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Section 9
The Effectiveness of Psychosocial Interventions in Bipolar Disorder: Part One

Question 9 | Test | Table of Contents

In recent years, the Kraeplinian view that bipolar disorder has a better prognosis than schizophrenia has been challenged. Although prophylactic pharmacotherapy is effective and remains the mainstay of treatment for bipolar disorder, a large percentage of patients either experience residual affective symptoms or ongoing mood cycling. Therefore, patients with either bipolar disorder I or II experience significant impairment in psychosocial functioning, leading to high morbidity and mortality. Although comprehensive psychotherapy research in bipolar disorder has lagged behind research in other disorders such as anxiety or unipolar depression, a shift in emphasis over the last decade has resulted in psychosocial interventions being viewed as critical to bridging the gap between theoretical efficacy and real-world effectiveness. 

Several important manualized, reproducible, adjunctive psychosocial interventions have been developed, including CBT, PE, FFT, and IPT.  These focused psychotherapies for bipolar disorder were developed on the basis of previous experience in treating both unipolar depression and schizophrenia and were subsequently evaluated in larger controlled studies. In this paper, we discuss the rationale for psychosocial interventions in bipolar illness and then review the current evidence that CBT and other psychosocial interventions offer a distinct benefit to bipolar disorder patients, compared with standard treatment.

Rationale for Psychotherapy
To understand the utility of psychotherapy, it is important to view psychiatric disorders in a stress-diathesis context. Ultimately, it is believed that psychosocial stress is transduced into low-grade affective symptoms in a genetically vulnerable individual and that these low-grade affective symptoms eventually become the prodromes of a major affective episode of mania or depression. In Lam's psychological model of bipolar illness, the mechanism for the biological-psychological interaction is via cognitive traits such as an extreme drive for achievement and perfectionism. This sets the stage for a feed-forward mechanism whereby dysphoria is amplified into depression and excitement and anxiety are amplified into hypomania or mania.

Research has shown that psychosocial factors such as life events, family environment, cognitive style, and social support play an important role in risk for the onset, course, and expression of bipolar illness.  For example, increased relapse and poor outcome is associated with high expressed emotion (for example, hostility or over involvement) in parents or spouses. As a result, modification of the family environment through psychotherapy may be able to reduce expressed emotion in the families of bipolar disorder patients, with the hope that this reduction will also translate into decreased relapse and improved symptom control. Another rationale for psychotherapy in bipolar disorder is based on the assumption that bipolar affective illness is similar to unipolar depression and will therefore respond to the same interventions that have been shown to be effective in unipolar depression. Although there are some differences, the phenomenology of bipolar depression is similar to that of unipolar depression (especially depression with atypical features).  Several studies have even found that the psychosocial risks for bipolar disorder are similar to the risks for unipolar depression. Given such similarities, effective psychological treatment interventions for unipolar depression, such as CBT or IPT, have been recently applied to treat acute bipolar depression with the hope that these treatments will reduce the risk of mood destabilization by being antidepressant medication-sparing.

Given the aforementioned reasons for using psychotherapy in bipolar disorder treatment, there has been considerable advocacy to enhance treatment delivery by basing future psychosocial interventions on psychological models that integrate concepts of the multiple levels at which mood fluctuation occurs. However, current psychotherapies for bipolar disorder are rooted in models that have only been partially tested and, as such, do not truly accommodate the complexity of this illness. Recent research attests to the usefulness of a collaborative therapeutic approach in bipolar disorder and suggests that many different types of psychosocial intervention can have beneficial effects on illness outcome.  Table 1 summarizes the specific issues that occur in bipolar disorder and the corresponding treatments that could help alleviate these problems.

Psycho Education
The term PE originally referred to the provision of education on mental health for patients; it has expanded to include teaching patients to recognize symptoms and adopt adaptive coping strategies. PE may be given individually and often includes family members in a limited way, but group interventions constitute most of the interventions. Such PE  treatments may also be embedded in multifaceted intervention studies where the contribution of PE is difficult to disentangle, as in Simon et al. The first controlled PE trial, from Peet and Harvery, demonstrated the efficacy of PE in improving patients' attitudes to and compliance with lithium treatment.

The most notable study in group PE was conducted by Colom et al,^^ in which 60 patients each were randomized to PE or control groups. After 21 sessions over a 9-month period, patients in the PE group showed a significant reduction in the time to next relapse, as well as a decrease in depressive symptoms and episodes. A follow-up study showed that these results held even for patients who were fully compliant with lithium treatment, implying that improved medication compliance was not the only explanatory factor.

With respect to family PE, Rea et al^^ looked at the differential effects of family PE compared with individual PE in 21 sessions over 9 months. At 2-year follow-up, family PE patients had fewer relapses and were less likely to be hospitalized. Several studies have looked at providing PE to family members of subjects with bipolar disorder, with some gains for the family member and limited or no gains.  Overall, the controlled trials in PE and the fact that PE principles are embedded in other therapeutic approaches highlights the efficacy of PE; comparisons of PE with other approaches are discussed later.

