Psychosocian Interventions for Individuals with Bipolar Disorder

Compiled by, Ivan K. Goldberg, M.D.

Psychiatry Res. 2005 Sep 15;136(2-3):101-11.

Perceived criticism from family members as a predictor of the one-year course of
bipolar disorder.

Miklowitz DJ, Wisniewski SR, Miyahara S, Otto MW, Sachs GS.

Department of Psychology, Muenzinger Bldg., University of Colorado, Boulder, CO
80309-0345, USA. miklow@psych.colorado.edu

Few studies have examined the prognostic value of family factors in the course
of bipolar affective disorder. The current study examined a self-report measure
of expressed emotion as a predictor of the 1-year course of the illness.
Patients with bipolar disorder (N=360) filled out the four-item Perceived
Criticism Scale concerning one or more relatives or close friends. Independent
evaluators followed patients over 1 year and rated them on measures of
depressive and manic symptoms and the percentage of days in recovery status.
Patients’ ratings of the severity of criticisms from relatives did not predict
patients’ mood disorder symptoms at follow-up. However, patients who were more
distressed by their relatives’ criticisms had more severe depressive and manic
symptoms and proportionately fewer days well during the study year than patients
who were less distressed by criticisms. Patients who reported that their
relatives became more upset by the patients’ criticisms had less severe
depressive symptoms at follow-up. Results indicate that a brief rating of
subjective distress in response to familial criticism is a useful prognostic
device and may aid in planning psychosocial interventions for patients with
bipolar disorder.

PMID: 16023735 [PubMed – indexed for MEDLINE] ———-
Arch Gen Psychiatry. 2005 Sep;62(9):996-1004.

Two-year outcomes for interpersonal and social rhythm therapy in individuals
with bipolar I disorder.

Frank E, Kupfer DJ, Thase ME, Mallinger AG, Swartz HA, Fagiolini AM,
Grochocinski V, Houck P, Scott J, Thompson W, Monk T.

Western Psychiatric Institute and Clinic, Department of Psychiatry, University
of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA. franke@upmc.edu

CONTEXT: Numerous studies have pointed to the failure of prophylaxis with
pharmacotherapy alone in the treatment of bipolar I disorder. Recent
investigations have demonstrated benefits from the addition of psychoeducation

or psychotherapy to pharmacotherapy in this population. OBJECTIVE: To compare 2
psychosocial interventions: interpersonal and social rhythm therapy (IPSRT) and
an intensive clinical management (ICM) approach in the treatment of bipolar I
disorder. DESIGN: Randomized controlled trial involving 4 treatment strategies:
acute and maintenance IPSRT (IPSRT/IPSRT), acute and maintenance ICM (ICM/ICM),
acute IPSRT followed by maintenance ICM (IPSRT/ICM), or acute ICM followed by
maintenance IPSRT (ICM/IPSRT). The preventive maintenance phase lasted 2 years.
SETTING: Research clinic in a university medical center. PARTICIPANTS: One
hundred seventy-five acutely ill individuals with bipolar I disorder recruited
from inpatient and outpatient settings, clinical referral, public presentations
about bipolar disorder, and other public information activities. INTERVENTIONS:
Interpersonal and social rhythm therapy, an adaptation of Klerman and Weissman’s
interpersonal psychotherapy to which a social rhythm regulation component has
been added, and ICM. MAIN OUTCOME MEASURES: Time to stabilization in the acute
phase and time to recurrence in the maintenance phase. RESULTS: We observed no
difference between the treatment strategies in time to stabilization. After
controlling for covariates of survival time, we found that participants assigned
to IPSRT in the acute treatment phase survived longer without a new affective
episode (P = .01), irrespective of maintenance treatment assignment.
Participants in the IPSRT group had higher regularity of social rhythms at the
end of acute treatment (P<.001). Ability to increase regularity of social
rhythms during acute treatment was associated with reduced likelihood of
recurrence during the maintenance phase (P = .05). CONCLUSION: Interpersonal and
social rhythm therapy appears to add to the clinical armamentarium for the
management of bipolar I disorder, particularly with respect to prophylaxis of
new episodes.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 16143731 [PubMed – indexed for MEDLINE] ———-
Compr Psychiatry. 2005 Jul-Aug;46(4):272-7.

Attitudes regarding the collaborative practice model and treatment adherence
among individuals with bipolar disorder.

Sajatovic M, Davies M, Bauer MS, McBride L, Hays RW, Safavi R, Jenkins J.

Department of Psychiatry, Case Western Reserve University School of Medicine,
Cleveland, OH 44106, USA. martha.sajatovic@uhhs.com

An emerging literature suggests that a collaborative care model, in which
patients are active managers of their illness within a supportive social
environment, is a beneficial approach for individuals with bipolar disorder. One
aspect of treatment that is often suboptimal among individuals with bipolar
disorder is treatment adherence. Establishing an ideal collaborative model may
offer an opportunity to enhance treatment adherence among individuals with
bipolar disorder. This paper presents results from a qualitative exploration of
patients’ attitudes towards the collaborative care model and how individuals
with bipolar disorder perceive treatment adherence within the context of the
collaborative care model. All participants were actively enrolled in outpatient
treatment at a Community Mental Health Center and part of a larger study that
evaluated the Life Goals Program, a manual-driven structured group psychotherapy
for bipolar disorder that is based on the collaborative practice model. The Life
Goals Program is designed to assist individuals to participate more effectively
in the management of their bipolar illness and to improve their social and
work-related problems. Individuals were queried regarding their opinions on the
ingredients for an effective client-provider relationship. Quantitative data
were collected on baseline treatment adherence as well. Individuals treated for
bipolar disorder in a community mental health clinic identified 12 key elements
that they felt were critical ingredients to a positive collaborative experience
with their mental health care provider. The authors conceptualized these
elements around 3 emerging themes: patient-centered qualities, provider-centered
qualities, and interactional qualities. Individuals with bipolar disorder
perceived the ideal collaborative model as one in which the individual has
specific responsibilities such as coming to appointments and sharing
information, whereas the provider likewise has specific responsibilities such as
keeping abreast of current “state-of-the-arf” prescribing practices and being a
good listener. Treatment adherence was identified as a self-managed
responsibility within the larger context of the collaborative model. Individuals
with bipolar disorder in this study placed substantial emphasis on the
interactional component within the patient-provider relationship, particularly
with respect to times when the individual may be more symptomatic and more
impaired. It is important that clinicians and care providers gather information
related to patients’ perceptions of the patient-provider relationship when
designing or evaluating services aimed at enhancing treatment adherence.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 16175758 [PubMed – indexed for MEDLINE] ———-
Br J Psychiatry. 2005 Jun;186:500-6.

Cost-effectiveness of relapse-prevention cognitive therapy for bipolar disorder:
30-month study.

Lam DH, McCrone P, Wright K, Kerr N.

Psychology Department, Institute of Psychiatry, DeCrespigny Park, London SE5
8AF. D.Lam@iop.kcl.ac.uk

BACKGROUND: We have reported the advantageous clinical outcome of adding
cognitive therapy to medication in the prevention of relapse of bipolar
disorder. AIMS: This 30-month study compares the cost-effectiveness of cognitive
therapy with standard care. METHOD: We randomly allocated 103 individuals with
bipolar 1 disorder to standard treatment and cognitive therapy plus standard
treatment. Service use and costs were measured at 3-month intervals and
cost-effectiveness was assessed using the net-benefit approach. RESULTS: The
group receiving cognitive therapy had significantly better clinical outcomes.
The extra costs were offset by reduced service use elsewhere. The probability of
cognitive therapy being cost-effective was high and robust to different therapy
prices. CONCLUSIONS: Combination of cognitive therapy and mood stabilizers was
superior to mood stabilizers alone in terms of clinical outcome and
cost-effectiveness for those with frequent relapses of bipolar disorder.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 15928361 [PubMed – indexed for MEDLINE] ———-
Psychiatr Clin North Am. 2005 Jun;28(2):371-84.

Psychosocial treatments for bipolar disorders.

Scott J, Colom F.

Division of Psychological Medicine, Institute of Psychiatry, P.O. Box 96, De
Crespigny Park, Denmark Hill, London SE5 8AF, UK. j.scott@iop.kcl.ac.uk

Psychosocial problems may be causes or consequences of BP relapses,and adding
psychologic therapies to usual-treatment approaches may improve the prognosis of
those at risk of persistent symptoms or frequent episodes. The three core
individual manualized therapies (IPSRT, cognitive therapy, and FFT) have all
developed specific models for use in BP. Colom et al’s group psychoeducation
model also has a clearly developed rationale and format, and it allows
individuals to share their views of BP with others, to learn adaptive coping
strategies from the other 8 to 12 members of the group, and to have regular
contact with an expert therapist. Careful review of the four more extended and
comprehensive approaches and the brief technique-driven interventions
demonstrates that the effective therapies incorporate one or more of the modules
show in Box 1. At present,the choice between the four extended models is more
likely to be dictated by patient choice or the availability of a trained
therapist. The technique-driven interventions are briefer than the specific
therapies (about 6-9 sessions compared with about 20-22 sessions) and usually
offer a generic, fixed treatment package targeted at a circumscribed issue such
as medication adherence or managing early symptoms of relapse. These brief
interventions can be delivered by a less-skilled or less-experienced
professional than the specific model. They potentially seem to be useful in
day-to-day clinical practice in general adult psychiatry settings; additional
larger-scale, randomized trials should be encouraged. Given the reduction in
relapse rates and hospitalizations associated with the use of psychologic
therapy as an adjunct to medication, it is likely that these approaches will
prove to be clinically and cost effective. They may provide a significant
improvement in the quality of life of individuals with BP (and indirectly to
that of their partners and family members). Brief,evidence-based therapies
represent an important component of good clinical practice in the management of
BP. Studies of a comprehensive, whole-system approach to the collaborative
psychobiosocial management of BP are being undertaken in the United States. If
these approaches improve the quality and continuity of care for individuals with
BP, they will have further implications for the delivery and organization of
mental health services. The number and variety of trials of psychosocial
interventions is exciting for researchers and clinicians interested in BP.
Enthusiasm for advocating these approaches should be tempered by an
acknowledgment that the trials undertaken so far largely demonstrate efficacy in
selected samples of patients treated at specialist BP clinics or psychologic
treatment research centers. Translating efficacy into effectiveness requires
evidence that the approaches used in the treatment trials are equally beneficial
when used by the wider therapist community treating patients seen routinely in
non-specialist or nonresearch centers. These patients often have multiple
problems or complex presentations that preclude their involvement in
pharmacologic or psychologic treatment studies, but monitoring the outcomes of
these representative samples will be important in determining the true place of
psychologic approaches in the management of BP. Large-scale studies are now
underway on both sides of the Atlantic (the Medical Research Council study in
the United Kingdom and the STEP-BD project in the United States).These trials
are likely to answer basic questions about the benefits and limitations of
psychologic therapies in the acute and maintenance treatment of BP in the
clinical realm and will increase understanding of the
effectiveness-versus-efficacy question.

