Primary Psychiatry. 2007:14(3):59-69
Dr. Geller is resident psychiatrist in the Department of Psychiatry at Mount Sinai Hospital in New York City. Dr. Goldberg is associate professor of clinical psychiatry at the Mount Sinai School of Medicine in New York City and director of the Affective Disorders Program at Silver Hill Hospital in New Cananan, Connecticut.
Disclosures: Dr. Geller reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Goldberg is on the advisory boards and/or speaker’s bureaus of Abbott, AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, GlaxoSmithKline, and Pfizer; and receives grant support from Eli Lilly and GlaxoSmithKline.
Please direct all correspondence to: Joseph F. Goldberg, MD, Silver Hill Hospital, 208 Valley Rd, New Canaan, CT 06840; Tel: 203-801-2363; Fax: 203-966-9336; E-mail: JFGoldberg@yahoo.com.
Until recently, clinicians believed that pharmacotherapy alone was the mainstay of care for patients with bipolar disorder, and psychotherapeutic intervention held little or no benefit. However, over the past several decades, evidence has shown that several validated, disease-specific forms of psychotherapy demonstrate unique value as adjuncts to pharmacotherapy management. Based on the stress-vulnerability model of mental illness, which highlights the interplay of biopsychosocial factors in disease risk and relapse, psychotherapies have been recognized as providing unique therapeutic benefits based on cognitive, interpersonal, and other psychosocial dimensions of illness. In addition, clinicians have realized that patients and people in their lives can learn techniques to more effectively manage bipolar disorder. This article describes evidence-based psychotherapeutic approaches for the treatment of bipolar disorder. Four psychotherapeutic modalities have been validated through randomized, controlled clinical trials and have shown efficacy in combination with standard pharmacologic treatment. Evidence-based psychotherapies for bipolar disorder include cognitive-behavioral therapy, family-focused treatment, interpersonal and social rhythm therapy, and psychoeducation. This article reviews each of these modalities and identifies evidence behind each approach.
Despite pharmacotherapy advances across manic, depressed, mixed, and maintenance phases of bipolar disorder, symptomatic recurrence continues to be evident in a majority of patients.1 Residual2 and subsyndromal3 symptoms frequently persist between distinct episodes and can trigger relapses,1-4 impair functioning, and disrupt quality of life.5 Since functional recovery often lags behind symptomatic or syndromic recovery, patients must negotiate occupational and social ramifications of affective episodes on a daily basis.2,6,7 Poor quality of life may be evident even during periods of euthymia.5,8 Chronic illness may lead to persistent demoralization, which can impact illness outcome.5 Despite the efficacy of psychotropic agents under optimal circumstances, ≥50% of bipolar disorder patients deviate from adequate adherence.9,10 Thus, pharmacotherapy alone seldom represents optimal management of bipolar disorder.
Given the great psychosocial consequences of bipolar disorder, psychotherapy represents a critical treatment component. Research in the past 2 decades has led to several modalities of psychotherapy based on bipolar disorder disease models. As an adjunct to pharmacotherapy, clinical trials indicate that appropriate psychotherapies can reduce relapse rates by up to 40%.11 Moreover, effective psychotherapies can provide patients with skills that enable them to negotiate the cognitive challenges and psychosocial stresses that directly result from manic and depressive episodes. This article examines specific forms of psychotherapy relevant to the management of bipolar disorder and highlights methods for clinicians to incorporate the basic elements of each form to improve treatment outcomes.
Origins, Rationales, and Goals of Psychotherapy
Although the etiology of bipolar disorder remains unknown, theoretical foundations behind effective psychotherapy have evolved in the past 2 decades. Psychotherapy efforts grew from early 20th century psychodynamic formulations by Winnicott12 and Klein,13 among other researchers. “Manic defense” was understood as an intrapsychic phenomenon in which depression represented anger turned inward and mania represented an unconscious defense against depression. While there has been little empirical study of this hypothesis, there is some evidence to suggest the presence of low self-esteem in patients with mania.14 Psychoanalytic orientations maintain that insight into the nature of presumed conflicts represent a directly curative process. Diminished awareness of illness is recognized among individuals with bipolar disorder15—and poor insight could drive illness denial and treatment nonadherence—but there have been few studies of possible psychodynamic contributors to bipolar disorder or the potential efficacy of psychoanalytic treatment as a means to ameliorate affective symptoms.
