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.