Adjunctive Psychotherapy for Bipolar Disorder

Bipolar disorder, associated with substantial morbidity and mortality, is a complex mental illness characterized by fluctuating periods of mood elevation, irritability, and depression. Individuals with bipolar disorder often struggle to establish and maintain fulfilling interpersonal relationships and are less likely to maintain meaningful employment (1, 2). Whereas pharmacotherapy often forms the foundation of any treatment plan, increasing evidence suggests that psychosocial interventions as adjuncts to pharmacological treatment may improve medication adherence as well as bolster cognitive and interpersonal coping skills (3, 4), ultimately lengthening intervals between episodes and improving overall quality of life (5).

Psychotherapy may provide much-needed space and time to explore complex thoughts and emotions associated with a diagnosis of bipolar disorder. In their prolific text on manic-depressive illness, Goodwin and Jamison (6) address a range of feelings and thoughts that individuals with bipolar disorder commonly describe. Bipolar disorder, with severe symptoms such as elation, suicidal ideation, or psychosis, is often frightening and overwhelming for patients. Some individuals may approach their illness with steadfast denial and even anger, refusing to accept the reality of intense mood symptoms and a changed level of functioning. After commencing treatment, patients may be disappointed at slow progress or fear recurrence of mania or depression. Further, individuals with bipolar disorder often worry that their illness will preclude their enjoying interpersonal relationships, productive employment, and a generally high quality of life.

This article will advocate the use of adjunctive psychosocial interventions for adults and youth with bipolar disorder by first providing a general overview of options for psychotherapy and reviewing randomized, controlled trials of psychoeducation, cognitive behavior therapy, interpersonal and social rhythm therapy, and family-focused therapy. When randomized, controlled studies have not been conducted, relevant reviews of trials with an open design will be included. I will briefly outline therapeutic components shared by multiple treatments and highlight their potential for positive impact on the course of illness and quality of life. Specific applications for youth and issues concerning the effectiveness and availability of specialized psychotherapies for bipolar disorder will also be discussed. Finally, recommendations for clinicians will be provided.

Treatment strategies and evidence

Psychoeducation

Both individual and group psychoeducation presuppose that individuals informed about the etiology, course, and treatments for bipolar illness are more likely to anticipate their own symptoms and ask for requisite help before episodes become unmanageable. In other words, educated patients may suffer less in the long run.

Psychoeducation programs generally focus on teaching patients about symptoms associated with mania, hypomania, and depression as well as available psychopharmacological (i.e., mood stabilizers, antimanic agents, and antidepressants) and psychosocial treatments. Risks specific to bipolar disorder associated with substance abuse, pregnancy, and sleep patterns are often described (7).

Whereas one randomized, controlled trial of individual psychoeducation points to a reduction in mania recurrence (8), most research has focused on evaluation of group psychoeducation formats. Group psychoeducation may help prevent recurrence of manic, hypomanic, and depressive episodes in patients treated with medication (9, 10). Further, one effectiveness study of veterans with bipolar disorder suggests that group psychoeducation may improve quality of life and social functionality (11). However, one study suggests that individuals in depressive episodes may show attenuated benefits (12).

Cognitive behavioral therapy

Cognitive behavior therapy (CBT) for bipolar disorder presumes a diathesis-stress model, in which changes in thoughts and emotions lead to changes in behavior, attenuated psychosocial functioning, interpersonal problems, and possibly physical symptoms (e.g., sleep problems, stress, and others). These changes and problems may then trigger the onset of depression and mania. The cycle is continual, whereby it is thought that individuals experiencing depressive and manic symptoms will have subsequent changes in their thoughts and emotions (13).

CBT makes considerable efforts to enhance adherence to psychopharmacological treatment regimens. Educating patients about the different classes of medications commonly indicated for the treatment of bipolar disorder is thought to make them more likely to adhere. Like psychoeducation, patients undergoing CBT learn about bipolar disorder so that they can begin to recognize their own illness patterns, enabling them to detect symptoms early and prevent full episode relapse (13).

Behaviorally, patients are trained to increase positive behaviors (e.g., sleeping regularly, socializing, and participation in recreation) while decreasing negative behaviors (e.g., using alcohol or drugs or having irregular sleep patterns). Cognitively, patients learn to identify common thinking errors, hone in on distorted cognitions, and chart negative automatic thoughts to enhance recognition. Worksheets designed to track behaviors and cognitions can be reproduced for clinical use from The Bipolar Workbook (14).

The evidence base for efficacy of CBT in bipolar disorder is ambiguous. Individual CBT with psychopharmacologically treated patients with bipolar I and II disorder who are currently euthymic or subsyndromal seems to increase the length of time before a depressive relapse (15). However, an effectiveness study comparing adjunctive individual CBT with treatment as usual suggests that CBT does not seem to prevent relapse into a mood episode for patients with bipolar disorder who have previously experienced more than 11 mood episodes (16). One open trial suggests that adjunctive group CBT may improve psychosocial functioning for individuals with bipolar disorder (17). A randomized, controlled trial comparing group CBT with group drug counseling demonstrated its efficacy in reducing substance use in individuals with co-occurring bipolar and substance use disorders (18). In addition, one study suggests that CBT added to psychoeducation leads to a greater reduction in depressive symptoms than psychoeducation alone in adults with bipolar disorder (19).