Modern bipolar disorder psychotherapy began with the empiric studies of Beck16 and Kovacs and Beck17 in the 1960s and 1970s, which identified links between cognitive distortions and depression. In unipolar depression, cognitive-behavioral therapy (CBT) came to represent an intervention designed to reduce depressive symptoms, with comparable efficacy to antidepressants.18 Adaptations to bipolar disorder began in the 1990s, initially as an amalgam of psychoeducation with tenets from CBT for unipolar depression19 and as an adjunct to pharmacotherapy. A second innovative effort to develop skills-based psychotherapy came from the work of Klerman and colleagues,20 which focused on the interpersonal correlates of depression leading to the development of interpersonal psychotherapy (IPT). Subsequently, adaptations of IPT by Frank and colleagues21 and Malkoff-Schwartz and colleagues22 incorporated recognition of the impact of disruptions to daily rhythms (eg, chronobiologic or circadian influences such as sleep-wake cycle perturbations) and led to the development of interpersonal/social rhythm therapy (IP/SRT) specific to bipolar disorder. Family-focused therapy (FFT) represents a third skills-based psychotherapy, developed by Miklowitz and colleagues,23-25 which was designed to address the impact of interpersonal, emotional, and communication styles within families of bipolar disorder patients. Psychoeducation represents a fourth type of psychotherapy approach relevant to bipolar disorder,26,27 which focused on improving disease management skills, including the recognition of prodromes and the barriers to medication adherence.
Each type of psychotherapy has been validated through empirical studies on their effect on symptomatic and functional recovery in bipolar disorder. In addition, structured group-based psychotherapies have been developed that draw on cognitive-behavioral and psychoeducational principles and have been adapted for specific subgroups (eg, inpatients or those with comorbid substance use disorders). Most formalized individual- and group-based psychotherapies have been manualized and are typically administered in time-limited, structured sessions in modular fashion over several months. Further, psychoeducational principles have formed the basis of institutional team approaches for increasing self-management in bipolar disorder patients, as seen in the collaborative care model developed by the United States Department of Veterans Affairs.28,29
When Should Formal Psychotherapy Be Administered?
Few studies have clarified when psychotherapy yields optimal efficacy in the course of bipolar illness. Most clinicians agree that during acute mania or in the presence of florid psychosis, impaired attention and behavioral disinhibition likely preclude meaningful work in focused individual psychotherapies. Regarding depressive symptom severity, it is plausible that impaired attention, ability to shift sets, and capacity for flexible thinking (eg, melancholia) could render psychotherapies less effective in severe than in mild-to-moderate depression. However, randomized studies have not yet demonstrated whether or not structured psychotherapies improve quality of life or functional outcome when treatment occurs during euthymic versus non-euthymic mood states.
In nonrandomized data from the National Institute of Mental Health Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), Miklowitz and colleagues30 observed that among severely depressed bipolar patients, symptomatic and functional improvement occurred more often during high-frequency, intensive psychotherapy of any type. Patients with less severe depression at baseline showed clinical improvements with less frequent and intensive psychotherapy. Strategies based on accurate patient symptom self-reporting may be more beneficial when patients, motivated by a distressing affective state, report affective complaints, which has been suggested to occur more during depression than mania.26,27
The “kindling” model of affective relapse posits that stressful life events may be especially likely to precipitate affective episodes early in the lifetime course of illness.31 While studies have found that life stresses contribute to relapse throughout the life course of bipolar disorder,32,33 it is possible that the psychosocial stigmata of bipolar disorder may be particularly susceptible to modification by psychotherapeutic interventions before the elapse of multiple affective episodes.
Clinicians who are knowledgeable in the basic principles of bipolar-specific psychotherapies are able to utilize them to enhance pharmacotherapy outcomes across phases of treatment. For example, Miklowitz and colleagues34 found that despite the presence of optimized serum lithium levels, high-expressed emotion in the immediate families of bipolar disorder patients are associated with increased symptoms and poorer functioning.