Publication Types:
Review

PMID: 15826737 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2005 Apr;7(2):192-7.

Acute treatment outcomes in patients with bipolar I disorder and co-morbid
borderline personality disorder receiving medication and psychotherapy.

Swartz HA, Pilkonis PA, Frank E, Proietti JM, Scott J.

Department of Psychiatry, University of Pittsburgh School of Medicine, Western
Psychiatric Institute and Clinic, Pittsburgh, PA 15213, USA. swartzha@upmc.edu

OBJECTIVE: Patients suffering from both bipolar I disorder and borderline
personality disorder (BPD) pose unique treatment challenges. The purpose of this
matched case-control study was to compare acute treatment outcomes of a sample
of patients who met standardized diagnostic criteria for both bipolar I disorder
and BPD (n = 12) to those who met criteria for bipolar I disorder only (n = 58).
METHOD: Subjects meeting criteria for an acute affective episode were treated
with a combination of algorithm-driven pharmacotherapy and weekly psychotherapy
until stabilization (defined as four consecutive weeks with a calculated average
of the 17-item version of the Hamilton Rating Scale for Depression and
Bech-Rafaelsen Mania scale totaling < or = 7). RESULTS: Only three of 12 (25%)
bipolar-BPD patients achieved stabilization, compared with 43 of 58 (74%)
bipolar-only patients. Two of the three bipolar-BPD patients who did stabilize
took over 95 weeks to do so, compared with a median time-to-stabilization of 35
weeks in the bipolar-only group. The bipolar-BPD group received significantly
more atypical mood-stabilizing medications per year than the bipolar-only group
(Z = 4.3, p < 0.0001). Dropout rates in the comorbid group were high.
CONCLUSIONS: This quasi-experimental study suggests that treatment course may be
longer in patients suffering from both bipolar I disorder and BPD. Some patients
improved substantially with pharmacotherapy and psychotherapy, suggesting that
this approach is worthy of further investigation.

PMID: 15762861 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2005 Apr;7(2):166-75.

Spontaneous and directed application of verbal learning strategies in bipolar
disorder and obsessive-compulsive disorder.

Deckersbach T, Savage CR, Dougherty DD, Bohne A, Loh R, Nierenberg A, Sachs G,
Rauch SL.

Harvard Bipolar Research Program, Department of Psychiatry, Massachusetts
General Hospital, Harvard Medical School, Charlestown, MA 02129, USA.
tdeckersbach@partners.org

OBJECTIVES: Individuals with bipolar disorder exhibit neuropsychological
impairments when they are euthymic (neither depressed nor manic). One of the
most consistently reported cognitive problems in euthymic individuals with
bipolar disorder is impairment in verbal episodic memory. Recent findings
suggest that episodic memory difficulties in these individuals are attributable
to difficulties using organizational strategies during encoding. The purpose of
the present study was (i) to investigate whether difficulties using
organizational strategies in bipolar disorder are due to a failure in
spontaneously initiating verbal organization strategies or are due to
difficulties implementing such strategies, and (ii) to compare the
characteristics of verbal organizational impairment in bipolar disorder with
those observed in individuals with obsessive-compulsive disorder (OCD). METHODS:
Study participants were 20 individuals with bipolar I disorder (BP-I), 20
individuals with OCD, and 20 healthy control participants matched for age,
gender, and education. Participants completed a verbal encoding paradigm that
involved spontaneous and directed use of verbal organization strategies during
encoding of word lists. RESULTS: Compared with control subjects, both BP-I and
OCD participants showed impaired verbal organization in the spontaneous encoding
condition. In the directed encoding condition, OCD patients organized the word
lists as well as control participants whereas BP-I participants exhibited lower
verbal organization than both control and OCD participants. OCD and BP-I
participants’ free recall performance did not differ from that of control
participants in the spontaneous encoding condition. In the directed encoding
condition, BP-I participants recalled fewer words than OCD or control
participants. CONCLUSIONS: Episodic memory difficulties in OCD are associated
with difficulties spontaneously initiating verbal organization strategies during
encoding whereas the ability to implement verbal organization when instructed to
do so is preserved. BP-I participants, on the other hand, exhibit difficulties
in both spontaneously initiating verbal organization strategies and in the
ability to implement such strategies when instructed to do so.

PMID: 15762858 [PubMed – indexed for MEDLINE] ———-
Am J Psychiatry. 2005 Feb;162(2):324-9.

Comment in:
Evid Based Ment Health. 2005 Nov;8(4):102.

Relapse prevention in patients with bipolar disorder: cognitive therapy outcome
after 2 years.

Lam DH, Hayward P, Watkins ER, Wright K, Sham P.

Department of Psychology, Institute of Psychiatry, King’s College, London, UK.
spjtdhl@iop.kcl.ac.uk

OBJECTIVE: In a previous randomized controlled study, the authors reported
significant beneficial effects of cognitive therapy for relapse prevention in
bipolar disorder patients up to 1 year. This study reports additional 18-month
follow-up data and presents an overview of the effect of therapy over 30 months.
METHOD: Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent
relapses were randomly assigned into a cognitive therapy plus medication group
or a control condition of medication only. Independent raters, who were blind to
patient group status, assessed patients at 6-month intervals. RESULTS: Over 30
months, the cognitive therapy group had significantly better outcome in terms of
time to relapse. However, the effect of relapse prevention was mainly in the
first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to
189) in bipolar episodes out of a total of 900 for the whole 30 months and 54
fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the
last 18 months. Multivariate analyses of variance showed that over the last 18
months, the cognitive therapy group exhibited significantly better mood ratings,
social functioning, coping with bipolar prodromes, and dysfunctional goal
attainment cognition. CONCLUSIONS: Patients in the cognitive therapy group had
significantly fewer days in bipolar episodes after the effect of medication
compliance was controlled. However, the results showed that cognitive therapy
had no significant effect in relapse reduction over the last 18 months of the
study period. Further studies should explore the effect of booster sessions or
maintenance therapy.

Publication Types:
Clinical Trial
Randomized Controlled Trial
———-
PMID: 15677598 [PubMed – indexed for MEDLINE]

Bipolar Disord. 2005 Feb;7(1):49-56.

Content-specificity of dysfunctional cognitions for patients with bipolar mania
versus unipolar depression: a preliminary study.

Goldberg JF, Wenze SJ, Welker TM, Steer RA, Beck AT.

Bipolar Disorders Research Program, Department of Psychiatry Research, The
Zucker Hillside Hospital, North Shore Long Island Jewish Health System, Glen
Oaks, NY 11004, USA. jfgoldberg@yahoo.com

OBJECTIVE: Dysfunctional beliefs or cognitions are considered to be fundamental
to both the phenomenology and pathogenesis of depression. However, the cognitive
aspects of mania have not been as thoroughly investigated. We sought to compare
the maladaptive beliefs and cognitions of 23 bipolar manic or hypomanic
patients, 28 patients with unipolar major depression, and 24 normal adults.
METHOD: The Cognition Checklist for Mania (CCL-M) was used to assess the
beliefs. This 61-item self-report instrument is scored for seven subscales
measuring (a) self-importance, (b) interpersonal grandiosity, (c) inappropriate
spending, (d) excitement and risk-taking, (e) interpersonal frustrations, (f)
goal-driven activity, and (g) past or future outlooks on life, and also yields a
total score. RESULTS: The mean CCL-M total score of the bipolar-manic patients
was significantly higher than the mean CCL-M total score of the
unipolar-depressed patients, and the patients’ mean CCL-M total score was also
higher than that of the normal adults. The mean scores of the subscales
measuring excitement and past and future memories and expectations were also
significantly higher for the bipolar-manic than unipolar-depressed patients.
CONCLUSIONS: Bipolar-manic patients endorse with maladaptive beliefs and
cognitions that are associated with mania more than do unipolar-depressed
patients and normal adults. The implications for the early identification of
cognitions associated with prodromal states of mania, and for psychotherapeutic
interventions, are discussed. Copyright (c) 2005, Blackwell Munksgaard.

PMID: 15654932 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2005 Feb;7(1):22-32.

Psychological therapies for bipolar disorder: the role of model-driven
approaches to therapy integration.

Jones SH, Sellwood W, McGovern J.

Academic Division of Clinical Psychology, University of Manchester and Pennine
Care Trust, Greater Manchester, UK. steven.jones@man.ac.uk

OBJECTIVES: The psychological and social aspects of bipolar disorder are
receiving increasing recognition. Recently, there have been promising
developments in psychological interventions, but there is scope for further
improvement of therapeutic outcomes. This paper argues for the use of more
detailed psychological models of bipolar disorder to inform the further
development of therapeutic approaches. METHOD: Evidence for psychological,
family and social factors in bipolar disorder is reviewed. The efficacy of
current individual and family interventions are discussed. A model, which has
potential to synthesize group and individual approaches, is outlined. RESULTS:
Psychological, social and family factors have important influences on the onset,
course and outcome of bipolar disorder. Interventions based on vulnerability
stress models have proved effective. However, to enhance efficacy future
developments need to be based on models that integrate current understandings of
the multiple levels at which mood fluctuations occur. A particular recent model
is discussed which leads to specific proposals for future intervention research.
CONCLUSIONS: Psychological and family approaches to BD have much potential. They
clearly have a role in conjunction with appropriate pharmacological treatment.
If this potential is to be fully realized future developments need to be based
on psychological models that can accommodate the complexity of this illness.
Copyright (c) 2005, Blackwell Munksgaard.

Publication Types:
Review

PMID: 15654929 [PubMed – indexed for MEDLINE] ———-
Can J Psychiatry. 2005 Feb;50(2):95-100.

