title: Internet-Based Cognitive Behavioral Therapy for Residual Symptoms in Bipolar Disorder Type II: A Single-Subject Design Pilot Study.
abstract: BACKGROUND
  Bipolar disorder is a chronic condition with recurring episodes that often lead to suffering, decreased functioning, and sick leave. Pharmacotherapy in the form of mood stabilizers is widely available, but does not eliminate the risk of a new depressive or (hypo)manic episode. One way to reduce the risk of future episodes is to combine pharmacological treatment with individual or group psychological interventions. However, access to such interventions is often limited due to a shortage of trained therapists. In unipolar depression there is now robust evidence of the effectiveness of Internet-based psychological interventions, usually comprising psychoeducation and cognitive behavioral therapy (CBT). Internet-based interventions for persons suffering from bipolar disorder could increase access to psychological treatment.
  
  
  OBJECTIVE
  The aim of this study was to investigate the feasibility of an Internet-based intervention, as well as its effect on residual depressive symptoms in persons diagnosed with bipolar disorder type II (BP-II). The most important outcomes were depressive symptoms, treatment adherence, and whether the patient perceived the intervention as helpful.
  
  
  METHODS
  A total of 7 patients diagnosed with bipolar disorder type II at a Swedish psychiatric outpatient clinic were offered the opportunity to participate. Of the 7 patients, 3 (43%) dropped out before treatment began, and 4 (57%) were treated by means of an online, Internet-based intervention based on CBT (iCBT). The intervention was primarily aimed at psychoeducation, treatment of residual depressive symptoms, emotion regulation, and improved sleep. All patients had ongoing pharmacological treatment at recruitment and established contact with a psychiatrist. The duration of BP-II among the treated patients was between 6 and 31 years. A single-subject design was used and the results of the 4 participating patients were presented individually.
  
  
  RESULTS
  Initiating treatment was perceived as too demanding under current life circumstances for 3 patients who consequently dropped out during baseline assessment. Self-ratings using the Montgomery-Åsberg Depression Rating Scale-Self-rated (MADRS-S) showed symptom reduction in 3 (75%) of the 4 treated cases during iCBT. In the evaluation of the treatment, 2 patients reported that they perceived that the treatment had reduced symptoms a little, 1 that it had reduced symptoms very much, and 1 not at all. Treatment adherence (ie, module completion) was fairly high in 3 cases. In general, the modules were perceived as fairly helpful or very helpful by the patients. In one case, there was a reliable change-according to the Reliable Change Index-in self-rated symptoms of depression and perseverative thinking.
  
  
  CONCLUSIONS
  The treatment seemed to have acceptable feasibility. The iCBT intervention could be an effective way to treat residual symptoms in some patients with bipolar disorder type II. This should be investigated in a larger study.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01742351; https://clinicaltrials.gov/ct2/show/NCT01742351 (Archived by WebCite at http://www.webcitation.org/6XnVpv4C3).
authors.affiliation: Psychiatric Research Centre, School of Health and Medical Science, Örebro University, Örebro, Sweden. fredrik.hollandare@orebroll.se.
authors.forename: Fredrik
authors.identifier: http://orcid.org/0000-0001-9500-7763
authors.initials: F
authors.lastname: Holländare
authors.forename: Annsofi
authors.identifier: http://orcid.org/0000-0002-3355-5403
authors.initials: A
authors.lastname: Eriksson
authors.forename: Lisa
authors.identifier: http://orcid.org/0000-0002-2457-5744
authors.initials: L
authors.lastname: Lövgren
authors.forename: Mats B
authors.identifier: http://orcid.org/0000-0001-6726-7787
authors.initials: MB
authors.lastname: Humble
authors.forename: Katja
authors.identifier: http://orcid.org/0000-0001-9429-9012
authors.initials: K
authors.lastname: Boersma
keywords: Internet; behavioral therapy; bipolar disorder; cognitive therapy; pilot projects