A related and unstudied construct examines methods for clinicians to determine patient candidacy or appropriate fit for a specific psychotherapy modality. Methods are analogous to how psychoanalytic treatment appropriateness is gauged based on factors such as psychological mindedness and capacity for introspection. There are no explicit criteria that can determine which psychotherapy is best suited to a bipolar disorder patient. In practical terms, clinicians may draw upon techniques from each existing psychotherapy by recognizing relevant phenomena, such as visible tendencies toward cognitive distortions or the marked presence of family interpersonal factors (eg, emotional over-involvement).
Nonspecific factors in psychotherapy, such as therapeutic alliance, also can obscure one modality’s method of action over another. Furthermore, there has been suggestion that any form of structured psychotherapy may yield a substantial benefit over pharmacotherapy management alone, regardless of the specific modality employed. Controlled trials have not been conducted with sufficient statistical power to draw such comparative conclusions across the differential effects of specific psychotherapies.
Each structured psychotherapy finds that affective states can be triggered and perpetuated by psychological factors such as individual cognitive style, and social factors such as negative life events, disruption in sleep-wake cycle, and family communication styles high in expressed emotion. Though the specific therapeutic approaches differ in theoretical underpinnings and emphasis, all target medication non-adherence, family or other interpersonal conflict, stressful life events, alcohol or drug abuse, and social and circadian rhythm disruption. These therapies also share common goals that include increasing knowledge and awareness of the illness, decreasing relapse rates, and improving overall functioning and quality of life. Basic tenets associated with each modality are summarized in Table 1.
CBT is based on a theoretical model that states chronic mood symptoms lead to negative distortions in thoughts, attitudes, and assumptions about the world and oneself in relation to it. Consequently, negative cognitions serve to perpetuate depression. Patients with depression show biases in their tendencies to selectively perceive or recall negative information about themselves and process depressive material more efficiently than material of neutral or positive content.35-38 Bipolar disorder patients have been shown to demonstrate dysfunctional attitudes that bear on goal attainment, dependency, and achievement.39 Dysfunctional attitudes appear more pervasive in hypomanic patients than in remitted or euthymic bipolar patients, but are less extensive than attitudes found in unipolar depressed patients.40 The cognitive model stresses the interplay between thoughts, feelings, and behaviors. Treatment employs an active therapeutic stance and typically involves structured sessions with agenda-setting, review of prior learning and homework, completion of the current agenda and skills practice, assignment of new homework, and eliciting patient feedback about the session.
Psychotherapy mechanics involve examining and challenging the basis of automatic thoughts as they become identified or the distortion of preconscious information processing that shapes attitudes, assumptions, and beliefs due to faulty evidence or reasoning processes. Patients record examples of dysfunctional thought patterns based on daily life experiences in a logbook and scrutinize evidence to support the basis of their beliefs by generating rational responses to each thought. Unhappiness concerning a job promotion that was given to a colleague instead of the patient could trigger overgeneralized thoughts and feelings of failure, predictions about future inability to achieve success, and assumptions of low self-worth. Feelings of envy or unlovability could be stimulated. Psychotherapy would generate alternative explanations and interpretations for the event (eg, the colleague had greater seniority or was better qualified for the promotion) and rational responses to cognitive distortions (eg, “The other person may have been better qualified than I was,” or “I could be happier with a different job”).
Automatic thoughts of patients with depression are notable for themes of loss and failure, as contrasted with a greater focus on themes concerning threat, danger, and unpredictability among patients with primary anxiety disorders. This “cognitive content-specificity hypothesis” postulates that differences in information processing and attention lead to differences in symptomatology.41 Researchers have utilized this hypothesis to design assessment instruments useful for bipolar disorder. Reilly-Harrington42 suggested that attributional styles and dysfunctional attitudes interacted with negative life events to increase manic and depressive symptoms over time. Similarly, bipolar manic patients have been shown to endorse maladaptive cognitions and beliefs associated with mania more so than unipolar depressed patients or healthy subjects. This finding supports the association between biased information processing systems and maladaptive cognitive schemas relative to affective episodes.43 Principles of CBT maintain that restructuring of cognitive patterns and beliefs may influence the course of bipolar disorder. As cognitive aberrations may precede behavioral aberrations, identifying prodromal cognitions associated with depression, mania, and hypomania could prove useful in predicting and preventing destructive behavioral sequelae.
