Culturally adapted psychoeducation for bipolar disorder: a multicentre, assessor-masked, randomised controlled trial
Abstract
Background: Adjunctive psychoeducation can reduce recurrence of mood episodes in bipolar disorder (BD), but evidence from low-resource settings is scarce. We evaluated whether culturally adapted psychoeducation (CaPE) plus treatment-as-usual (TAU) prolongs time to recurrence in adults with BD in remission in Pakistan, a lower-middle-income country. Methods: In this multi-centre, assessor-masked randomised controlled trial, adults with remitted bipolar I or II disorder at seven urban centres in Pakistan were randomly assigned to CaPE plus TAU or TAU alone. CaPE comprised 12 weekly individual sessions delivered by master's-level psychologists. The primary outcome was time to recurrence of any mood episode over 48 weeks, assessed with the Longitudinal Interval Follow-up Evaluation. Secondary outcomes included recurrence of depressive and manic/hypomanic episodes and clinical and quality-of-life measures. The trial is registered with ClinicalTrials.gov ( NCT05223959 ). Findings: Between June 2022 and March 2025, 303 participants were randomly assigned (148 TAU, 155 CaPE plus TAU); 12-month data were available for 284 of 303 (93.7%). Over 48 weeks, CaPE prolonged time to recurrence of any mood episode versus TAU (adjusted hazard ratio 0.54, 95% CI 0.42–0.69; p < 0.001). At 12 months, CaPE improved recovery (measured with the Bipolar Recovery Questionnaire, on which higher scores indicate greater recovery; adjusted difference 144.8, 95% CI 51.5–238.1; p = 0.002), knowledge and attitudes (78.2, 22.6–133.8; p = 0.006), medication adherence (−0.4, −0.8 to −0.1; p = 0.013), and depressive symptoms (−5.3, −7.8 to −2.7; p < 0.0001). All adjusted estimates account for age, sex assigned at birth, marital status, weeks since diagnosis, and weeks in treatment. Interpretation: Individual culturally adapted psychoeducation added to routine care reduced recurrence risk and improved clinical outcomes in Pakistani adults with BD, and could optimise maintenance treatment in Pakistan and other low-resource settings. Funding: Canadian Institutes of Health Research .
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BibTeX
@article{husain2026culturally,
title = {{Culturally adapted psychoeducation for bipolar disorder: a multicentre, assessor-masked, randomised controlled trial}},
author = {M. Ishrat Husain and Muqaddas Asif and Ameer B. Khoso and Madeha Umer and Suleman Shakoor and Tayyeba Kiran and M. Ramzan Tahir and Aatir H. Rajput and Mohsin Saqib and M. Omair Husain and Saad Masood and Ali A. Mufti and Farooq Naeem and Moti Ram Bhatia and K.M. Sajjad Siddiqui and Asad Tamizuddin and Claire de Oliveira and Wei Wang and Siqi Xue and Juveria Zaheer and Nusrat Husain and Nasim Chaudhry and Benoit H. Mulsant and Imran B. Chaudhry},
journal = {eClinicalMedicine},
year = {2026},
month = oct,
doi = {10.1016/j.eclinm.2026.104271},
url = {https://linkinghub.elsevier.com/retrieve/pii/S2589537026005249},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Culturally adapted psychoeducation for bipolar disorder: a multicentre, assessor-masked, randomised controlled trial
AU - M. Ishrat Husain
AU - Muqaddas Asif
AU - Ameer B. Khoso
AU - Madeha Umer
AU - Suleman Shakoor
AU - Tayyeba Kiran
AU - M. Ramzan Tahir
AU - Aatir H. Rajput
AU - Mohsin Saqib
AU - M. Omair Husain
AU - Saad Masood
AU - Ali A. Mufti
AU - Farooq Naeem
AU - Moti Ram Bhatia
AU - K.M. Sajjad Siddiqui
AU - Asad Tamizuddin
AU - Claire de Oliveira
AU - Wei Wang
AU - Siqi Xue
AU - Juveria Zaheer
AU - Nusrat Husain
AU - Nasim Chaudhry
AU - Benoit H. Mulsant
AU - Imran B. Chaudhry
PY - 2026
DA - 2026/10/24
JO - eClinicalMedicine
DO - 10.1016/j.eclinm.2026.104271
UR - https://linkinghub.elsevier.com/retrieve/pii/S2589537026005249
AB - Background: Adjunctive psychoeducation can reduce recurrence of mood episodes in bipolar disorder (BD), but evidence from low-resource settings is scarce. We evaluated whether culturally adapted psychoeducation (CaPE) plus treatment-as-usual (TAU) prolongs time to recurrence in adults with BD in remission in Pakistan, a lower-middle-income country. Methods: In this multi-centre, assessor-masked randomised controlled trial, adults with remitted bipolar I or II disorder at seven urban centres in Pakistan were randomly assigned to CaPE plus TAU or TAU alone. CaPE comprised 12 weekly individual sessions delivered by master's-level psychologists. The primary outcome was time to recurrence of any mood episode over 48 weeks, assessed with the Longitudinal Interval Follow-up Evaluation. Secondary outcomes included recurrence of depressive and manic/hypomanic episodes and clinical and quality-of-life measures. The trial is registered with ClinicalTrials.gov ( NCT05223959 ). Findings: Between June 2022 and March 2025, 303 participants were randomly assigned (148 TAU, 155 CaPE plus TAU); 12-month data were available for 284 of 303 (93.7%). Over 48 weeks, CaPE prolonged time to recurrence of any mood episode versus TAU (adjusted hazard ratio 0.54, 95% CI 0.42–0.69; p < 0.001). At 12 months, CaPE improved recovery (measured with the Bipolar Recovery Questionnaire, on which higher scores indicate greater recovery; adjusted difference 144.8, 95% CI 51.5–238.1; p = 0.002), knowledge and attitudes (78.2, 22.6–133.8; p = 0.006), medication adherence (−0.4, −0.8 to −0.1; p = 0.013), and depressive symptoms (−5.3, −7.8 to −2.7; p < 0.0001). All adjusted estimates account for age, sex assigned at birth, marital status, weeks since diagnosis, and weeks in treatment. Interpretation: Individual culturally adapted psychoeducation added to routine care reduced recurrence risk and improved clinical outcomes in Pakistani adults with BD, and could optimise maintenance treatment in Pakistan and other low-resource settings. Funding: Canadian Institutes of Health Research .
SN - 2589-5370
ER -