Perceived quality of life in patients with bipolar disorder. Does group
psychoeducation have an impact?

Michalak EE, Yatham LN, Wan DD, Lam RW.

Department of Psychiatry, University of British Columbia, Vancouver.
emichala@interchange.ubc.ca

OBJECTIVE: A large body of research has now accumulated concerning quality of
life (QoL) for patients with major depressive disorder, both in terms of
describing levels of well-being and in terms of assessing the impact of
treatment interventions. However, there is little information concerning QoL for
patients with bipolar disorder (BD), and there is relatively little published
evidence concerning the effectiveness of psychological interventions for BD. We
aimed to assess the impact of a time-limited psychoeducation (PE) group therapy
upon perceived QoL among patients with BD. METHOD: Participants were patients (n
= 57) with BD type I or II who were clinically described as euthymic or mildly
symptomatic. Treatment intervention was a standardized, 8-week group PE course
delivered in a mood disorders program in British Columbia, Canada. Using
retrospective chart review and the Quality of Life Enjoyment and Satisfaction
Questionnaire (Q-LES-Q), we assessed QoL at baseline and at 8 weeks. RESULTS:
Mean baseline Q-LES-Q scores were 56%, representing moderate impairment in QoL.
Group PE was associated with a 5-point increase in Q-LES-Q scores (where higher
scores indicate better QoL). Examination of the questionnaire’s subscales
revealed that 2 domains (that is, physical functioning and general satisfaction)
increased significantly following PE, with the remaining domains showing
nonsignificant trends toward improved functioning. Multivariate analysis
indicated that only one factor (having had a recent episode of depression)
significantly predicted pre- and posttreatment Q-LES-Q scores. CONCLUSION:
Patients with BD continue to show impaired QoL even when clinically euthymic.
Although preliminary, our results show that group PE is associated with improved
QoL in this population, both in terms of general satisfaction and in relation to
levels of physical functioning. The use of PE as an adjunct to pharmacotherapy
in BD should be further studied with particular emphasis on characterizing the
effects of treatment intervention on perceived QoL.

PMID: 15807225 [PubMed – indexed for MEDLINE] ———-
Am J Psychother. 2005;59(2):137-47.

Existential despair and bipolar disorder: the therapeutic alliance as a mood
stabilizer.

Havens LL, Ghaemi SN.

Harvard Medical School, Boston, MA, USA.

Talking with a manic patient is not easy, but it is also not hopeless. Manic
patients are hopeful, ever hopeful, and indeed often too hopeful. But their
hopes and dreams, however big, are usually brief and soon damaged by the
realities of life. Ultimately, most patients with bipolar disorder become
chronically depressed, denied of their hopes by others. Appropriate medication
treatment is necessary, but not sufficient, for many such persons. The job of
the clinician is twofold initially: first, to seek to existentially be with
manic patients and then, to counterprojectively give perspective to those
patients about their manic worldview, without completely denying it. This
twofold approach then can lead to a healthy therapeutic alliance, which itself
has a mood-stabilizing effect. Along with mood-stabilizing medications, this
alliance can then lead patients toward full recovery. Put more simply,
clinicians need to talk to manic patients about their hopes, to explore the
limits of their grandiosity without judging it, to seek out their strengths and
to validate them. They also need to go where the patients are, to encounter
patients and find the person beneath the illness, to provide a strong
relationship, an alliance that cannot be shaken, to conflict with the patient
sometimes and not at other times. It is a tall order, and one not infrequently
avoided. Yet the times seem to call for a return to actually talking with manic
patients, and maybe curing them with such talk. Or perhaps that is grandiose.

PMID: 16170918 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2005;66 Suppl 5:34-9.

The package of care for patients with bipolar depression.

Vieta E.

Clinical Institute of Neuroscience, Hospital Clinic, University of Barcelona,
IDIBAPS, Barcelona, Spain. evieta@clinic.ub.es

Although pharmacotherapy is the mainstay of the comprehensive program of medical
care for the management of patients with bipolar disorder, the additional
benefits of psychosocial interventions for the patient, family, and caregivers
are now being recognized and increasingly adopted. Several facets of bipolar
disorder can be addressed more effectively by instituting adjunctive
psychosocial interventions. Recent clinical evidence indicates that combining
pharmacotherapy with psychosocial interventions, which are tailored to patients’
individual needs, may decrease the risk of relapse, improve patient adherence,
and decrease the number and length of hospitalizations. A multidisciplinary
approach may also enhance long-term patient outcomes such as mood stability,
enhanced occupational and/or social functioning, and overall quality of life.
Psychoeducation helps individuals become active and informed participants in the
management of their illness, promoting a collaborative relationship between
patients and their caregivers. However, psychosocial interventions are not
useful for all patients with bipolar illness and may be more useful in
addressing some problems than others. Evidence would suggest that psychosocial
interventions, with continuing pharmacotherapy, are best used as prophylaxis and
during periods of remission to prevent further episodes. Further randomized,
clinical trials will help to define which components of psychosocial
intervention are most effective in patients with bipolar disorder.

Publication Types:
Review

PMID: 16038600 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2005;66 Suppl 5:11-6.

Challenges in the management of bipolar depression.

Suppes T, Kelly DI, Perla JM.

Department of Psychiatry, University of Texas Southwestern Medical Center,
Dallas 75390-9121, USA. trisha.suppes@utsouthwestern.edu

Bipolar depression has started to receive more attention in clinical trials only
relatively recently, despite the fact that patients spend more time in the
depressed phase than in the manic phase of bipolar disorder. The diagnosis and
management of bipolar depression are challenging, and many patients are
undiagnosed or misdiagnosed due to symptom similarities with unipolar depression
or other illnesses and/or comorbidities. Untreated or inappropriately treated
bipolar depression adds to the burden of illness and is associated with a
greater risk of suicide. Treatment options include lithium, lamotrigine,
atypical antipsychotics, and traditional antidepressants, such as the selective
serotonin reuptake inhibitors. However, traditional antidepressants are
recommended with caution due to their potential risk of switching patients into
mania. Some atypical antipsychotics have shown efficacy in bipolar depression,
although longer-term studies are warranted. The choice of treatment for
different subgroups of patients with bipolar depression, including those with
comorbid anxiety, may vary and also needs further study. Other important issues
that require further investigation include the recognition of the core features
of bipolar depression and the threshold symptoms for treatment, as well as the
optimal treatment choices for monotherapy or combination therapy, and acute
versus long-term management of bipolar depression.

Publication Types:
Review

PMID: 16038597 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2005;66 Suppl 1:24-9.

Improving treatment adherence in bipolar disorder through psychoeducation.

Vieta E.

Bipolar Disorders Program, Hospital Clinic IDIBAPS, University of Barcelona,
Barcelona, Spain. evieta@clinic.ub.es

The chronicity and cyclical nature of bipolar disorder combined with the
irrationality typical during bipolar mood episodes often encourage pharmacologic
treatment nonadherence, which heightens the severity of the illness. Although
clinicians acknowledge treatment nonadherence to be a major issue among bipolar
patients, assessing nonadherence is difficult, and improving treatment adherence
is a complicated and delicate matter. Treatment adherence can be improved among
patients with bipolar disorder through psychoeducation about the nature of their
disorder and the vital importance of treatment adherence. Founded on a
biopsychosocial, medical model of mental disorders, psychoeducation empowers the
patient by providing a practical and theoretical approach to understanding and
dealing with the symptoms and consequences of bipolar disorder. Psychoeducation
identifies bipolar disorder as a biological abnormality that requires regular
pharmacologic treatment and teaches patients to cope with symptoms and maintain
regularity in daily social and occupational functioning. Psychoeducated patients
show improvements in treatment adherence and in other clinical outcomes,
including reduced number of mood episodes and hospitalizations and increased
time between episodes. As an adjunct to pharmacotherapy of bipolar disorder,
psychoeducation is a promising management component that increases treatment
adherence and quality of life for patients.

PMID: 15693749 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2005;66 Suppl 1:13-7.

Diagnosis and management of patients with bipolar II disorder.

Yatham LN.

Division of Mood Disorders, University of British Columbia, Vancouver, Canada.
yatham@interchange.ubc.ca

Bipolar II disorder is frequently misdiagnosed as major depressive disorder. In
particular, correct diagnosis of bipolar II disorder may be delayed by years due
to the predominance of depressive symptoms and the relative subtlety of
hypomania, which may manifest only briefly and without elevated mood. The
prevalence of bipolar II disorder varies from 0.5% to about 5% depending on the
criteria used. Diagnosis can be improved by using mood disorder questionnaires,
systematic probing, and prospective mood diary charting. There is a dearth of
research into treatment of bipolar disorder. The limited available evidence
suggests that lithium and lamotrigine may have efficacy in preventing relapse of
mood episodes. Acute bipolar II depression could be treated with a combination
of a mood stabilizer plus an antidepressant or pramipexole and in rare cases
with antidepressant monotherapy. Hypomania will likely respond to monotherapy
with antimanic agents. Adjunctive psychosocial treatments may provide additional
benefit in patients with bipolar II disorder.

Publication Types:
Review

PMID: 15693747 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2005;66 Suppl 1:7-12.

Long-term treatment in bipolar disorder.

Swann AC.

Department of Psychiatry, University of Texas Medical School, Houston, TX 77030,
USA. Alan.C.Swann@uth.tmc.edu

Bipolar disorder is a lifelong illness with a course that is usually chronic or
recurrent. Severity of complications is generally proportionate to the number of
episodes, especially depression. In addition to potentially preventing episodes,
effective treatment reduces mortality. This article reviews long-term treatment
strategies for bipolar disorder, focusing on depressive episodes, and discusses
treatment studies, including problems in design. Treatment effectiveness,
including reduction of suicide risk, is enhanced if patients and physicians
collaboratively recognize and treat prodromal symptoms, preventing the emergence
of episodes. Strategies for treatment differ as one progresses from obtaining
syndromal recovery in the acute episode, to functional recovery during
continuation treatment, to stability during maintenance treatment. Successful
long-term treatment of bipolar disorder requires integrated pharmacologic and
nonpharmacologic treatments combined with a therapeutic alliance that
facilitates a proactive, preventive approach to the illness.

