***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: CONTEXT Despite the availability of efficacious treatments , the long-term course of bipolar disorder is often unfavorable . OBJECTIVE To test the effectiveness of a multicomponent intervention program to improve the quality of care and long-term outcomes for persons with bipolar disorder . DESIGN R and omized controlled trial with allocation concealment and blinded outcome assessment . SETTING Mental health clinics of a group-model prepaid health plan . PATIENTS Of 785 patients in treatment for bipolar disorder who were invited to participate , 509 attended an evaluation appointment , 450 were found eligible to participate , and 441 enrolled in the trial . INTERVENTIONS Participants were r and omly assigned to a multicomponent intervention program or to continued care as usual . Three nurse care managers provided a 2-year systematic intervention program , including the following : a structured group psychoeducational program , monthly telephone monitoring of mood symptoms and medication adherence , feedback to treating mental health providers , facilitation of appropriate follow-up care , and as-needed outreach and crisis intervention . MAIN OUTCOME MEASURES In-person blinded research interviews every 3 months assessed mood symptoms using the Longitudinal Interval Follow-up Examination . Health plan administrative records were used to assess the use and cost of mental health services . RESULTS Intent-to-treat analyses demonstrated that the intervention significantly reduced the mean level of mania symptoms ( z = 2.09 , P = .04 ) and the time with significant mania symptoms ( 19.2 vs 24.7 weeks ; F(1 ) = 6.0 , P = .01 ) . There was no significant intervention effect on mean level of depressive symptoms ( z = 0.19 , P = .85 ) or time with significant depressive symptoms ( 47.6 vs 50.7 weeks ; F(1 ) = 0.56 , P = .45 ) . Benefits of the intervention were found only in a subgroup of 343 persons with clinical ly significant mood symptoms  at the baseline assessment . The incremental cost ( adjusted ) of the intervention was 1251 dollars ( 95 % confidence interval , 55 - 2446 dollars ) , including approximately 800 dollars for the intervention program services and an approximate 500 dollars increase in the costs of other mental health services . CONCLUSIONS Population -based systematic care programs can significantly reduce the frequency and severity of mania in bipolar disorder , and cost increases are modest considering the clinical gains . The incorporation of more specific cognitive and behavioral content or more effective medication regimens may be necessary to significantly reduce the symptoms of depression BACKGROUND Efficacy trials suggest that structured psychological therapies may significantly reduce recurrence rates of major mood episodes in individuals with bipolar disorders . AIMS To compare the effectiveness of treatment as usual with an additional 22 sessions of cognitive-behavioural therapy ( CBT ) . METHOD We undertook a multicentre , pragmatic , r and omised controlled treatment trial ( n=253 ) . Patients were assessed every 8 weeks for 18 months . RESULTS More than half of the patients had a recurrence by 18 months , with no significant differences between groups ( hazard ratio=1.05 ; 95 % CI 0.74 - 1.50 ) . Post hoc analysis demonstrated a significant interaction ( P=0.04 ) such that adjunctive CBT was significantly more effective than treatment as usual in those with fewer than 12 previous episodes , but less effective in those with more episodes . CONCLUSIONS People with bipolar disorder and comparatively fewer previous mood episodes may benefit from CBT . However , such cases form the minority of those receiving mental healthcare BACKGROUND All follow-up studies of causes of death in affective disordered patients have found they have markedly elevated suicide rates and a less reproducible increased mortality from other causes . The reported rates by gender , disorder type and treatment are more variable . METHODS Hospitalised affective disordered patients ( n=406 ) were followed prospect ively for 22 years or more . Later , mortality was assessed for 99 % of them at which time 76 % had died . RESULTS St and ardised Mortality Rates ( observed deaths/expected deaths ) for patients were elevated especially for suicide and circulatory disorders in both men and women . Women actually had higher suicide rates but that did not take into account the twofold increase in general population rates for men . Unipolar patients had significantly higher rates of suicide than bipolar Is or IIs . In all groups long term medication treatment with antidepressants alone or with a neuroleptic , or with lithium in combination with antidepressants and /or neuroleptics significantly lowered suicide rates even though the treated were more severely ill . Although at the age of onset the suicide rates were most elevated , from ages 30 to 70 the rates were remarkably constant despite the different courses of illness . LIMITATIONS The