A recently developed self-report rating scale that assesses cognitive schemas in patients with bipolar disorder, the Cognitive Checklist for Mania, has been used to characterize the extent to which bipolar disorder patients endorse thought patterns consistent with either depression or mania.43,44 In a pilot study of 35 inpatients with major depressive disorder, 20 with schizoaffective disorder, and 45 with bipolar I disorder, mean scores for manic patients exceeded scores for depressed-phase or mixed-episode patients. The finding showed that patients with mania can be reliably distinguished from others based upon endorsement of particular cognitions on a standardized questionnaire. Other ratings of cognitive distortions measured in clinical trials have focused on dysfunctional attitudes, which appear to persist in patients with bipolar disorder despite improvements in subjective mood.45
In addition to reducing depressive symptoms, CBT targets medication adherence, early detection of prodromes and appropriate intervention, stress and lifestyle management, and alleviation of comorbid conditions such as anxiety or substance use disorders. CBT therapists work with patients to identify thought distortion and to respond rationally to biased cognitions in order to provide symptomatic relief. CBT therapists frequently use stories and metaphors to convey key concepts and utilize in-session rehearsal and role-play to prepare patients for real-life challenges. In addition, therapists may employ motivational interviewing as described by Rollnick and Miller.46 This technique encourages patients to draw conclusions about the importance of medication and treatment adherence by reviewing their personal illness history and consequences of adherence or non-adherence to prescribed regimens.
Cognitive-Behavioral Therapy Outcome Studies
As summarized in Table 2,47-54 there are several short- and long-term randomized trials involving CBT for bipolar disorder. Evidence indicates that CBT added to pharmacotherapy reduces short-term relapse rates, decreases hospitalization, and improves medication adherence.47-51 Gains achieved through CBT appear to be most robust during active treatment and soon thereafter52 but may attenuate during longer-term (eg, >12 month) follow-up.49,52,53 A randomized trial of CBT versus treatment-as-usual found no difference in recurrence rates except for an advantage of CBT among patients with £12 lifetime episodes.54 The aggregate of studies suggest that CBT does not reduce overall episode recurrence in bipolar disorder,55 but may be helpful to diminish associated features such as depression severity or medication non-adherence.
Brief CBT appears helpful for patients with few prior affective episodes.11 Data are mixed on whether CBT is more effective for depression or mania. Lam and colleagues52 found a reduction in depressive episodes but not manic/hypomanic episodes. Perry and colleagues48 found the opposite, with fewer manic relapses but no difference on depressive relapse rates.
Cochran47 conducted a randomized outcome study examining the effect of CBT on medication adherence. Patients who received 6 weeks of CBT demonstrated improved lithium compliance compared with those who received usual care. Additionally, these patients were less likely to discontinue care against medical advice than were control patients. The CBT-treated group also had fewer total hospitalizations.
Perry and colleagues48 conducted a controlled trial to assess the efficacy of teaching bipolar disorder patients how to recognize initial symptoms and seek treatment. Sixty-nine patients with recent relapse (within the past 12 months) were randomized to usual care versus 7–12 CBT sessions. The CBT intervention achieved a 30% reduction in manic relapses, shorter and less frequent hospitalizations for mania, but no difference in rates of depression or time to first depressive relapse. The CBT intervention significantly improved overall social functioning and employment.
Lam and colleagues50-52 conducted a 30-month CBT trial involving 6 months of active treatment and 2 years of follow-up aimed at relapse prevention. The beneficial effect of CBT was strongest during the 6 months of active treatment and during the initial 6 months following treatment. During these 12 months of the study period, CBT reduced total bipolar episodes, days spent in bipolar episode, and number of bipolar admissions. Improvement in mood symptoms and social functioning were observed. During the last 18 months, CBT continued to yield fewer days in bipolar episode but failed to reduce relapse rate.