Family-Focused Therapy
FFT* for bipolar disorder has evolved to be delivered to families in 3 phases.'" The first phase involves PE, whereas the final 2 phases focus on communication and problem-solving skills.^^ Treatment is typically 21 sessions over the course of 9 months. The first FFT trial" employed 101 patients with remitted bipolar disorder I, of whom 30 were randomized to receive regular FFT and 71 to a crisis management control group. Treatment in the FFT group consisted of 21 sessions lasting 1 hour and delivered over the course of 9 months, whereas the crisis management group received 2 sessions of family PE and emergency counseling sessions as needed. In a 1 -year period, FFT subjects showed lower rates of relapse to depression but not to mania. Further follow-up over 2 years confirmed that FFT patients had a longer time to affective relapse, with the benefits being principally in reduced depressive symptoms.^'*

A treatment-development study involving 30 subjects^^ expanded this approach, involving integrated individual and family therapy (up to 50 sessions). This study showed similar benefit in longer survival times and improvement, primarily in depressive symptoms. Coupled with the earlier studies involving family PE, these studies underscore the efficacy of family-based interventions but also demonstrate the need for a large number of sessions for efficacy. Health resource implications may limit the generalizablity of such intensive family interventions. Further, the relative merit of family approaches, compared with other approaches, needs to be clarified. Some data on this will be emerging shortly from the STEP-BD series of studies in the United States.^* The single published study with comparative data looked at 92 bipolar disorder I patients assigned to either pharmacotherapy alone, multifamily PE plus pharmacotherapy, or family therapy plus pharamacotherapy for a current mood episode. There were no differences between the 3 groups in time to recovery or in percentage achieving recovery, which perhaps accentuates the point that recovery from an episode and relapse prevention are distinctly different treatment goals. Nevertheless, the signatc coming from both PE and family interventions is clearly that such interventions are useful for relapse prevention.

Several brief, technique-driven CBT interventions have been developed and tested in RCTs with small to medium sample sizes.^^ These interventions are psycho educational in nature but use CBT techniques such as homework and self monitoring. The first published RCT by Cochran^* involving CBT for bipolar disorder recruited 28 subjects who recently attended a lithium clinic. One-half of the patients were randomly assigned to standard treatment and the remaining one-half received 6 individual sessions of CBT focusing on medication adherence. Subjects were evaluated at the end of treatment and at 6-month follow-up. Those who received the brief CBT intervention were found to have significantly fewer relapses and higher adherence rates (21% in the lithium discontinuation group, compared with 57% in the standard treatment group). Data regarding group differences in symptoms of mania or depression were not reported; however, this study powerfully reinforces the value of a brief, simple clinical intervention that can be integrated into both primary care and general psychiatric practice. Given that mood stabilizer medication and health care delivery have both changed dramatically over the 2 decades since Cochran' s study was published, replication of this study design in larger community samples is indicated.

A brief, technique-driven intervention was developed by Perry et al^' to help bipolar disorder patients identify their unique prodromal symptoms of relapse and seek medication rescue in a timely manner. Subjects with bipolar 1 disorder at risk for relapse (« = 69) were randomized to receive either 7 to 12 individual sessions of CBT with a psychology graduate student or treatment as usual. The 1-hour CBT sessions focused on identifying each individual's unique early warning signs of relapse and then developing and rehearsing action plans involving seeking prompt treatment from a mental health professional as well as additional medication to try to forestall relapse. Over an 18-month period, the 35 subjects in the CBT treatment group experienced a 30% greater reduction in manic, but not in depressive, episodes in addition to improved overall employment and social functioning. Longer time to manic episode and shorter duration of hospitalization for mania was observed in the CBT group, compared with the control group. It is noteworthy that this simple intervention had little effect on depressive symptoms but possibly inadvertently increased the use of antidepressant medication in the treatment group by sensitizing these individuals to recognize their abnormal mood state and, consequently, seek more frequent treatment for their depressive symptoms.
- Zaretsky AE, Canadian Journal Of Psychiatry. Revue Canadienne De Psychiatric, 2007 Jan; Vol. 52

Personal Reflection Exercise #2
The preceding section contained information about the effectiveness of psychosocial interventions in bipolar disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Dunne, L., Perich, T., & Meade, T. (2019). The relationship between social support and personal recovery in bipolar disorder. Psychiatric Rehabilitation Journal, 42(1), 100–103.

Goldberg, S. G. (2019). Narratives of bipolar disorder: Tensions in definitional thresholds. The Humanistic Psychologist, 47(4), 359–380.

Sperry, S. H., & Kwapil, T. R. (2020). Bipolar spectrum psychopathology is associated with altered emotion dynamics across multiple timescales. Emotion.

What are the three phases of Family Focused Therapy for bipolar disorder? To select and enter your answer go to Test.

Section 10
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