CBT was one of three individualized intensive psychotherapies compared with brief psychoeducation in a study run in conjunction with the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) (20), examining whether adjunctive intensive psychotherapy hastened time to recovery in patients meeting the criteria for bipolar I or II disorder and a current episode of major depression. Patients receiving CBT or another intensive psychotherapy exhibited accelerated time to recovery from a major depressive episode compared with those receiving briefer psychoeducation.

Interpersonal and social rhythm therapy

Interpersonal and social rhythm therapy (IPSRT), based on the principles of interpersonal therapy (21), focuses on managing mood symptoms and resolving interpersonal problems. Clinicians work with patients with bipolar disorder to stabilize mood by optimizing “social rhythms,” such as sleep, social interactions, and intellectual engagement. In IPSRT, mood is thought to be best buttressed jointly by a personalized pharmacotherapy regimen and predictable and advantageous circadian rhythms. Interpersonal problems are addressed by focusing on one of five key problem areas: unresolved grief, social role transitions, interpersonal role disputes with a spouse, parent, or child, common interpersonal deficits such as chronic isolation or dissatisfaction with relationships, and grief for the lost healthy self. This final problem area concentrates on reconciling a patient's new identity as an individual with bipolar disorder with his or her identity preceding diagnosis (22).

A course of IPSRT typically consists of four phases: the initial treatment phase, the intermediate phase of treatment, the continuation or maintenance phase, and the final phase of treatment. After a focused history-taking of interpersonal relationships and social routines, a therapist educates patients about bipolar disorder during the initial phase. Social rhythms are regulated in the intermediate phase and maintained in the maintenance phase. An interpersonal problem area is selected during the initial phase, and together clinician and patient intervene in this area during both the intermediate and maintenance phases. When stability has been reached and maintained for some time, therapist and patient move toward a natural point to terminate or reduce frequency of treatment (23).

The efficacy of IPSRT has been evaluated in two randomized clinical trials. The first (24) compared IPSRT to psychopharmacological management/psychoeducation in 175 individuals with bipolar I disorder in acute mood episodes. The authors concluded that assignment to IPSRT in the acute phase of treatment was associated with longer time to recurrence in the 2-year maintenance phase after controlling for confounding variables such as comorbid anxiety, marital status, and cooccurring medical problems. IPSRT was of the second of three intensive psychotherapies compared with brief psychoeducation in the STEP-BD initiative (20). Patients receiving IPSRT, CBT, or a third intensive psychotherapy exhibited accelerated time to recovery from a major depressive episode compared with those receiving briefer psychoeducation. IPSRT was also no better at staving off relapse to depression than other intensive psychotherapies although patients receiving any of the three intensive psychotherapies spent longer periods of time in remission.

Family-focused therapy

Family relationships and how a family handles stressful situations may have considerable impact on the course of an individual's bipolar disorder (25). Family-focused therapy (FFT), works on the premise that improving relationships within the family will decrease overall stress for the patient, leading to fewer affective episode relapses and a potentially more modest symptom profile (26).

A course of FFT is designed with multiple goals in mind. First, therapists work with families to help them understand the features of bipolar disorder and the inner experience of the patient as well as to accept that they are vulnerable to future episodes. Next, therapists encourage families to understand the importance of psychopharmacological treatments for bipolar disorder. Families focus on developing coping strategies to deal with stressful life events that often trigger recurrences of mood episodes. Finally, strengthening interpersonal relationships within the family is an important goal in FFT (26).

FFT consists of four modules that build on one another and create an arsenal of skills for the family. “Psychoeducation,” the first module, provides the family with information about bipolar disorder. The second, “Communication Enhancement Training,” encourages changes in the structure and function of problematic family relationships via practice with basic communication skills such as active listening, expressing positive feelings, making positive requests for change, and expressing negative emotions about specific behaviors. Finally, the problem-solving module helps families identify, agree upon, and generate solutions for topics that engender conflict within the family. Less conflict often leads to less family distress and stress for the patient (26).

The efficacy of FFT as an adjunct to pharmacotherapy for adults with bipolar disorder was demonstrated by Miklowitz et al. (27, 28) in a randomized, controlled trial comparing FFT with an education control in more than 100 families. Individuals randomly assigned to FFT were less likely to relapse into a depressive episode than those randomly assigned to the shorter treatment. Furthermore, depressive symptoms were fewer for the FFT than for the control groups. FFT, along with CBT and IPSRT, was also included as an intensive psychotherapy in STEP-BD (described above). Like CBT and IPSRT, FFT accelerated time to recovery from a major depressive episode compared with that for those receiving briefer psychoeducation (20).