Publication Types:
Review

PMID: 15693746 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2005;66 Suppl 1:3-6.

Treatment options for bipolar depression.

Bowden CL.

Department of Psychiatry, University of Texas Health Science Center, San
Antonio, TX 78229-3900, USA. bowdenc@uthscsa.edu

Bipolar disorder is often misdiagnosed as major depressive disorder because of
the high frequency of depressive symptomatology in many patients with bipolar
disorder. Depressive episodes that are resistant to treatment may also be
associated with a worse course of illness in bipolar disorder, but we do not yet
understand all the factors in the connection between bipolar disorder and
depression. The data on the effectiveness of antidepressants in the treatment of
depression in bipolar disorder vary greatly, and there have been few
prospective, randomized studies on the subject. From the data so far, the rates
of induction of mania for selective serotonin reuptake inhibitors and
lamotrigine seem similar to those seen with placebo. The optimal length of time
to continue antidepressant treatment in patients with bipolar disorder has not
yet been determined; however, research tends to indicate that a longer term of
treatment (6 months or more) may aid in the prevention of relapse. Newer U.S.
Food and Drug Administration-approved treatments for depression in bipolar
disorder include a combination of olanzapine and fluoxetine, which is used for
depressive episodes in bipolar disorder, and lamotrigine, which is used for
maintenance treatment of bipolar I disorder. Psychoeducation has also been
examined as a possible treatment for depression in bipolar disorder, and a study
has shown that patients receiving psychoeducation plus medication may have a
lower rate of relapse than patients who receive medication alone.

Publication Types:
Review

PMID: 15693745 [PubMed – indexed for MEDLINE] ———-
Psychol Med. 2005 Jan;35(1):69-77.

Sense of hyper-positive self and response to cognitive therapy in bipolar
disorder.

Lam D, Wright K, Sham P.

Psychology Department, Institute of Psychiatry, London, UK.
spjtdhl@iop.kcl.ac.uk

INTRODUCTION: Cognitive therapy (CT) for bipolar disorder emphasizes the
monitoring and regulation of mood, thoughts and behaviour. The Sense of
Hyper-Positive Self Scale (SHPSS) measures the extent to which bipolar patients
value themselves and perceive themselves to possess personal attributes (e.g.
dynamism, persuasiveness and productiveness) associated with a state of being
‘mildly high’, which does not reach the severity of clinical hypomania. It is
hypothesized that patients who score highly on the SHPSS do not respond well to
cognitive therapy. METHOD: One hundred and three bipolar-I patients were
randomized into CT and control groups. The SHPSS was administered at baseline
and at a 6-month follow-up. RESULT: The SHPSS had good test-retest reliability
after 6 months. At baseline, the Goal-Attainment Dysfunctional Attitudes
contributed significantly to the SHPSS scores after the mood measures were
controlled for in a regression analysis. There was a significant interaction
between baseline SHPSS scores and group allocation in predicting relapse during
therapy. Patients who scored highly on the SHPSS had a significantly increased
chance of relapse after controlling for mood scores, levels of social
functioning at recruitment, and the previous number of bipolar episodes.
CONCLUSION: Not all patients benefited from CT. For patients with high SHPSS
scores, CT was less efficacious. The results also indicate that future studies
could evaluate targeting these attributes and dysfunctional beliefs with
intensive cognitive behavioral techniques.

PMID: 15842030 [PubMed – indexed for MEDLINE] ———-
Am J Psychiatry. 2005 Feb;162(2):324-9.

Relapse prevention in patients with bipolar disorder: cognitive therapy outcome
after 2 years.

Lam DH, Hayward P, Watkins ER, Wright K, Sham P.

Department of Psychology, Institute of Psychiatry, King’s College, London, UK.
spjtdhl@iop.kcl.ac.uk

OBJECTIVE: In a previous randomized controlled study, the authors reported
significant beneficial effects of cognitive therapy for relapse prevention in
bipolar disorder patients up to 1 year. This study reports additional 18-month
follow-up data and presents an overview of the effect of therapy over 30 months.
METHOD: Patients with DSM-IV bipolar I disorder (N=103) suffering from frequent
relapses were randomly assigned into a cognitive therapy plus medication group
or a control condition of medication only. Independent raters, who were blind to
patient group status, assessed patients at 6-month intervals. RESULTS: Over 30
months, the cognitive therapy group had significantly better outcome in terms of
time to relapse. However, the effect of relapse prevention was mainly in the
first year. The cognitive therapy group also spent 110 fewer days (95% CI=32 to
189) in bipolar episodes out of a total of 900 for the whole 30 months and 54
fewer days (95% CI=3 to 105) in bipolar episodes out of a total of 450 for the
last 18 months. Multivariate analyses of variance showed that over the last 18
months, the cognitive therapy group exhibited significantly better mood ratings,
social functioning, coping with bipolar prodromes, and dysfunctional goal
attainment cognition. CONCLUSIONS: Patients in the cognitive therapy group had
significantly fewer days in bipolar episodes after the effect of medication
compliance was controlled. However, the results showed that cognitive therapy
had no significant effect in relapse reduction over the last 18 months of the
study period. Further studies should explore the effect of booster sessions or
maintenance therapy.

PMID: 15677598 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2005 Feb;7(1):22-32.

Psychological therapies for bipolar disorder: the role of model-driven
approaches to therapy integration.

Jones SH, Sellwood W, McGovern J.

Academic Division of Clinical Psychology, University of Manchester and Pennine
Care Trust, Greater Manchester, UK. steven.jones@man.ac.uk

OBJECTIVES: The psychological and social aspects of bipolar disorder are
receiving increasing recognition. Recently, there have been promising
developments in psychological interventions, but there is scope for further
improvement of therapeutic outcomes. This paper argues for the use of more
detailed psychological models of bipolar disorder to inform the further
development of therapeutic approaches. METHOD: Evidence for psychological,
family and social factors in bipolar disorder is reviewed. The efficacy of
current individual and family interventions are discussed. A model, which has
potential to synthesize group and individual approaches, is outlined. RESULTS:
Psychological, social and family factors have important influences on the onset,
course and outcome of bipolar disorder. Interventions based on vulnerability
stress models have proved effective. However, to enhance efficacy future
developments need to be based on models that integrate current understandings of
the multiple levels at which mood fluctuations occur. A particular recent model
is discussed which leads to specific proposals for future intervention research.
CONCLUSIONS: Psychological and family approaches to BD have much potential. They
clearly have a role in conjunction with appropriate pharmacological treatment.
If this potential is to be fully realized future developments need to be based
on psychological models that can accommodate the complexity of this illness.
Copyright (c) 2005, Blackwell Munksgaard.

Publication Types:
Review

PMID: 15654929 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2004 Dec;6(6):498-503.

The current status of psychological treatments in bipolar disorders: a
systematic review of relapse prevention.

Scott J, Gutierrez MJ.

Department of Psychological Medicine, Institute of Psychiatry, Denmark Hill,
London, UK. j.scott@iop.kcl.ac.uk

OBJECTIVE: This paper reviews published randomized-controlled treatment trials
of psychological therapies added to standard psychiatric treatment versus
medication and standard psychiatric treatment alone to explore whether
adjunctive psychotherapy reduces relapse rates in individuals with bipolar
disorders (BDs). METHOD: Relapse rates were calculated for individual trials
that met inclusion criteria and then pooled odds ratios were calculated using
meta-analytic techniques. RESULTS: The majority of studies quoted demonstrate
that individuals receiving psychological treatments had significantly fewer
relapses. The length of therapy required was between 10 and 20 h over 6-9 months
and the models of effective therapies had many shared characteristics in terms
of style and content. CONCLUSIONS: Adjunctive psychological treatments for
individuals with BDs are acceptable and feasible and reduce relapse risk. There
are relatively few differences in the benefits that accrue from the different
therapy models. It is now important to explore whether they have added value in
terms of additional health gains and social functioning compared with standard
treatment approaches. Blackwell Munksgaard, 2004

PMID: 15541065 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2004 Dec;6(6):480-6.

A perspective on the use of psychoeducation, cognitive-behavioral therapy and
interpersonal therapy for bipolar patients.

Colom F, Vieta E.

Bipolar Disorders Program, Hospital Clinic, University of Barcelona, IDIBAPS,
Barcelona, Spain.

OBJECTIVES: Although pharmacological treatment is at present essential for
treating bipolar patients, a number of psychological interventions have recently
been shown to be efficacious as add-on therapies for the prophylactic treatment
of bipolar illness. The study aimed critically to examine the efficacy of
several tested patient-focused therapies. METHODS: A systematic review of the
literature on this topic was performed, using MEDLINE, PSYCLIT and CURRENT
CONTENTS. ‘Bipolar’, ‘Psychotherapy’, ‘Psychoeducation’, ‘Interpersonal’ and
‘Cognitive-behavioral’ were entered as keywords. RESULTS: To date,
psychoeducation and cognitive-behavioral therapy are the psychological
interventions that have been shown to be more efficacious in the prophylaxis of
new recurrences. There remains a need for studies investigating the role and
efficacy of psychological interventions during acute phases of the illness.
CONCLUSIONS: As their therapeutic goals are complementary, a combination of
psychotherapy and pharmacotherapy may allow patients to achieve better
symptomatic and functional recovery. Further research is needed to determine
which patients may be better candidates for psychological interventions and to
estimate the relative effects of the different components of psychological
approaches on outcome. Blackwell Munksgaard, 2004

PMID: 15541063 [PubMed – indexed for MEDLINE] ———-
CNS Spectr. 2004 Nov;9(11 Suppl 12):27-32.

The role and impact of psychotherapy in the management of bipolar disorder.

Otto MW, Miklowitz DJ.

Department of Psychology, Center for Anxiety and Related Disorders, Boston
University, 648 Beacon St., 6th Floor, Boston, MA 02215-2013, USA.

A growing body of evidence documents the value of structured psychotherapeutic
interventions for the co-management of bipolar disorder in the context of
ongoing medication treatment. This article reviews the rationale, elements, and
outcomes for those psychosocial treatments for bipolar disorder that have been
examined in randomized trials. The available evidence suggests that
interventions delivered in individual, group, or family settings, can provide
significant benefit to patients undergoing pharmacotherapy for bipolar disorder.

PMID: 15529090 [PubMed – indexed for MEDLINE] ———-
Clin Child Fam Psychol Rev. 2004 Jun;7(2):71-88.

