence is associated with mood swings, social stigmatization, and lower social support in BD [4]. Psychosocial interventions might play an essential role in promoting social rehabilitation and improving pharmacotherapy adherence. Studies have demonstrated that non-pharmacological interventions, such as psychoeducation and cognitive-behavioral and interpersonal therapy, promote effects in the treatment of acute mood episodes and maintenance treatment in BD [5]. These actions favors the early recognition of warning signs of mood instability and promote the development of healthier lifestyles [4].
Psychoeducation is an intervention strategy based on providing patients and/or relatives with information about the disorder to enhance their understanding and enable early identification of warning signs and mood changes, improving treatment adherence [5][6][7]. Psychoeducational strategies in BD might promote the frequency of new mood episodes and medication adherence [8]. The Barcelona Psychoeducation Program was associated with an almost ninefold decrease ratios regarding new mood episodes and reduced the number of symptomatic days, as well as the hospitalization's length of stay (LOS) [9]. Family psychoeducation intervention has been correlated with mood episode reduction in patients with BD [7]. When family members acquire better knowledge about the disorder, they contribute to the early detection of the first symptoms of changes in mood [10,11].
This systematic review aims to investigate the role of psychoeducation in BD in patients and in their family members.

Search strategies and selection criteria
The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist. A systematic literature search was performed through the Medline (Medical Literature Analysis and Retrieval System Online/PubMed), Scopus and Lilacs databases. Studies published up to April 2021 were included. The key terms used were "bipolar disorder" and "psychoeducation". Studies in Portuguese and English were selected. Two independent reviewers (J.L.R. and I.G.B) analyzed the titles and abstracts; afterward, texts that fulfilled the requirements were included. The inclusion criteria were as follows: (1) Original psychoeducation intervention studies; (2) Placebo-controlled studies; and (3) Interventions aimed at adult patients with BD. The exclusion criteria were as follows: (1) Review, case series, and case report; (2) Interventions aimed at groups of patients with other mental or behavioral disorders; (3) Book chapters or reviews, systematic reviews or meta-analyses; (4) Studies written in languages other than English or Portuguese; (5) Low-quality studies according to the Newcastle-Ottawa scale (NOS) scale; and (6) Interventions aimed at children or adolescent patients with BD. Only original studies with a control group or baseline data for psychoeducation interventions in patients with BD and their relatives were included.

Data extraction and quality assessment
The systematic review has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) with registration number CRD42020168910.
We developed a data extraction table based on a Cochrane model [12]. One of the revisors (J.L.R.) extracted data and another (I.G.B) verified them. To reduce selection bias, two revisors (J.L.R. and I.G.B.) assessed the methodological quality of all the studies according to the NOS criteria [13]. The NOS is a "star system"-based scale, which scores a maximum of 4 stars corresponding to selecting studying groups, 3 stars for the ascertainment of either the exposure or outcome of interest, and 2 for the comparability of the groups; thus, the total NOS maximum score is 9. In the present study, we considered a minimum score of 5 on the NOS scale sufficient to be included [13]. In the circumstances of any disagreement between those 2 revisors, a third revisor was consulted (B.F.C) for consensus.
All extracted data included information about publication (including author name and year of publication), some group characteristics (sample size, gender, mean age, mood state and subtype of BD), methods (psychoeducation protocols; number of sessions; instruments that were applied, and who had performed them; kind of study, either a blinded or a randomized one) and their main outcomes.

Description of studies
Six hundred sixty-seven publications were identified from the literature search (PubMed: Five hundred and eighty-four; Scopus: Sixty-one and Lilacs: Twenty-four). Duplicated studies were excluded (n = 34). Five hundred thirty-nine were excluded after title and abstract screening. Twenty studies were included from manual extraction. Seventy-two studies were excluded: Four of these were article reviews; thirty-seven did not include psychoeducation treatment; four were about intervention strategies in patients under 18 years of age; five studies were qualitative studies; one study was about a protocol; and thirteen studies were duplicated. Eight studies were classified as low quality according to the NOS scale (i.e., scored less than or equal to five stars) and were excluded from the present manuscript. A total of forty-seven publications were selected for this review, of which thirty-eight studies included patients with BD and nine studies included relatives of patients with BD ( Figure 1). Eight studies evaluated Group psychoeducation (GP) [45][46][47][48][49][50][51]. BD included in the GP compared to controls exhibited a longer interval between mood episodes [44], higher adherence to pharmacological treatment [45,46], and lower rates of hospital admissions [44]. GP interventions were not associated with functional, social or family improvements [
Four studies diagnosed patients according to the DSM-III criteria [49,[51][52][53], and four studies applied the DSM-IV[46- 48,50]. One study did not state the BD diagnostic criteria [50]. Two studies assessed BD type I and BD type II patients [48,50]  the BD type [45,47,51,53]. One hundred thirteen relatives were included in psychoeducation programs: one hundred and six were couples; twelve were sons/daughters; and ten were brothers/ sisters. Fifty-four parents were included in the control groups, eighty-nine were couples, two were sons/daughters, six were brothers/sisters, and two were friends.
Psychoeducation programs aimed at family members of patients with BD: Psychoeducation interventions and outcomes are summarized in Table 4. Two studies [52,53] compared the program of pharmacotherapy and FFT and Crisis management with naturalistic follow-up (CMNF). There was no difference in the severity of mood symptoms after a one-year follow-up[52]. There was a reduction in the frequency of mood episodes in the FFT compared to the CMNF [52].
Three studies assessed the psychoeducational family intervention (PFI) strategy compared to a nonintervention control group [51,53,54]. There were no improvements in the frequency of mood episodes [50], adherence to treatment [53], or caregiver burden [55]. The group submitted to PFI showed a significant improvement in relation December 19, 2021 Volume 11 Issue 12 to the perception of professional support received and help in times of emergency [51].
Two studies compared multifamily group psychoeducation, individual family therapy (IFT), and solution focused group psychotherapy (SFGP) [52,54]. There were no differences between these strategies regarding reduction in frequency of mood episodes [53,56], quality of life[52], or changes in functional status [53,54]. One study found that parents submitted to IFT reduced the incidence of hospital admissions [54].
The Guide for Caregivers of People with BD [50] was not associated with changes in relatives' symptoms of anxiety, depression or mania; stress discharge; knowledge of the disease; or changes in the caregiver burden [50].