Family-Focused Therapy and the Role of Expressed Emotion
FFT has attracted attention as a useful approach for mobilizing the support system of a patient to improve care in bipolar disorder.23-25,56 Derived originally from studies of negative expressed emotion and particular family communication styles as contributors to relapse in schizophrenia,57-60 FFT focuses on efforts to reduce family stress (eg, emotional overinvolvement) and negative communication styles (eg, hostility and criticism) that may directly foster relapse. Miklowitz and colleagues34 studied 23 bipolar patients and found a five-fold increase in relapse rates among those patients from families with communication styles high in expressed emotion. However, randomized trials have found that family-expressed emotion status is associated with levels of depression during treatment but not time until affective relapse.61
Given the high degree of family stress and caregiver burden in bipolar disorder,62,63 family-based treatments may be particularly valuable when interpersonal tensions in the home environment are evident. Family members are engaged in treatment by learning how to recognize early relapse symptoms, while patients are encouraged to write contracts on how families should respond when signs are present. In addition, FFT may decrease affective morbidity to the extent that negative expressed emotion can exacerbate symptoms in bipolar disorder patients.34
Family-Focused Therapy Outcome Studies
Findings from randomized trials of FFT for bipolar disorder are summarized in Table 3.23-25,56,61,64,65 In a series of studies comparing FFT to crisis management in 101 bipolar outpatients, Miklowitz and colleagues23-25 found that 21 sessions of FFT decreased depressive and manic symptoms significantly and also offered protection against depressive recurrences.
Prior expressed emotion studies60 have demonstrated a clear relationship between high expressed emotion and relapse in schizophrenia. Thus, family-expressed emotion has been posited as a key substrate for FFT. However, Kim and colleagues61 found that baseline expressed emotion status was not a significant predictor of outcome during randomized treatment either with family intervention or crisis management, the latter representing a treatment-as-usual condition. Family intervention consisted of either FFT or integrated family and individual treatment. During 2-year follow-up, patients from families with higher levels of expressed emotion reported higher levels of depression regardless of treatment condition, although across treatments, expressed emotion status made no difference in time to disease relapse. When expressed emotion components were dissected, higher levels of criticism predicted higher levels of depression and mania. In mania, the association was stronger in the family treatment group than in the crisis management group. High levels of emotional over-involvement did not predict higher levels of mania or depression.
Rea and colleagues56 conducted a randomized, controlled trial that showed an outpatient, family-based treatment for bipolar disorder decreased the risk of hospitalization and relapse compared with individual treatment. These investigators followed 53 recently hospitalized, bipolar, manic patients for 1 year of active treatment and a 1-year follow-up. While the family-treated group did not differ from the individual-treatment group during the active treatment phase, a dramatic difference was noted between the groups in the year following treatment. Compared to individually-treated patients, family-therapy patients experienced lower rates of relapse (28% versus 60%) and hospitalization (12% versus 60%).
Interpersonal/Social Rhythm Therapy
Frank and colleagues66,67 have adapted IPT theories to the treatment of bipolar disorder. IP/SRT combines interpersonal psychotherapy with behavioral modification and regularization of daily routines. IP/SRT emphasizes that negative life events can impede recovery in bipolar disorder, especially through disruption of social and circadian rhythms. Given that disruptions in sleep-wake cycle have been shown to precipitate affective episodes, instituting good sleep hygiene has been posited as a protective factor in preventing negative life events from destabilizing vulnerable people.68 Therapists help patients normalize daily routines, particularly in the hours of sleeping, eating, and exercising. The concept of social “zeitgebers” [time-givers]69 summarizes this model and postulates that unstable or disrupted daily routines lead to circadian rhythm disruption, which spurs affective episodes in at-risk individuals.
Interpersonal components of IP/SRT, which are derived from IPT, include attention to interpersonal problems and disputes, role transitions, and interpersonal deficits. Grief work is also a focus of this therapy; for many patients newly adjusting to a diagnosis of bipolar disorder, this includes grief for loss of the formerly healthy self.
Interpersonal/Social Rhythm Therapy Outcome Studies
IP/SRT appears to be more efficacious in depressive as opposed to manic symptoms. This finding parallels results of CBT reported by Lam and colleagues51,52 that showed greater effectiveness for CBT in depression than mania. Findings are also consistent with those reported for FFT by Miklowitz and colleagues,23-25 yielding a reduction in depressive but not manic symptoms.