Psychosocial interventions for children with early-onset bipolar spectrum
disorder.

Lofthouse N, Fristad MA.

Department of Psychiatry, The Ohio State University, Columbus, Ohio 43210-1250,
USA.

Once considered virtually nonexistent, bipolar disorder in children has recently
received a great deal of attention from mental health professionals and the
general public. This paper provides a current review of literature pertaining to
the psychosocial treatment of children with early-onset bipolar spectrum
disorder (EOBPSD). Commencing with evidence of the emerging interest in this
topic, we then focus on terminology, the rationale for studying EOBPSD in
children, current research and clinical progress, possible explanations for the
recent increase in recognition, and essential issues that form the foundation of
effective psychosocial treatment. Next we explore areas of research with direct
implications for psychosocial treatment. These include biological and
psychosocial risk factors associated with bipolar disorder; and the psychosocial
treatment of adult-onset bipolar disorder, childhood-onset unipolar disorder,
and anger management in children. Following this, we discuss treatments being
developed and tested for children with EOBPSD. Finally, we conclude with
recommendations for future studies needed to move the field forward.

PMID: 15255173 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2004;65 Suppl 10:16-23.

Strategies for preventing the recurrence of bipolar disorder.

Ghaemi SN, Pardo TB, Hsu DJ.

Bipolar Disorder Research Program, Department of Psychiatry, Cambridge Health
Alliance, Cambridge, Mass 02139, USA. ghaemi@hms.harvard.edu

In interpreting the maintenance literature for bipolar disorder, attention needs
to be paid to important methodological issues. In this article, we initially
examine the methodological topics that need to be considered, and we then
examine the content of the evidence regarding maintenance treatments. Agents
used in the long-term treatment of bipolar disorder possess varying degrees of
supportive evidence. By consensus, the number of randomized studies and years of
clinical experience with lithium mark it as the evidentially strongest long-term
agent for bipolar disorder. Recent studies also demonstrate likely long-term
benefit with lamotrigine, and possibly olanzapine. Although we possess fewer
randomized data, some such evidence exists and, along with clinical experience,
supports the likely long-term utility of valproate in the treatment of bipolar
disorder as well. Some psychotherapies also may possess adjunctive maintenance
efficacy.

PMID: 15242328 [PubMed – indexed for MEDLINE] ———-
J Affect Disord. 2004 Jun;80(2-3):101-14.

Psychotherapy of bipolar disorder: a review.

Jones S.

University of Manchester, Manchester, UK. steven.jones@man.ac.uk

BACKGROUND: Bipolar disorder is often only partially treated by medication
alone, which has led to recent developments in the adjunctive psychological
treatment of bipolar disorder. This paper aims to examine the current evidence
for effectiveness of psychological interventions for bipolar disorder and to
identify issues for future research in this area. METHOD: A review of outcome
studies of psychological interventions reported since 1990, including
psychoeducation, cognitive-behavioral, interpersonal and social rhythm and
psychoanalytic therapy. RESULTS: The research to date indicates that a range of
psychological approaches appear to benefit people with bipolar disorder. The
clearest evidence is for individual CBT which impacts on symptoms, social
functioning and risk of relapse. LIMITATIONS: Many studies lack appropriate
control groups and standardized measures of symptoms and diagnosis. Better
designed studies would reduce the risk of over-estimates of effect sizes and
subsequent failure to replicate. Further developments of psychotherapy need to
be based on clear theoretical models of bipolar disorder. CONCLUSIONS: Many
current studies are uncontrolled and of poor quality leading to a risk of
over-estimating effectiveness of some interventions. Suggestions are made for
future research including improving quality of studies, basing treatment
developments on clear theoretical models and identifying specific treatment
components for particular phases of the bipolar illness course.

PMID: 15207923 [PubMed – indexed for MEDLINE] ———-
Eur Arch Psychiatry Clin Neurosci. 2004 Apr;254(2):92-8.

Psychological treatment for bipolar disorders–a review of randomized controlled
trials.

Gutierrez MJ, Scott J.

Psychological Treatments Research, Institute of Psychiatry, Denmark Hill, 96,
London, SE5 8AF, UK.

The increased acceptance of stress-vulnerability models of severe mental
disorders and of brief evidence-based psychological treatments in their
treatment has finally led to increased interest in the role of psychotherapies
in bipolar disorders. This paper reviews the results from randomized controlled
trials of psychological therapies as an adjunct to standard medications. The
evidence suggests that the addition of a psychological therapy may significantly
reduce symptoms, enhance social adjustment and functioning, and reduce relapses
and hospitalizations in patients with bipolar disorder. However, the
methodological problems in the published randomized controlled trials and the
heterogeneity in the outcomes achieved (some therapies reduce manic but not
depressive relapses, others have the opposite effect) suggests that further
studies are required to fully establish the place of these approaches in day to
day practice.

PMID: 15146338 [PubMed – indexed for MEDLINE] ———-
J Am Acad Child Adolesc Psychiatry. 2004 May;43(5):528-37.

Child- and family-focused cognitive-behavioral therapy for pediatric bipolar
disorder: development and preliminary results.

Pavuluri MN, Graczyk PA, Henry DB, Carbray JA, Heidenreich J, Miklowitz DJ.

University of Illinois at Chicago, USA. npavuluri@psych.uic.edu

OBJECTIVE: To describe child- and family-focused cognitive-behavioral therapy
(CFF-CBT), a new developmentally sensitive psychosocial intervention for
pediatric bipolar disorder (PBD) that is intended for use along with medication.
CFF-CBT integrates principles of family-focused therapy with those of CBT. The
theoretical framework is based on (1). the specific problems of children and
families coping with bipolar disorder, (2). a biological theory of excessive
reactivity, and (3). the role of environmental stressors in outcome. CFF-CBT
actively engages parents and children over 12 hour-long sessions. METHOD: An
exploratory investigation was conducted to determine the feasibility of CFF-CBT.
Participants included 34 patients with PBD (mean age 11.33 years, SD = 3.06) who
were treated with CFF-CBT plus medication in a specialty clinic. Treatment
integrity, adherence, and parent satisfaction were assessed. Symptom severity
and functioning were evaluated before and after treatment using the severity
scales of the Clinical Global Impression Scales for Bipolar Disorder (CGI-BP)
and the Children’s Global Assessment Scale (CGAS) respectively. RESULTS: On
completion of therapy, patients with PBD showed significant reductions in
severity scores on all CGI-BP scales and significantly higher CGAS scores
compared to pretreatment results. High levels of treatment integrity, adherence,
and satisfaction were achieved. CONCLUSIONS: CFF-CBT has a strong theoretical
and conceptual foundation and represents a promising approach to the treatment
of PBD. Preliminary results support the potential feasibility of the
intervention.

PMID: 15100559 [PubMed – indexed for MEDLINE] ———-
Acta Psychiatr Scand. 2004 Feb;109(2):83-90.

Psychoeducation and cognitive-behavioral therapy in bipolar disorder: an update.

Gonzalez-Pinto A, Gonzalez C, Enjuto S, Fernandez de Corres B, Lopez P, Palomo
J, Gutierrez M, Mosquera F, Perez de Heredia JL.

Psychiatric Department, Santiago Apostol Hospital, Osakidetza Mental Health
System, Vitoria, Spain. agonzalez@sssc.osakidetza.net

OBJECTIVE: To review the available literature on psychoeducation and
cognitive-behavioral therapy (CBT) in bipolar disorder (BD) and to give an
integral view of these therapies. METHOD: Studies were identified through
Medline searches in English language publications between 1971 and 2003. This
was supplemented by a hand search and the inclusion of selected descriptive
articles on good clinical practice. RESULTS: A number of studies demonstrate
that psychoeducation enhances adherence to treatment, and one finds that it
improves outcome in BD. Other studies find that CBT diminishes depressive
symptoms and improves quality of life in BD. Occasionally some adverse effects
may occur with psychotherapy and, although they are sporadic, should not be
overlooked. CONCLUSION: When combined with pharmacological treatment,
psychoeducation helps to improve adherence. Training in the identification of
early manic symptoms helps to improve outcomes and decreases the number of
manic relapses in BD.

PMID: 14725587 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2003;5 Suppl 2:80-7.

Targeted psychosocial interventions for bipolar disorder.

Zaretsky A.

Department of Psychiatry, FG-42 2075 Bayview Avenue, University of
Toronto, Toronto, Ontario, M4N 3M5, Canada. ari.zaretsky@sw.ca

Pharmacotherapy is the foundation of treatment for bipolar disorder, but
research suggests that adjunctive psychosocial interventions that are
manualized, reproducible, time-limited, empirically supported, and strategically
target a number of critical domains, can efficiently provide additional
benefits. Psychoeducation as an adjunct of pharmacotherapy may be beneficial,
but questions remain about the utility of this treatment for patients who are
already compliant with medication treatment. Family educational interventions
have demonstrated encouraging results in relapse prevention, but follow-up data
are limited and application to patients who have limited social networks may be
problematic. Reports on interpersonal and social rhythm therapy in patients with
bipolar disorder are scarce, and what is available shows no differential effect
on time to remission or relapse, but a significant impact on subsyndromal
symptoms. Follow-up data suggest that patients receiving cognitive behavior
therapy have significantly fewer bipolar episodes, shorter episodes, fewer
hospitalizations, and less subsyndromal mood symptoms. It is unclear, however,
if cognitive behavior therapy is superior to other active psychosocial
treatments and whether its mechanism in patients with bipolar disorder is
through changing dysfunctional cognitions or simply enhancing early symptom
detection. Psychotherapies should be considered early in the course of illness
to improve medication compliance and to help patients identify prodromes of
relapse in order to take steps for prevention. In addition, some strategies may
have a beneficial effect on residual symptoms, particularly symptoms of
depression, and thus help move patients toward a more comprehensive functional
recovery.

PMID: 14700017 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2003 Apr;5(2):144-9.

Response of patients with panic disorder and symptoms of hypomania to cognitive
behavior therapy for panic.

Bowen RC, D’Arcy C.