patients were identified as in patients and followed prospect ively . The treatments were uncontrolled and are not quantifiable but were documented during the follow-up . CONCLUSIONS Men and women hospitalised for affective disorders have elevated mortality rates from suicide and circulatory disorders . Unipolars have higher suicide rates than bipolar Is or IIs . Long term medication treatment lowers the suicide rates , despite the fact that it was the more severely ill who were treated OBJECTIVE Lifetime rates of  suicide attempts among patients with bipolar I disorder were compared to rates during a 2-year period of intensive treatment with pharmacotherapy and with one of two adjunctive psychosocial interventions . METHOD Subjects entered the study during an acute mood episode . Subjects were treated with primarily lithium pharmacotherapy and with either psychotherapy specific to bipolar disorder , which included help in regularizing daily routines , or nonspecific , intensive clinical management involving regular visits with empathic clinicians . Data on prior suicide attempts were obtained retrospectively from interviews with the NIMH-Life-Chart method . Data on suicide attempts during the clinical trial were collected systematic ally throughout the protocol . RESULTS The rate of suicide attempts  was 1.05 per 100 person-months before patients entered the trial . Patients experienced a threefold reduction in the rate of suicide attempts during the acute treatment phase ( until the patient achieved stabilization , defined by completion of 4 weeks during which the patient had a mean score of < or = 7 on the 17-item Hamilton Depression Rating Scale and < or = 7 on the Bech-Rafaelsen Mania Scale ) and a 17.5-fold reduction during maintenance treatment . Poisson loglinear regression analysis modeling the relationship between the observed rates and the three protocol stages ( pretreatment , acute , and maintenance ) showed that the reductions were significant in the acute and maintenance phases , compared with the pretreatment phase . No patient with one or more suicide attempts before entering the trial attempted suicide during the protocol . CONCLUSIONS A treatment program in a maximally supportive clinical environment can significantly reduce suicidal behavior in high-risk patients with bipolar I disorder BACKGROUND The efficacy and effectiveness of cognitive therapy ( CT ) is well established for unipolar disorders , but little is known about its utility in bipolar disorders . This study aim ed to explore the feasibility and efficacy of using CT as an adjunct to usual psychiatric treatment in this patient population . METHOD Subjects referred by general adult psychiatrists were assessed by and independent rater and then r and omly allocated to immediate CT ( N = 21 ) or 6-month waiting-list control , which was then followed by CT ( N = 21 ) . Observer and self-ratings of symptoms and functioning were undertaken immediately prior to CT , after a 6-month course of CT and a further 6-months later . Data on relapse and hospitalization rates in the 18 months before and after commencing CT were also collected . RESULTS At 6-month follow-up , subjects allocated to CT showed statistically significantly greater improvements in symptoms and functioning as measured on the Beck Depression Inventory , the Internal State Scale , and the Global Assessment of Functioning than those in the waiting-list control group . In the 29 patients who eventually received CT  , relapse rates in the 1 8 months after commencing CT showed a 60 % reduction in comparison with the 18 months prior to commencing CT . Seventy per cent of subjects who commenced therapy viewed CT as highly acceptable . CONCLUSION Although the results of this study are encouraging , the use of CT in subjects with bipolar disorders is more complex than in unipolar disorders and requires a high level of therapist expertise . The therapy may prove to be particularly useful in the treatment of bipolar depression BACKGROUND Few studies have examined the combined effects of psychosocial treatment and pharmacotherapy for bipolar disorder . This study used a r and omized , controlled design to examine a 9-month , manual-based program of family-focused psychoeducational treatment ( FFT ) . METHODS Bipolar patients ( N = 101 ) were recruited shortly after an illness episode and r and omly assigned to 21 sessions of FFT ( n = 31 ) or to a comparison treatment involving two family education sessions and follow-up crisis management ( CM ; n = 70 ) . Both treatments were delivered over 9 months ; patients were simultaneously maintained on mood stabilizing medications . Patients were evaluated every 3 months for 1 year as to relapse status , symptom severity , and medication compliance . RESULTS Patients assigned to FFT had fewer relapses and longer delays before relapses during the study year than did patients in CM . Patients in FFT also showed greater improvements in depressive ( but not manic ) symptoms . The most dramatic improvements were among