Posttraumatic stress disorder (PTSD) is common among individuals with bipolar disorder, and individuals with bipolar disorder are twice as likely as those in the general population to have PTSD. Comorbid PTSD may affect the course of illness and response to treatment, and previous studies from the Dauten Family Center for Bipolar Treatment Innovation at Massachusetts General Hospital have documented higher rates of suicidal ideation and attempts in those with comorbid PTSD and bipolar disorder. While PTSD and bipolar disorder commonly occur together, no specific treatment guidelines exist for this population. In a recent study, Douglas Katz, PhD, Timothy Petersen, PhD and colleagues from the Dauten Family Center examine the use of prolonged exposure in individuals with comorbid PTSD and bipolar disorder.
Prolonged exposure (PE) is a type of cognitive behavioral therapy that teaches individuals to gradually approach and tolerate trauma-related memories, feelings and situations and is a well-established and efficacious treatment for PTSD. This is the first study to examine the feasibility and preliminary efficacy of PE for patients with bipolar disorder and PTSD.
Adults with bipolar disorder and comorbid PTSD were recruited for the study. Prolonged exposure therapy consisted of 10 weekly sessions and included the following components: 1) psychoeducation, 2) rationale for exposure-based treatment, 3) repeated in vivo exposures to trauma-relevant stimuli, 4) repeated, prolonged imaginal exposures to traumatic memories, and 5) verbal processing of exposures.
Participants completed assessments of PTSD symptoms, suicidality, state and trait anxiety, depressive symptoms, and mania at baseline, at sessions 5 and 10, and at 6 months post-treatment.
Improvements in PTSD Symptoms and Suicidality
A total of 32 patients enrolled in this study; 75 % (24/32) completed all ten PE sessions and 50% completed the 6-month follow-up assessment. PTSD symptoms decreased from baseline to session 10 and continued to decrease throughout the follow-up period. At baseline, participants had an average score of 50.03 on the PTSD Checklist for DSM-5 (PCL-5); the average score declined to 24.12 at week 10, indicating an average decrease from moderately severe PTSD to remission. (Remission from PTSD is defined as a score of 33 and below).
Suicidality showed a similar pattern of decrease over the course of treatment and across the follow-up period. Participants demonstrated significant reductions in overall suicide risk from baseline to the end of treatment at 10 weeks. Average suicidality scores rebounded modestly during the 6-month post-treatment follow-up period but remained below baseline levels. Although one participant with chronic suicidal ideation experienced an increase in suicidal thinking after initiation of PE and withdrew from the study, exposure therapy was not associated with increased suicidal ideation in this sample.
Depressive symptoms decreased from baseline through Session 10 but rebounded slightly during the 6-month post-treatment follow-up period but remained below baseline levels. State and trait anxiety increased initially through Session 5 but then decreased and remained stable. Mania scores remained stable at all assessment periods.
Although the current study is limited by its small sample size and absence of a control treatment group, the results are promising. The researchers note that many of the patients included in the study had experienced PTSD symptoms for several years prior to entry into the study and, despite the chronicity of their symptoms, experienced remission of their PTSD symptoms within five weeks. The findings of the current study suggest that PE is a feasible and preliminarily efficacious treatment for patients with bipolar disorder and comorbid PTSD and deserves further examination in a larger study.
Other MGH researchers contributing to this research include Dustin Rabideau, Abigail Stark, Kedie Pintro, Antonietta Alvarez-Hernandez, Noah Stancroff, Yunfeng Deng, Evan Albury, Nevita George, Selen Amado, Christina Temes, Andrew Nierenberg, and Louisa Sylvia.
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Katz D, Petersen T, Rabideau DJ, Stark A, Pintro K, Alvarez-Hernandez A, Stancroff N, Deng Y, Albury E, Kuperberg M, George N, Amado S, Temes C, Nierenberg AA, Sylvia L. A trial of prolonged exposure therapy for outpatients with comorbid bipolar disorder and posttraumatic stress disorder (PTSD). J Affect Disord. 2024 Jan 1; 344:432-439.
Katz D, Petersen T, Amado S, Kuperberg M, Dufour S, Rakhilin M, Hall NE, Kinrys G, Desrosiers A, Deckersbach T, Sylvia L, Nierenberg AA. An evaluation of suicidal risk in bipolar patients with comorbid posttraumatic stress disorder. J Affect Disord. 2020 Apr 1;266:49-56.
Douglas Katz, PhD is the Director of Psychology at the Dauten Family Center for Bipolar Innovation, a staff psychologist in the Primary Care Psychiatry practice at MGH, and an Instructor at Harvard Medical School. Dr. Katz’s main clinical interests are the use of mindfulness-based cognitive therapy (MBCT), cognitive behavioral therapy (CBT), and dialectical behavior therapy (DBT) in the treatment of mood and anxiety disorders. His primary research interests are suicide in bipolar disorder and the nexus of trauma and bipolar disorder.
Timothy Petersen, PhD is a clinical psychologist in the Department of Psychiatry at Mass General and an Assistant Professor of Psychiatry at Harvard Medical School. Clinically he focuses on using cognitive behaviorally based interventions for difficult to treat mood disorders. His research has included the seminal NIH Sequential Treatment Alternatives to Relieve Depression (STAR*D) investigation, as well as studies investigating psychotherapeutic interventions to reduce relapse in those with mood disorders.