Department of Psychiatry, University of Saskatchewan, Saskatoon, SK, Canada.
bowen@duke.usask.ca

OBJECTIVES: The purpose of this cohort study was to determine in patients with
Panic Disorder (PD): (1). the prevalence of subsyndromal symptoms of hypomania,
and (2). whether subsyndromal hypomania symptoms affect the outcome of
cognitive behavior therapy (CBT) for panic. METHODS: Using the Diagnostic
Interview Schedule, and DSM-III-R criteria we identified 18 individuals with a
history of symptoms of hypomania among 56 patients with PD. Patients were treated
in an open CBT group program. They were assessed before treatment and 6 and 12
months later. We used the Brief Symptom Inventory (BSI), the Perceived Stress
Scale (PSS), the Pearlin-Schooler Mastery Scale (PMS), and the Social Adjustment
Scale (SAS) at all assessments. RESULTS: The total group significantly improved
on all measures. The Clinically Significant Change was 71.4% and the Reliable
Change Index 48.2%. Between 6 and 12 months, there was a trend for the hypomania
symptom subgroup (PH) to continue to improve on the BSI Depression Scale, the
Perceived Stress Scale, the Pearlin-Schooler Mastery Scale, and the Social
Adjustment Scale but to lose gains on the BSI Phobic Anxiety and Somatization
subscales compared with the group without symptoms of hypomania (PNH).
CONCLUSIONS: Thirty-two percent of patients with PD had symptoms of hypomania.
With CBT for panic, patients with PD and symptoms of hypomania improve as much
as those without hypomania symptoms. The presence or absence of symptoms of
hypomania might help explain the inconsistent effects of depression and
personality disorders on the treatment of PD.

PMID: 12680905 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2003 Feb;64(2):182-91.

Integrated family and individual therapy for bipolar disorder: results of a
treatment development study.

Miklowitz DJ, Richards JA, George EL, Frank E, Suddath RL, Powell KB, Sacher JA.

Department of Psychology, University of Colorado, Boulder 80309, USA.
miklow@psych.colorado.edu

BACKGROUND: Several studies have established the efficacy of psychosocial
interventions as adjuncts to pharmacotherapy in the symptom maintenance of
bipolar disorder. This study concerned a new psychosocial approach – integrated
family and individual therapy (IFIT) – that synthesizes family psychoeducational
sessions with individual sessions of interpersonal and social rhythm therapy.
METHOD: Shortly after an acute illness episode, 30 bipolar patients (DSM-IV
criteria) were assigned to open treatment with IFIT (up to 50 weekly sessions of
family and individual therapy) and mood-stabilizing medications in the context
of a treatment development study. Their outcomes over 1 year were compared with
the outcomes of 70 patients from a previous trial who received standard
community care, consisting of 2 family educational sessions, mood-stabilizing
medications, and crisis management (CM). Patients in both samples were evaluated
as to symptomatic functioning at entry into the project and then every 3 months
for 1 year. RESULTS: Patients in IFIT had longer survival intervals (time
without relapsing) than patients in CM. They also showed greater reductions in
depressive symptoms over 1 year of treatment relative to their baseline levels.
The results could not be explained by group differences in baseline symptoms or
pharmacologic treatment regimens. CONCLUSION: Combining family and individual
therapy with medication may protect episodic bipolar patients from early relapse
and ongoing depressive symptoms. Further examination of this integrative model
within randomized controlled trials is warranted.

PMID: 12633127 [PubMed – indexed for MEDLINE] ———-
Arch Gen Psychiatry. 2003 Feb;60(2):145-52.

A randomized controlled study of cognitive therapy for relapse prevention for
bipolar affective disorder: outcome of the first year.

Lam DH, Watkins ER, Hayward P, Bright J, Wright K, Kerr N, Parr-Davis G, Sham P.

Department of Psychology, Institute of Psychiatry, London, England.
spjtdhl@iop.kcl.ac.uk

BACKGROUND: Despite the use of mood stabilizers, a significant proportion of
patients with bipolar affective disorder experience frequent relapses. A pilot
study of cognitive therapy (CT) specifically designed to prevent relapses for
bipolar affective disorder showed encouraging results when used in conjunction
with mood stabilizers. This article reports the outcome of a randomized
controlled study of CT to help prevent relapses and promote social functioning.
METHODS: We randomized 103 patients with bipolar 1 disorder according to the
DSM-IV, who experienced frequent relapses despite the prescription of commonly
used mood stabilizers, into a CT group or control group. Both the control and CT
groups received mood stabilizers and regular psychiatric follow-up. In addition,
the CT group received an average of 14 sessions of CT during the first 6 months
and 2 booster sessions in the second 6 months. RESULTS: During the 12-month
period, the CT group had significantly fewer bipolar episodes, days in a bipolar
episode, and number of admissions for this type of episode. The CT group also
had significantly higher social functioning. During these 12 months, the CT
group showed less mood symptoms on the monthly mood questionnaires. Furthermore,
there was significantly less fluctuation in manic symptoms in the CT group. The
CT group also coped better with manic prodromes at 12 months. CONCLUSION: Our
findings support the conclusion that CT specifically designed for relapse
prevention in bipolar affective disorder is a useful tool in conjunction with
mood stabilizers.

PMID: 12578431 [PubMed – indexed for MEDLINE] ———-
Aust N Z J Psychiatry. 2003 Feb;37(1):41-8.

Schema-focused cognitive therapy for bipolar disorder: reducing vulnerability to
relapse through attitudinal change.

Ball J, Mitchell P, Malhi G, Skillecorn A, Smith M.

Bipolar Disorders Clinic, Prince of Wales Hospital, Randwick, New South Wales,
Australia. jillian@unsw.edu.au

OBJECTIVE: Acceptance of, and adaptability to illness, are major determinants of
adherence to treatment and functional recovery. This paper addresses the major
psychosocial factors associated with bipolar disorder and the role of
psychological interventions in symptom management and adaptability to the
illness experience. A new model is presented highlighting the role of
developmental experiences and temperament in determining reactions to bipolar
disorder. The authors propose that by addressing reactions to the illness
experiences and effects on self-concept through schema-focused cognitive
therapy, functional recovery is more likely to occur among those patients
functioning below expectation. METHOD: A systematic review of the current
literature including an Index Medicus/MEDLINE search was conducted, focusing on
risk factors, cognitive vulnerabilities and triggers associated with bipolar
disorder. Psychological treatments available for the treatment of bipolar
disorder are reviewed and details of a novel schema-focused cognitive model for
this condition are presented. Traditional models of adaptation to chronic
illness are outlined and incorporated into the proposed model. Schema-focused
cognitive therapy is proposed as an approach to help patients reduce cognitive
vulnerability to relapse in addition to adopting effective mood management
strategies. RESULTS AND CONCLUSIONS: There is a need for psychological
treatments which reduce the risks associated with poor functionality in patients
with bipolar disorder. Schema-focused cognitive therapy specifically targets the
temperament, developmental experiences and cognitive vulnerabilities that
determine adjustment to illness. This proposed treatment, combined with
pharmacotherapy, may offer new psychotherapeutic options for the future.

PMID: 12534655 [PubMed – indexed for MEDLINE] ———-
J Affect Disord. 2003 Jan;73(1-2):171-81.

Psychoeducational and cognitive-behavioral strategies in the management of
bipolar disorder.

Otto MW, Reilly-Harrington N, Sachs GS.

Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114,
USA. motto@partners.org

Despite advances in the pharmacologic treatment of bipolar disorder, it is clear
that additional strategies are needed to provide patients with longer-term mood
stability. Recent years have witnessed the development of a number of
psychosocial strategies for bipolar disorder that are design as adjuncts to
ongoing pharmacotherapy. In this article we describe psychoeducational and
cognitive-behavioral approaches to the management of bipolar disorder, with
emphasis on broader treatment packages that can be offered by cognitive-behavior
therapists working in specialty bipolar clinics, as well as specific strategies
that can be integrated into standard pharmacotherapy for the disorder. A growing
body of evidence documents the potential value of these interventions, and
large-scale studies are underway, including the Systematic Treatment Enhancement
Program for Bipolar Disorder (STEP-BD), which will provide outcome on these
interventions from the perspective of large, multicenter trials.

PMID: 12507750 [PubMed – indexed for MEDLINE] ———-
Nervenarzt. 2002 Jul;73(7):620-8.

[Cognitive behavioral therapy as supplement to pharmacotherapy of manic
depressive disorders. What is the empirical basis?] [Article in German]

Meyer TD, Hautzinger M.

Psychologisches Institut, Abteilung fur Klinische und Physiologische
Psychologie, Universitat Tubingen. th.meyer@uni-tuebingen.de

Medications will be always necessary in the treatment of bipolar affective
disorders. More and more, however, the importance of an adjunctive psychotherapy
is emphasized. Numerous controlled therapy trials showed that unipolar depressed
patients can be effectively treated with cognitive behavior therapy (CBT).
Therefore a literature search was done to check for the empirical evidence
concerning the efficacy of CBT for bipolar disorders. We conducted a literature
search using Medline, PsycINFO, and Psyndex, considering all publications
dealing with the topic “psychotherapy and bipolar disorder” till July 2001. This
search resulted in 241 articles. Ten percent of these publications were
considered to be controlled trials. Four studies explicitly tested the efficacy
of CBT. Compared to standard medical treatment, CBT proved to be efficient
concerning symptomatic and functional outcome. However, there remain many
questions to be answered, e.g., if there are differential effects on the course
of manic and depressive symptoms and how stable the results will be in the long
run.

PMID: 12212524 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2001 Jul;62(7):556-9.

Cognitive-behavioral management of patients with bipolar disorder who relapsed
while on lithium prophylaxis.

Fava GA, Bartolucci G, Rafanelli C, Mangelli L.

Department of Psychiatry, State University of New York at Buffalo, USA.

BACKGROUND: The application of cognitive-behavioral treatment (CBT) to patients
with bipolar disorder who had an affective episode while on lithium prophylaxis
has received little research attention. The aim of this preliminary study was to
test whether reduction of residual symptomatology by cognitive-behavioral
methods could yield long-term beneficial effects in patients with bipolar
disorder, as was found to be the case in recurrent unipolar depression. METHOD:
Fifteen patients with RDC bipolar disorder, type I, who relapsed while on
lithium prophylaxis despite initial response and adequate compliance were
treated by cognitive-behavioral methods in an open trial. A 2- to 9-year
follow-up was performed. RESULTS: Five of the 15 patients had a new affective
episode during follow-up. CBT was associated with a significant reduction of
residual symptomatology. CONCLUSION: These preliminary results suggest that a
trial of CBT may enhance lithium prophylaxis and improve long-term outcome of
bipolar disorder.