FFT patients whose families were high in expressed emotion . The efficacy of FFT could not be explained by differences among patients in medication regimes or compliance . CONCLUSIONS Family-focused psychoeducational treatment appears to be an efficacious adjunct to pharmacotherapy for bipolar disorder . Future studies should evaluate family treatment against other forms of psychotherapy matched in amount of therapist-patient contact Recently hospitalized bipolar , manic patients ( N = 53 ) were r and omly assigned to a 9-month , manual-based , family-focused psychoeducational therapy ( n = 28 ) or to an individually focused patient treatment ( n = 25 ) . All patients received concurrent treatment with mood-stabilizing medications . Structured follow-up assessment s were conducted at 3-month intervals for a 1-year period ofactive treatment and a 1-year period of posttreatment follow-up . Compared with patients in individual therapy , those in family-focused treatment were less likely to be rehospitalized during the 2-year study period . Patients in family treatment also experienced fewer mood disorder relapses over the 2 years , although they did not differ from patients in individual treatment in their likelihood of a first relapse . Results suggest that family psychoeducational treatment is a useful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalization frequently associated with bipolar disorder BACKGROUND Despite the use of mood stabilizers , a significant proportion of patients with bipolar affective disorder experience frequent relapses . A pilot study of cognitive therapy ( CT ) specifically design ed to prevent relapses for bipolar affective disorder showed encouraging results when used in conjunction with mood stabilizers . This article reports the outcome of a r and omized controlled study of CT to help prevent relapses and promote social functioning . METHODS We r and omized 103 patients with bipolar 1 disorder according to the DSM-IV , who experienced frequent relapses despite the prescription of commonly used mood stabilizers , into a CT group or control group . Both the control and CT groups received mood stabilizers and regular psychiatric follow-up . In addition , the CT group received an average of 14 sessions of CT during the first 6 months and 2 booster sessions in the second 6 months . RESULTS During the 12-month period , the CT group had significantly fewer bipolar episodes , days in a bipolar episode , and number of admissions for this type of episode . The CT group also had significantly higher social functioning . During these 12 months , the CT group showed less mood symptoms on the monthly mood question naires . Furthermore , there was significantly less fluctuation in manic symptoms in the CT group . The CT group also coped better with manic prodromes at 12 months . CONCLUSION Our findings support the conclusion that CT specifically design ed for relapse prevention in bipolar affective disorder is a useful tool in conjunction with mood stabilizers Abstract Objective : To determine the efficacy of teaching patients with bipolar disorder ( manic-depressive psychosis ) to identify early symptoms of relapse and seek prompt treatment from health services . Design : Single blind r and omised controlled trial with matching on four baseline variables using a minimisation algorithm . Setting : Mental health services in four NHS trusts ( one teaching , three non-teaching ) . Subjects : 69 patients with bipolar disorder who had had a relapse in the previous 12 months . Interventions : Seven to 12individual treatment sessions from a research psychologist plus routine care or routine care alone . Main outcome measures : Time to first manic or depressive relapse , number of manic or depressive relapses , and social functioning examined by st and ardised interviews every six months for 18 months . Results : 25th centile time to first manic relapse in experimental group was 65weeks compared with 17weeks in the control group . Event curves of time to first manic relapse significantly differed between experimental and control groups ( log rank 7.04 , df=1 , P=0.008 ) , with significant reductions in the number of manic relapses over 18months ( median difference 30 % ( 95 % confidence interval 8 % to 52 % ) , P=0.013 ) . The experimental treatment had no effect on time to first relapse or number of relapses with depression , but it significantly improved overall social functioning ( mean difference 2 
    Output:
    
Conclusions : Although psychological models of bipolar disorder fail to inform the psychotherapy treatment to the same extent as in unipolar depression , manualized adjunctive , short-term psychotherapies have been shown to offer fairly consistent benefits to bipolar disorder patients .
Cognitive-behavioural therapy , family-focused therapy , and psychoeducation offer the most robust efficacy in regard to relapse prevention , while interpersonal therapy and cognitive-behavioural therapy may offer more benefit in treating residual depressive symptoms