Psychosocial interventions for youth

Since the National Institute of Mental Health convened a roundtable to reach consensus regarding how to define prepubertal bipolar disorder in 2001 (29), psychosocial treatments have been developed and adapted to meet the needs of a younger group of patients. Although an intensive review is beyond the primary scope of this article, I will briefly highlight five child- and adolescent-focused interventions with empirical backing. It is important to note that the quality of clinical trials supporting the efficacy of adjunctive psychosocial interventions in youth is not as strong as is that for adults.

First, multifamily psychoeducation groups (MFPG) adjunctive group treatment for parents and young children has been shown to be effective in reducing overall mood symptoms in children ages 8–12 with major depression or bipolar disorder (30). MFPG consists of eight 90-minute, concurrent sessions for parents and children focusing on education about the illness, management of symptoms, problem solving and communication training, and support (31).

FFT has been adapted for adolescents by Miklowitz et al. (32). Its objectives mirror those of FFT for adult patients; however, educational materials within the psychoeducation, communication enhancement, and problem-solving modules are designed to attract a younger audience's attention. The efficacy of FFT-adolescent (FFT-A) as an adjunct to psychopharmacological treatment has been demonstrated in a 2-year randomized trial comparing FFT-A with an education control in adolescents (33). Of note, it has also been shown to be a feasible treatment for the prevention of bipolar disorder in youth at high risk by virtue of having a parent with the illness (34).

Three additional treatments that have shown some promise for the treatment of bipolar disorder in younger populations are dialectical behavior therapy (DBT), child- and family-focused cognitive behavior therapy (CFF-CBT), and interpersonal and social rhythm therapy for adolescents (IPSRT-A). DBT adapted for adolescents is designed to be delivered over a 1-year period and consists of family skills training with the entire family and individual psychotherapy with the youth (35). CFF-CBT consists of 12 weekly sessions that run in parallel for parents and children. Key components of CFF-CBT form a “rainbow,” and focus on Routine, Affect regulation, coping skills (“I can do it!”), reducing negative thoughts (“No negative thoughts and live in the now!”), developing balance (“Be a good friend and a balanced life style for parents”), problem solving (“Oh, how can we solve the problem?”), and developing Ways to get support (36). Its use with a pediatric bipolar disorder population has been shown to be feasible and acceptable to families (37). Adjunctive IPSRT-A, consisting of 18 sessions, was adapted from IPSRT for adults to be developmentally sensitive to adolescents with bipolar disorder (38). Again, resolution of interpersonal problem areas and regulation of sleep and social rhythms are the focus of IPSRT-A. It has been shown to be feasible in an open trial with adolescents (39).

Core components of psychosocial interventions for bipolar disorder:

Many of the psychosocial interventions described above share one or more fundamental elements. These include providing education about the illness, strengthening adherence to treatments, identifying environmental triggers via mood monitoring, enhancing support networks, and developing coping skills. Collectively, these facilitate patients' gaining a strong understanding of what a bipolar diagnosis entails as well as recognizing how the illness personally affects them.

Questions and controversy

For which patients with bipolar disorder is adjunctive psychotherapy most important? FFT and IPSRT may be good options for patients experiencing pronounced mood symptoms or actively in a depressive or manic episode (20, 24, 28). Conversely, currently euthymic patients or patients with a less severe course of bipolar disorder may benefit most from group psychoeducation or CBT (9,16). Finally, a recent review suggests that CBT and not psychoeducation, FFT, or IPSRT may most effectively treat patients with bipolar disorder and co-occurring anxiety disorders (40).

The effectiveness of psychotherapy for bipolar disorder—how well it works in community-based settings—is not well understood. Most trials to date have focused on examining the efficacy of specific psychotherapeutic interventions in patients with narrowly defined symptom profiles seeking care in university clinic settings. To truly understand whether psychotherapy is a broadly useful adjunct to pharmacology for bipolar disorder, treatments such as psychoeducation, CBT, IPSRT, and FFT will require systematic evaluation in community clinics such as VA centers, county mental health centers, and others. Although costs associated with rolling out such treatments are substantial, the reduced rates of hospitalization and use of other resources in patients receiving psychotherapy may render them cost-effective in the long run (41).

Recommendations from the author

Psychotherapy as an adjunct to medication is an effective option for patients with bipolar disorder and may delay or prevent relapse into depressive, manic, or hypomanic episodes as well as improve quality of life. Individual and group psychoeducation, CBT, IPSRT, and FFT offer patients bipolar disorder-specific tools and strategies for coping with the complexities of serious mental illness (Table 1). Particularly for youth, psychotherapy offers a way to involve the whole family in the treatment process and may help slow down or even stave off the development of severe symptoms. When feasible, treating clinicians should consider an adjunctive course of psychotherapy for patients with bipolar disorder.

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