PMID: 11488368 [PubMed – indexed for MEDLINE] ———-
Br J Psychiatry Suppl. 2001 Jun;41:s164-8.

Cognitive therapy as an adjunct to medication in bipolar disorder.

Scott J.

Division of Psychiatry, University Department of Psychological Medicine,
Gartnavel Royal Hospital, Glasgow, UK. jan.scott@clinmed.gla.ac.uk

BACKGROUND: There is increasing support for the use of cognitive behaviour
therapy as an adjunct to medication for patients with bipolar disorder. AIMS: To
explore current psychological models of bipolar disorder, describing the
clinical rationale for using cognitive therapy and providing a brief overview of
the approach. METHOD: Results from outcome studies are discussed. RESULTS:
Preliminary findings indicate that cognitive therapy may be beneficial for
patients with bipolar disorder. The collaborative, educational style of
cognitive therapy, the use of a stepwise approach and of guided discovery is
particularly suitable for patients who wish to take an equal and active role in
their therapy. CONCLUSIONS: Randomized, controlled trials of cognitive therapy
in bipolar disorder are required to establish the short-term and long-term
benefits of therapy, and whether any reported health gain exceeds that of
treatment as usual.

PMID: 11450178 [PubMed – indexed for MEDLINE] ———-
J Affect Disord. 2001 Jul;65(2):145-53.

Group cognitive behavioral therapy for bipolar disorder: a feasibility and
effectiveness study.

Patelis-Siotis I, Young LT, Robb JC, Marriott M, Bieling PJ, Cox LC, Joffe RT.

Hamilton Psychiatric Hospital, Mood Disorders Program, 100 West 5th St.,
Hamilton, Ontario L8N 3K7, Canada.

BACKGROUND: Bipolar disorder (BD) is a common disorder that results in
significant psychosocial impairment, including diminished quality of life and
functioning, despite aggressive pharmacotherapy. Psychosocial interventions that
target functional factors could be beneficial for this population, and we
hypothesized that the addition of group cognitive behavioral therapy (CBT) to
maintenance pharmacotherapy would improve functioning and quality of life.
METHODS: Patients diagnosed (by SCID) with bipolar disorder attending an
outpatient clinic of a mood disorders program participated in the study. All
patients were on maintenance mood stabilizers, and were required to have
controlled symptoms before entering the study. Mood symptoms were assessed with the Hamilton Depression Rating scale and Young Mania scale at baseline and 14
weeks. Objective and subjective functioning was rated at the same interval using
the Global Assessment of Functioning scale and the Medical Outcomes Survey
SF-36. Treatment was provided via a specific manual based on CBT principles that
could be applied to this population. RESULTS: Forty nine patients participated
in this open trial, and 38 patients completed treatment. Objective and
subjective indices of impairment showed improvement after 14 weeks. Both GAF and MOS scores increased significantly by the end of treatment. LIMITATIONS: This study was an open trial, and lack of control groups limits the interpretation of
results. Because the study concerned effectiveness, the results do not clarify
whether the improvement represents the normal course of illness or whether it is
the result of the CBT intervention. CONCLUSIONS: The addition of group CBT to
standard pharmacological treatment was acceptable to patients, and nearly 80% of
patients complied with treatment. Despite the fact that mood symptoms were
controlled at entry into the study, psychosocial functioning increased
significantly at the end of treatment. Adjunctive CBT should be further
investigated in this population.

PMID: 11356238 [PubMed – indexed for MEDLINE] ———-
Psychol Med. 2001 Apr;31(3):459-67.

Comment in:
Evid Based Ment Health. 2002 Feb;5(1):23.

A pilot study of cognitive therapy in bipolar disorders.

Scott J, Garland A, Moorhead S.

Department of Psychological Medicine, University of Glasgow, Gartnavel Royal
Hospital.

BACKGROUND: The efficacy and effectiveness of cognitive therapy (CT) is well
established for unipolar disorders, but little is known about its utility in
bipolar disorders. This study aimed to explore the feasibility and efficacy of
using CT as an adjunct to usual psychiatric treatment in this patient
population. METHOD: Subjects referred by general adult psychiatrists were
assessed by and independent rater and then randomly allocated to immediate CT (N
= 21) or 6-month waiting-list control, which was then followed by CT (N = 21).
Observer and self-ratings of symptoms and functioning were undertaken
immediately prior to CT, after a 6-month course of CT and a further 6-months
later. Data on relapse and hospitalization rates in the 18 months before and
after commencing CT were also collected. RESULTS: At 6-month follow-up, subjects
allocated to CT showed statistically significantly greater improvements in
symptoms and functioning as measured on the Beck Depression Inventory, the
Internal State Scale, and the Global Assessment of Functioning than those in the
waiting-list control group. In the 29 patients who eventually received CT,
relapse rates in the 1 8 months after commencing CT showed a 60 % reduction in
comparison with the 18 months prior to commencing CT. Seventy per cent of
subjects who commenced therapy viewed CT as highly acceptable. CONCLUSION:
Although the results of this study are encouraging, the use of CT in subjects
with bipolar disorders is more complex than in unipolar disorders and requires a
high level of therapist expertise. The therapy may prove to be particularly
useful in the treatment of bipolar depression.

PMID: 11305854 [PubMed – indexed for MEDLINE] ———-
Bipolar Disord. 2001 Feb;3(1):1-10.

Comment in:
Bipolar Disord. 2002 Aug;4(4):275.

Cognitive-behavioral therapy: applications for the management of bipolar
disorder.

Patelis-Siotis I.

Mood Disorders Program, Hamilton Psychiatric Hospital, Ont, Canada.
siotisi@fhs.mcmaster.ca

OBJECTIVES: This paper reviews cognitive-behavioral therapy (CBT) for bipolar
disorder (BD). Data on the poor outcome of about 50% of patients diagnosed with
BD supports the addition of a psychosocial intervention for the treatment of
this recurring disorder. The psychoeducational nature of CBT, the effectiveness
of CBT in increasing compliance to pharmacological treatment, and the ability of
CBT to prevent relapse in unipolar depression (UD) are well suited to the
treatment of BD. METHOD: Psychosocial interventions for BD will be briefly
reviewed. Individual and group CBT interventions (published and unpublished)
will also be reviewed. The significance of comorbid anxiety disorders regarding
response to treatment will also be discussed. A review of the treatment protocol
with the specific cognitive-behavioral interventions as applied to BD will be
presented. Finally, a case example will be presented to illustrate the
application of CBT to BD. RESULTS: Preliminary results indicate that CBT may be
an effective adjunctive, intervention for the treatment of BD. Specifically CBT
may be helpful in increasing compliance, improving quality of life and
functioning, help early symptom recognition, decrease relapse and decrease
depressive symptomatology. CONCLUSIONS: Preliminary data on CBT for BD are
promising but more rigorous randomized clinical trials are needed to confirm the
efficacy of CBT for BD. An other area of research should be to pursue the
understanding of cognitive processes in BD which would allow us to refine and
develop CBT interventions unique to this disorder.

PMID: 11256458 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2000;61 Supp 13:58-64.

Psychosocial interventions for bipolar disorder.

Craighead WE, Miklowitz DJ.

Department of Psychology, University of Colorado, Boulder 80309-0345, USA.
ecraighead@psych.colorado.edu

Patients with bipolar disorder are prone to recurrences even when they are
maintained on lithium or anticonvulsant regimens. The authors argue that the
outpatient treatment of bipolar disorder should involve both somatic and
psychosocial components. Psychosocial interventions can enhance patients’
adherence to medications, ability to cope with environmental stress triggers,
and social-occupational functioning. Family and marital psychoeducational
interventions and individual interpersonal and social rhythm therapy have
received the most empirical support in experimental trials. These interventions,
when combined with medications, appear effective in improving symptomatic
functioning during maintenance treatment. A beginning literature also supports
the utility of individual cognitive-behavioral and psychoeducational approaches,
particularly in enhancing medication adherence. Identifying the optimal format
for psychosocial treatments and elucidating their mechanisms of action are
topics for further study.

PMID: 11153813 [PubMed – indexed for MEDLINE] ———-
Biol Psychiatry. 2000 Sep 15;48(6):593-604.

Comment in:
Biol Psychiatry. 2000 Sep 15;48(6):430-2.

Interpersonal and social rhythm therapy: managing the chaos of bipolar disorder.

Frank E, Swartz HA, Kupfer DJ.

Department of Psychiatry, University of Pittsburgh, Western Psychiatric
Institute and Clinic, Pennsylvania 15213-2593, USA.

Interpersonal and social rhythm therapy is an individual psychotherapy designed
specifically for the treatment for bipolar disorder. Interpersonal and social
rhythm therapy grew from a chronobiological model of bipolar disorder
postulating that individuals with bipolar disorder have a genetic predisposition
to circadian rhythm and sleep-wake cycle abnormalities that may be responsible,
in part, for the symptomatic manifestations of the illness. In our model, life
events (both negative and positive) may cause disruptions in patients’ social
rhythms that, in turn, perturb circadian rhythms and sleep-wake cycles and lead
to the development of bipolar symptoms. Administered in concert with
medications, interpersonal and social rhythm therapy combines the basic
principles of interpersonal psychotherapy with behavioral techniques to help
patients regularize their daily routines, diminish interpersonal problems, and
adhere to medication regimens. It modulates both biological and psychosocial
factors to mitigate patients’ circadian and sleep-wake cycle vulnerabilities,
improve overall functioning, and better manage the potential chaos of bipolar
disorder symptomatology.

PMID: 11018230 [PubMed – indexed for MEDLINE] ———-
Psychiatr Pol. 2000 Jan-Feb;34(1):81-8.

[Development and application of cognitive therapy in affective disorders] [Article in Polish]

Dudek D, Zieba A.

Kliniki Psychiatrii Doroslych CM UJ.

Cognitive psychotherapy was originally created for out-patient treatment of mild
and moderate, non-psychotic, unipolar depressive disorder. Further development
of the therapy resulted in its use in various mental disorders. Cognitive
therapy has also been used in wide spectrum of affective disorders, including
severe, endogenous depression, chronic depression, bipolar disorder and
suicidality. Therapeutic programs involve individual, group, family and marital
cognitive psychotherapy. Effectiveness and clear conceptualization encourages to
wide use of this kind of therapy.