Frank and colleagues70 compared IP/SRT to an intensive clinical management (ICM) approach. When comparing these approaches in a two-phase (acute and maintenance) study, researchers found that bipolar type I patients who received IP/SRT in the acute treatment phase experienced longer survival time without new affective episodes and were more likely to remain well for 2 years of follow-up preventive maintenance. The outcome was favorable for participants who received IP/SRT during the acute phase regardless of what they received during the maintenance phase, which suggested that a critical period for providing IP/SRT may be immediately following an acute episode. Patients with many physical health problems or significant comorbid anxiety disorders did better with ICM. Further investigation is warranted into which patient subsets may benefit from standard IP/SRT. Interestingly, changing psychotherapy treatment arms (ie, IP/SRT to ICM or vice-versa) was also associated with higher recurrence rates and could reflect the adverse impact of disruptions to stable routines.64
The control condition in the study by Frank and colleagues70 was an active treatment as well. The ICM group received education on bipolar disorder, pharmacotherapy for the illness, sleep hygiene, and careful symptom monitoring, as well as medication effects, including adverse effects and non-specific support. Thus, therapeutic benefits provided by the ICM approach may have masked IP/SRT efficacy by comparison.
The primary objective of psychoeducation is to increase awareness of bipolar disorder and its management among patients and family members to facilitate early detection of prodromal symptoms. A fundamental premise is that patients can be taught to recognize early or prodromal signs of illness relapse before full episodes recur, and that patients’ enhanced capacity to detect and report early signs of illness may result in better and more responsive care.48 Psychoeducation can also increase adherence, enhance ability to cope with psychosocial repercussions of the illness, augment interpersonal skills, and improve overall quality of life.
Psychoeducation can be offered in individual or didactic group settings and take the form of a series of structured classes or lessons. It can also be offered in brief, educational interventions as part of routine medication management visits. Patients are taught skills to manage stress and regulate their lifestyle, avoid substance abuse, and reduce suicidality.
The prototype of a psychoeducational intervention is the Life Goals Program developed by Bauer and McBride.71 The Life Goals Program is a tightly structured group therapy intervention aimed at helping bipolar disorder patients more actively participate in their treatment while addressing functional deficits resulting from the illness. Group intervention consists of two phases. In the first phase, participants are taught illness management skills intended to increase knowledge about the disorder, affective triggers, and adaptive coping strategies. In the second phase, the program utilizes CBT augmented with interpersonal and psychodynamic interventions to help patients achieve their goals and address individual life circumstances, which can impede mental health maintenance. The program encourages group leaders to actively moderate the interpersonal milieu of the group and to maintain low emotional intensity, protecting group members from becoming overwhelmed. The Life Goals Program has shown that psychoeducational treatment, as part of a multimodal program, significantly decreases both emergency room use and costs.
Psychoeducational Outcome Studies
Psychoeducation has repeatedly been shown to be superior to usual care when utilized as part of a multimodal approach in the treatment of bipolar disorder. For example, Otto and colleagues72 observed that psychoeducation strategies augmenting standard pharmacotherapy are associated with longer-term mood and affective stability as compared with pharmacotherapy alone. When used in an integrated treatment setting, Colom and colleagues65 found that a 21-week psychoeducational intervention reduced the number of relapsed cases, rehospitalizations, and recurrences per patient as well as prolonged the time until affective recurrences. Colom and colleagues65 found a 60% recurrence in the control group versus 38% in the treatment group during the active treatment phase. During the 2-year follow-up phase, the effect was robustly maintained. There was a 92% recurrence in the control group compared with 67% recurrence in the treatment group. The effect held for recurrence to any episode, depression, hypomania, and mixed episode, but significance was not reached for reduction in time to mania.
The benefits of psychoeducation to delay time to affective recurrences appear longer with adjunctive psychotherapy plus pharmacotherapy than with pharmacotherapy alone, regardless of the presence of comorbid personality disorders.73 In contrast to most other forms of structured psychotherapy, psychoeducation appears less effective for reducing acute affective symptoms than for helping to prevent relapses or recurrences during maintenance treatment phases.