DISCUSSION
Psychoeducation applied to BD patients and their relatives is associated with a reduction in the frequency of new mood episodes and a reduction in the number of hospital admissions and LOS. Psychoeducational interventions applied to patients contribute to improvement in pharmacological treatment adherence. Psychoeducation does not seem to influence the severity of depressive or manic symptoms or functionality. PMBD was associated with a higher adherence to pharmacological treatment and a higher quality of life in one study [23]. Psychoeducation strategies applied to relatives had no effect on adherence to pharmacological treatment.
Psychoeducational strategies in patients with BD are associated with a lower frequency of mood swings. These results are in line with a previous meta-analysis that evaluated 650 patients; 45% did not present a new mood episode compared to 30% of controls [54]. A possible explanation for this association is that the occurrence of subsyndromal symptoms is one of the main risk factors for new episodes [57,58]. Psychoeducational strategies in patients promote increased understanding about their own disease[59], improve the abilities of recognizing mood subsyndromal symptoms, enable early interventions, and might contribute to refraining new mood episodes [60]. Psychoeducational strategies also provide information about healthier lifestyles, sleep routines, exercise and stress management tips. All these steps are important to the maintenance of the euthymic state in BD [59].
Psychoeducation interventions were effective in reducing the frequency of hospitalizations and LOS and enhanced adherence to pharmacological treatment. Knowledge regarding their own illness might enrich comprehension of the importance of medication use and its effects on mood [61]. Moreover, a higher adherence to treatment is associated with monotherapy and reduced drug side effects [4,62]. Psychoeducational approaches to family members had no influence on treatment adherence.
When applied to patients and family members, psychoeducational approaches did not have an effect on mood severity symptoms, functionality or the quality of life of BD patients. Mood changes might lead to social, interpersonal and occupational impairments and contribute negatively to quality of life [63,64]. Depressive episodes are the most common and the most persistent affective states in BD and are the main cause of functional disability[4]. Residual and persistent depressive symptoms, cognitive decline, sleep deprivation, past history of psychotic symptoms [65,66], current presence of psychiatric comorbidities, use of psychoactive substances [65][66][67][68], long course of the disease, number of mood episodes [69][70][71], and hospitalizations [72] are associated with a reduction in functionality [73].
Family member psychoeducation is related to a lower frequency of mood swings and to a reduction in LOS. As family members acquire knowledge of the disease, they become more able to help patients identify early mood changes, apply assertive strategies to deal with daily situations and crisis management [48,74]. Through the provision of care, acceptance of the disease and dialogue, family members present themselves to the patient as a source of aid and support for decisions about their treatment [75][76][77].
In regard to the limitations of the present study, we might consider meta-analysis to be unable to be performed, owing to the methodological differences between heterogeneous studies (sample size, duration of follow-up, main results, type of comparison group), the population characteristics (severity, comorbidity, clinical status of patients in recruiting phase) and the intervention itself (target population, format, content, duration). All of these factors hamper the generalization of the results. In addition, the findings of the present study reveal that the characteristics of the sampling must be carefully considered. Patients with severe chronic disease may have poorer treatment responses. Future research to clarify the effectiveness of psychoeducation and to identify the determinants of response to treatment might be required for this population.

CONCLUSION
The data from this systematic review show the positive effects of the psychoeducational intervention on both patients and family members. Despite the lack of effectiveness in some parameters, psychoeducation has been associated with other treatments as an additional intervention. It is recommended that additional studies should approach strategies that aim to maximize the benefits of those therapies, adding interventions focused on family and interpersonal relationships.

Research background
The bipolar disorder (BD) treatment is challenging, and there is some evidence that non-pharmacological interventions promote effects in the treatment of acute mood episodes and maintenance treatment. Psychoeducation is an intervention strategy based on providing patients and/or relatives with information about the disorder to enhance their understanding and enable early identification of warning signs and mood changes, improving treatment adherence, and have showed some results in order to help the BD treatments.

Research motivation
Even using adequate drug strategies, BD is characterized by high rates of occurrence of mood episodes, number of hospital admissions, and a progressive impairment. We aimed to summarize the best evidence of psychoeducation in the treatment of BD, considering patients and their family members.

Research objectives
This systematic review aims to investigate the role of psychoeducation in BD in patients and in their family members.

Research methods
A systematic search of original studies on psychoeducation with patients with Bipolar Affective Disorder and their families was carried out using Medline, Scopus and Lilacs databases. A data extraction table was created based on the Cochrane model and the methodological quality of the studies was assessed according to the criteria of the Newcastle-Ottawa scale.

Research results
Psychoeducation applied to BD patients and their relatives is associated with a reduction in the frequency of new mood episodes and a reduction in the number of hospital admissions and length of stay. Psychoeducational interventions applied to patients contribute to improvement in pharmacological treatment adherence, although the same effect it is not observed when applied to relatives. Psychoeducation does not seem to influence the severity of depressive or manic symptoms or functionality.

Research conclusions
Psychoeducation as an adjunct strategy to pharmacotherapy has been shown to be effective in the treatment of Bipolar Affective Disorder.