PMID: 10853359 [PubMed – indexed for MEDLINE] ———-
J Clin Psychiatry. 2000;61 Suppl 9:68-75.

Integration of pharmacotherapy and psychotherapy for bipolar disorder.

Rothbaum BO, Astin MC.

Department of Psychiatry and Behavioral Sciences, Emory University School of
Medicine, Atlanta, Ga, USA.

There is no question that pharmacotherapy is the treatment of choice for bipolar
disorder. However. an integration of psychotherapeutic techniques with
pharmacotherapy has been recommended by the American Psychiatric Association
practice guideline for the treatment of bipolar disorder. Psychotherapy aims to
address risk factors and associated features that are difficult to address with
pharmacotherapy alone. The most common psychotherapeutic approaches added to
pharmacotherapy for bipolar disorder include psychoeducation, individual
cognitive-behavioral therapy, marital and family interventions, individual
interpersonal therapy, and adjunctive therapies such as those for substance use.
Each of these approaches is described in detail, and research regarding their
efficacy is presented.

PMID: 10826664 [PubMed – indexed for MEDLINE] ———-
Psychiatry. 1999 Winter;62(4):357-69.

Adjunctive cognitive-behavioral therapy for rapid-cycling bipolar disorder: an
empirical case study.

Satterfield JM.

Division of General Internal Medicine, University of California, San Francisco
94143-0320, USA. jsatter@medicine.ucsf.edu

A basic biopsychosocial model of episode onset in rapid-cycling bipolar disorder
is presented with a special emphasis on cognitive and other psychosocial
contributors. A three-pronged, face-valid, cognitive-behavioral treatment
protocol meant to supplement medications is deduced from the available research
literature. The concrete treatment components focus on prevention of mood
cycles, early detection of cycle onset, and mood restabilization during cycles.
The treatment protocol was pilot tested on a rapid-cycling bipolar patient who
first received pharmacotherapy only followed by pharmacotherapy plus adjunctive
cognitive-behavioral therapy (CBT). Detailed treatment measures were collected
before, during, and after treatment. A comparison of Beck Depression Inventory
and Young Mania Scale scores in pharmacotherapy versus pharmacotherapy plus CBT
conditions suggest the addition of CBT produces significant clinical gains.
Scores on the Beck Anxiety Inventory and Hopelessness Scale provide further
support for the CBT treatment model. These preliminary results suggest
cognitive-behavioral or similarly structured psychosocial treatment models could
greatly enhance the medical treatment of rapid-cycling bipolar patients and
warrants further controlled investigation.

PMID: 10693232 [PubMed – indexed for MEDLINE] ———-
J Abnorm Psychol. 1999 Nov;108(4):555-7.

Comment on:
J Abnorm Psychol. 1999 Nov;108(4):558-66.

Psychosocial factors in the course and treatment of bipolar disorder:
introduction to the special section.

Miklowitz DJ, Alloy LB.

Department of Psychology, University of Colorado at Boulder 80309-0345, USA.
miklow@psych.colorado.edu

Bipolar disorder is associated with high rates of relapse and high social and
economic costs, even when patients are maintained on proper pharmacotherapy. The
background and rationale are offered here for a series of articles that address
the role of psychosocial agents in the course of bipolar disorder and
psychosocial treatments as adjuncts to pharmacotherapy in the disorder’s
outpatient maintenance. It is argued that stressful life events and disturbances
in social-familial support systems affect the cycling of the disorder against
the backdrop of genetic, biological and cognitive vulnerabilities. Current
models of psychosocial treatment focus on modifying the effects of social or
familial risk factors as an avenue for improving the course of the disorder.

PMID: 10609419 [PubMed – indexed for MEDLINE] ———-
J Subst Abuse Treat. 1999 Jan;16(1):47-54.

A relapse prevention group for patients with bipolar and substance use
disorders.

Weiss RD, Najavits LM, Greenfield SF.

Alcohol and Drug Abuse Program, McLean Hospital, Belmont, MA 02178, USA.
rdwss@aol.com

Although bipolar disorder is the Axis I disorder associated with the highest
risk of having a coexisting substance use disorder, no specific treatment
approaches for this dually diagnosed patient population have thus far been
developed. This paper describes a 20-session relapse prevention group therapy
that the authors have developed for the treatment of patients with coexisting
bipolar disorder and substance use disorder. The treatment uses an integrated
approach by discussing topics that are relevant to both disorders and by
highlighting common aspects of recovery from and relapse to each disorder.

PMID: 9888121 [PubMed – indexed for MEDLINE] ———-
Fam Process. 1998 Summer;37(2):215-32.

Beyond bipolar thinking: patterns of conflict as a focus for diagnosis and
intervention.

Simon FB.

Heidelberg Institute for Systemic Research, Germany.
simon@heidelberger-gruppe.com

Most family typologies in the history of family therapy organized the
observation according to bipolar scales. The implied assumption of such models
is that the attribution of the one observational characteristic is inevitably
bound to the negation of its opposite characteristic. This article presents a
formal observational schema that has the possibility to grasp contradictory,
conflicting characteristics. Using this schema, one can develop a clinically
relevant family typology, making distinctions between different patterns of
interaction by which conflicts and antagonistic tendencies in families are
organized. Clinical observation and experience suggests that one can distinguish
families with members with psychosomatic, manic-depressive, and schizophrenic
symptoms by the way they overcome conflicts and ambivalence.

PMID: 9693951 [PubMed – indexed for MEDLINE] ———-
Psychother Psychosom. 1998;67(1):3-9.

What is the role of psychotherapy in the treatment of bipolar disorder?

Colom F, Vieta E, Martinez A, Jorquera A, Gasto C.

Department of Psychiatry, Hospital Clinic i Provincial, Universitat de
Barcelona, Spain.

BACKGROUND: The authors review and criticize the different roles developed by
psychotherapy in the treatment of bipolar disorder, from psychodynamic
conceptions to a biopsychosocial model. METHODS: The main computerized database
(Medline, Current Contents, Psychological Abstracts) have been consulted, using
the terms ‘psychotherapy’, ‘psychosocial’ and ‘bipolar disorder’ as key words.
RESULTS: Psychoanalysis, psychoeducation, family therapy, cognitive-behavioral
therapy and interpersonal therapy have been used in the treatment of bipolar
patients. To date, none have established efficacy in controlled clinical trials
regarding aspects such as hospitalization, recurrences or suicidal behavior, as
medication alone does. Research on this issue usually undergoes methodological
pitfalls. Nonetheless, the psychoeducative approach combined with several
cognitive-behavioral techniques, either in group or individually, seem to be the
most promising, focusing on information, treatment compliance, and illness
management skills. CONCLUSIONS: There is a need for systematic clinical research
on psychotherapy applied to bipolar disorder in order to show its true
usefulness. Psychoeducation should prove its positive influence on the course
and outcome of bipolar disorder.

PMID: 9491434 [PubMed – indexed for MEDLINE] ———-
Behav Modif. 1990 Oct;14(4):457-89.

Behavioral family treatment for patients with bipolar affective disorder.

Miklowitz DJ, Goldstein MJ.

Department of Psychology, University of Colorado, Boulder 80309-0345.

Techniques of behavioral family management (BFM), which have been found to be
highly effective in delaying relapse for schizophrenic patients when used as
adjuncts to medication maintenance, are also applicable in the outpatient
treatment of recently hospitalized bipolar, manic patients. The authors describe
their adaptation of the educational, communication skills training, and
problem-solving skills training modules of BFM to families containing a bipolar
member. The observations that families of bipolar patients are often high
functioning, and that these families seem to enjoy interchanges that are highly
affective and spontaneous, led to certain modifications in the original BFM
approach. The authors found it necessary to be (a) more flexible and less
didactic, (b) more oriented toward dealing with affect and resistance to change,
and (c) more focused on the patient’s and family members’ feelings about
labeling, stigmatization, and medication usage. Research issues relevant to
testing the efficacy of this approach are also discussed.

PMID: 2252468 [PubMed – indexed for MEDLINE] ———-
Psychiatr Dev. 1989 Spring;7(1):49-70.

Moods, misattributions and mania: an interaction of biological and psychological
factors in the pathogenesis of mania.

Healy D, Williams JM.

Department of Psychiatry, University of Cambridge Clinical School, Addenbrooke’s
Hospital, UK.

Circadian rhythm dysfunction has recently been suggested to have a causal role
in major depressive disorders. Against this background, experiments on circadian
rhythms are outlined that yield a state of sustained sleepless activity. Such
states can be brought about it seems by manipulation of the external zeitgebers
to which rhythms are synchronized rather than by any alteration of the circadian
clock. This can be expected to yield a disorganized rhythmic state rather than
any discrete phase shifting or desynchronization of rhythms. This state it is
suggested should lead to a mild dysphoria, psychomotor activation and a subtle
disordering of thought form. It is proposed that these changes lead to the
typical clinical picture of mania when distorted cognitively by mechanisms
similar to those found in depression. There are a number of implications of this
hypothesis. Firstly, mania should commonly be precipitated by similar
psychosocial factors to those which precipitate depression. Secondly, similar
neuroendocrine findings should be found in both depression and mania. Thirdly,
similar agents should be effective in the treatment of mania and depression.
Fourthly, cognitive therapy may play a significant part in the management of
acute episodes of mania and reduce liability to chronicity.

PMID: 2552433 [PubMed – indexed for MEDLINE] ———-
Psychother Psychosom. 1986;46(1-2):13-22.

Different treatment modalities for recurrent bipolar affective disorders: an
integrative approach.

Johnson FN.

Pharmacological, behavioral and psychotherapeutic procedures for the acute and
prophylactic treatment of mania and depression are considered in outline. It is
argued that the manic state is the primary disorder, with depression being a
secondary homeostatic response to mania: the prophylaxis of depression thus
depends upon the successful long-term control of mania. Suggestions are made
regarding ways in which nonpharmacological techniques may be developed to
achieve the prophylactic effectiveness against recurrent bipolar affective
disorders which is, at the present time, to be found only among pharmacological
treatment procedures.

PMID: 3602337 [PubMed – indexed for MEDLINE]

no