Focus on Bipolar Disorder Treatment:
Psychosocial Management of Bipolar Disorder

The psychosocial management of bipolar disorder has been discussed in the latest volume of the Review of Psychiatry series and at the recent American Psychiatric Association meeting, held in May in Atlanta, Ga.

The most recent Review of Psychiatry publication, volume 24: Advances in Treatment of Bipolar Disorder (American Psychiatric Publishing, Inc., 2005), reviews the importance of psychosocial issues, including both formal models of psychotherapy and psychoeducational methods to enhance adherence to treatment, in several chapters. In the chapter "Long-Term Management of Bipolar Disorder," for example, Bowden and Singh emphasize the importance of encouraging a therapeutic alliance between patient and clinician. If the patient feels understood and secure within the therapeutic relationship and sees the clinician as someone who is both empathic and competent, then that patient will be more likely to adhere with treatment, to report medication side effects and breakthrough symptoms, and to understand and accept the illness.

In their chapter, Bowden and Singh also consider the place of psychotherapy in the maintenance management of bipolar disorder. According to a series of recent studies, adjunctive psychotherapy was found to provide additional benefits to medication alone, such as increased time between episodes, fewer days in the hospital, and decreased risk of relapse compared with patients who received treatment as usual (Frank et al. J Abnorm Psychol 1999;108:579-587; Lam et al. Arch Gen Psychiatry 2003;60:145-152; Miklowitz et al. Arch Gen Psychiatry 2003;60:904-912). The authors conclude that larger-scale studies are needed to extend these results in less highly selected populations.

In the chapter "Treatment of Children and Adolescents With Bipolar Disorder," Chang and coauthors state that successful treatment of bipolar disorder in children and adolescents has 3 components: medication, psychotherapy, and educational interventions. Although, as with pharmacotherapy, evidence for psychotherapy in this age group is limited, studies of cognitive therapy and family-focused therapy indicate their effectiveness as adjunctive therapy to medication in improving manic and depressive symptoms. Family and patient education has also been studied in children with bipolar disorder, with promising results: after families participated in 8 educational sessions, parents were more knowledgeable about their children's disorder and were more supportive of their children.

In the chapter "Special Considerations for Women With Bipolar Disorder," Rasgon and Zappert report on a patient group for whom adjunctive psychotherapy may be particularly relevant: pregnant women. Pharmacotherapy with several agents (i.e., divalproex and lithium) during pregnancy can pose known risks to the developing fetus, and even potentially safer alternatives, such as lamotrigine, are not extensively studied. In the face of such uncertainty, many women choose to discontinue their medications or, if that poses too great a risk of relapse, decrease their dose. In one study of women with unipolar depression, interpersonal psychotherapy was associated with full remission of depressive symptoms in pregnant women with depression (Spinelli MG. Am J Psychiatry 1997;154:1028-1030). Another small study found interpersonal psychotherapy effective in postpartum depression (O'Hara et al. Arch Gen Psychiatry 2000'57:1039-1045). Although treatments that are effective in unipolar depression are not certain to succeed in bipolar disorder, these findings certainly justify evaluating the use of specific forms of psychotherapy with expectant mothers with bipolar disorder. In addition, mobilization of support from family and friends during the pregnancy and postpartum can be helpful as well.

The psychosocial management of bipolar disorder was also addressed at the 2005 annual meeting of the American Psychiatric Association (APA). In a scientific report session on psychotherapy in general, Steven H. Lipsius reviewed the advantages of taking an empathic stance with patients versus a neutral stance (Scientific and Clinical Report Session 6). A neutral stance, in which the clinician shows no emotion or empathy, can alienate a patient, whereas an empathic stance, in which the clinician openly expresses empathy, can help the patient feel that he or she will be listened to and understood in a safe environment. This will, in turn, help the patient be more open and more able to confront both the illness and any other unresolved conflicts.

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At an industry-supported symposium, Kay R. Jamison discussed psychological factors that can impede compliance with treatment (Industry-Supported Symposium 34, supported by GlaxoSmithKline). One of these is that mild manic states are often enjoyable, with increased energy and creative ability (at least in the mind of the patient). Others include a resistance to accepting bipolar disorder as a lifelong illness in need of maintenance medication, living alone, and medication side effects. Jamison then reviewed several strategies for encouraging medication compliance, including both psychotherapy and education of both patients and their families. Jamison also emphasized research demonstrating that psychotherapy can help delay the time to relapse, as can group psychoeducational interventions.

New research posters at the APA also addressed psychosocial issues in the treatment of bipolar disorder. Again, one of the main impediments to successful long-term treatment is patient nonadherence. Sajatovic and colleagues conducted a randomized, controlled trial examining the effects of a standardized psychoeducation program versus standard care on certain aspects of adherence, such as attitudes toward medication (NR367). Preliminary results indicated that, after 3 months, those patients involved in the psychoeducation program had a statistically significant improvement in their attitudes toward medication compared with patients receiving treatment as usual.

Culver and coworkers reported the effects of dialectical behavior therapy (DBT) on patients with bipolar disorder (NR785). Using retrospective data from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, the investigators identified 16 female patients who received DBT in a group setting. Using a mirror-image design (i.e., each patient served as his/her own control), DBT resulted in a decrease in frequency and severity of depression and anhedonia, as well as a significant increase in Global Assessment of Functioning scores.

Michael E. Thase, M.D., stressed the importance of this research on the psychosocial management of bipolar disorder, commenting that, given the real limitations of pharmacotherapy, there was ample room for improvement. Thase suggested that the formerly prevailing view that bipolar disorder was best understood from a strictly medical model inadvertently inhibited research on the utility of adjunctive psychosocial therapies. Research documenting the benefits of various models of adjunctive psychosocial intervention for people with schizophrenia helped to foster a reexamination of the role of psychotherapy for bipolar disorder. Thase further noted that, despite the availability of several new classes of pharmacotherapy for bipolar disorder, only a minority of patients can obtain and sustain a complete recovery and, for the majority of patients, bipolar disorder is a complex, highly comorbid, and chronic or recurrent illness. Thase emphasized the essential role of adherence and opined that even the most effective medication will be useless if the prescription goes unfilled or the pills remain in the bottle.

Thase suggested that research on psychotherapy for bipolar depression should be given a particularly high priority. Given the relatively sparse data on antidepressants, it is hard to make the case that there really is a treatment of first choice for bipolar depression. If found to be effective, cognitive-behavioral, interpersonal, and family-focused psychotherapies hold the promise of offering benefits comparable to antidepressants, without the side effects or risk of induction of mania or rapid cycling.

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Drug names: divalproex (Depakote), lamotrigine (Lamictal), lithium (Eskalith, Lithobid, and others).

Disclosure of off-label usage: The author has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US. Food and Drug Administration-approved labeling has been presented in this article.

Supported by an educational grant from GlaxoSmithKline.