Substance Abuse Comorbidity
Drug and alcohol abuse or dependence arise in ≥50% of bipolar disorder patients and frequently contributes to poor treatment outcome.74-76 Patients and clinicians often assume bipolar disorder and substance misuse are linked as a reflection of patient efforts to self-medicate problems with mood as a driving force. Little evidence exists to support this hypothesis as an explanation for most instances of substance use comorbidity.77 Some clinicians find that patients who report that drug or alcohol use is self-medicating may have a different problem other than their addiction and may be rationalizing their substance abuse or avoiding confronting denial about having an addiction. Other patients may also misidentify the consequences of an addiction, such as a substance-induced depression. While there are few empirical studies on this issue, Weiss and colleagues78 observed that approximately 66% of patients with dual-diagnosis bipolar disorder and substance use disorders identified their substance use as an effort to self-regulate affective symptoms. It was that subgroup of patients who appeared to benefit most from a structured group psychotherapy (integrative group therapy), an adaptation of CBT with relapse prevention skills developed by Weiss and colleagues79,80 for the treatment of patients with bipolar disorder and comorbid substance abuse.
Because suicide attempts and completions remain disproportionately elevated among bipolar disorder patients, special mention is warranted regarding the role of psychotherapy in its management. Although lithium has come to represent a cornerstone of pharmacotherapy to enhance suicide prevention in bipolar disorder,81 there exist psychological dimensions relevant to suicide that psychotherapeutic interventions may be uniquely suited to address. Clinical trials suggest up to a three-fold reduction in suicidal behavior in bipolar disorder patients when a structured psychotherapy is added to pharmacotherapy.82
The assessment and treatment of depression remains a fundamental aspect of suicide prevention, although specific psychological constructs appear related to suicide risk, including hopelessness,83 desperation,84 and loss of resiliency.85 Furthermore, suicide prevention in high-risk patients may be improved by addressing reasons for living,86 management of stress related to interpersonal loss,87 and techniques to reduce inclinations to act on impulse (eg, mindfulness training).88 Brief (10-session) CBT among recent suicide attempters, regardless of diagnosis, has been shown to significantly reduce the risk for reattempts, as compared to usual treatment for up to 18 months.89 Similarly, family-based interventions aimed at enhancing communication and problem-solving may offer further benefit to help reduce suicide risk in bipolar disorder.90 Many of the key elements from existing structured psychotherapies can offer potential unique value for judging suicide risk and introducing strategies to help reduce suicidal actions.
Remission in bipolar disorder can be difficult to achieve and maintain. Functional impairment in areas such as work, education, recreational activities, interpersonal relationships, and living situation has been shown to persist significantly beyond symptomatic remission. Thus, achieving satisfactory quality of life for bipolar disorder patients remains difficult despite appropriate pharmacotherapy. There is currently a database with randomized, controlled trials involving several structured psychotherapies as adjuncts to pharmacotherapy that can help to reduce affective symptom burden, help to anticipate prodromal signs of relapse, reduce medication nonadherence, diminish suicide risk, and potentially improve global functioning. Findings from clinical trials suggest that some psychotherapy forms may be more effective when implemented acutely (eg, during depressive episodes) but with lesser effects for relapse prevention (eg, CBT, FFT), while others (such as psychoeducation) may be more advantageous for relapse prevention than acute symptom remission.
There may also be biologic reasons why psychotherapy is most effective early in the illness course. As suggested by the kindling hypothesis, emergence of affective episodes over time takes on greater automaticity, episodes are less reflective of particular life events or stressors, and an illness variant may be less amenable to therapeutic intervention. In addition, patients with increased episode frequency may simply have a more severe form of the disease, whose natural history is less responsive to intervention of any type.
Future studies are needed to better elucidate which specific forms of psychotherapy may be best suited to individual patients, to clarify which phases of illness are most appropriate for psychotherapeutic intervention (ie, acute depression versus maintenance treatment; depressed phase versus euthymic phase), and to discern the effects of psychotherapy on common comorbidities (eg, CBT for comorbid anxiety disorders). Specific mechanisms by which unique psychosocial interventions exert their effect (eg, targeting of dysfunctional thoughts; reductions in negative expressed emotion) are still incompletely understood and warrant further investigation. Given both the therapeutic benefits and potential cost efficiency of psychotherapy to reduce hospitalization and other higher levels of service utilization, it would seem incumbent upon healthcare policy makers and third-party insurers to help assure adequate provider training and minimize obstacles for patients to access community-based structured psychotherapies. PP
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