Your 24-year-old patient with bipolar disorder has been stable since her index manic episode and hospitalization two years ago. She now says, “Do I still need to take lithium? I’m not even sure I have bipolar disorder.”
If you treat patients with bipolar disorder, then you have reached what I call the moment of truth. Your patient has been doing so well, she’s not even sure she still has a psychiatric problem. This is one of the many opportunities for psychotherapy in bipolar disorder—in this case, helping your patient to come to terms with her illness.
Several evidence-based, psychosocial treatments, when used in combination with medication, have been shown to decrease the risk of relapse in bipolar disorder. (For two extensive reviews, see Miklowitz, DJ, Am J Psychiatry 2008;165(11):1408–1419 and Hollon SD and Ponniah K, Depression Anxiety 2010;27(10):891–932). These include cognitive-behavioral therapy (CBT), family-focused therapy (FFT), interpersonal and social rhythm therapy (IPSRT), and psychoeducation (PE). See the table on page 2 for the key underlying concepts of each of these treatments. Overall, compared with pharmacotherapy alone and clinical management controls, these adjunctive psychotherapies are associated with a 30% to 40% reduction in relapse rates over 12 to 30 months.
There are a few features that are shared by all of these psychotherapies: 1) mood monitoring to improve detection of early symptoms; 2) developing an early intervention action plan; 3) education about the importance of lifestyle modification; and 4) review of the risks and benefits of treatment/medications. Furthermore, these therapies help patients deal with a variety of psychological issues that are common in bipolar disorder: fear of relapse, denial, grief over lost time, dealing with stigma (in family, friends, employers), overcoming developmental delays caused by the illness, and managing self-esteem.
In my experience, patients are frequently not able to participate in these evidence-based psychotherapies for a variety of logistical, psychological, or financial reasons. Each one of these treatments involves twenty-plus sessions. Many communities simply don’t have therapists skilled in these therapies. Or, if a therapist is available, that therapist may not accept the patient’s insurance. So while I make every effort to refer my patients with bipolar disorder to a psychotherapist who is adept in these psychotherapies, I often find myself in the situation where I am providing both the medications and an ad-hoc kind of psychotherapy. Given this common situation, it really helps to have some understanding of each of the evidence-based psychotherapies for bipolar disorder.
Cognitive Behavioral Therapy
This includes the usual array of cognitive behavioral techniques, including thought records, systematic exposure to avoided activities, and a mood diary to help identify prodromal symptoms for mood episodes. While there have been several studies demonstrating efficacy of CBT, one multisite study of more severely ill patients showed no statistical separation between adjunctive CBT and treatment as usual (Scott J et al, Br J Psychiatry 2006;188(4):313–320).
- Have patients keep a diary of significant events and associated feelings, thoughts, and behaviors
- Use thought records to help patients question thoughts that might be unhelpful and unrealistic
- Encourage patients to gradually face activities they are avoiding
(Basco MR and Rush AJ. Cognitive-Behavioral Therapy for Bipolar Disorder. 2nd edition. New York: Guilford Press; 2005)
“Expressed emotion” (EE) describes the extent of hostility, over-involvement, and criticism in families. High levels of EE have been found to worsen the course of bipolar disorder (Kim EY and Miklowitz DJ, J Affect Disord 2004;1;82(3):343–352). Family-focused therapy is designed to lower EE and improve interpersonal communication within families. FFT aims to improve family communication, involving strategies such as reflective listening and actively requesting support from family members. Of course, for FFT to be feasible, patients must have a fairly involved support network—in one study, only 54% of patients had supports who could participate in FFT (Miklowitz DJ et al, Arch Gen Psychiatry 2007;64(4):419–426).
- Invite family members to some visits
- Assess the family dynamics—if communication seems tense or hostile, consider referring for family therapy
(it may be difficult to find a therapist trained specifically in FFT for bipolar disorder)
(Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach. 2nd edition. New York: Guilford Press; 2010)
Interpersonal and Social Rhythm Therapy
Interpersonal and social rhythm therapy is an adaptation of interpersonal therapy for depression. While interpersonal therapy is effective for depression, it was not found useful for bipolar disorder until a social rhythm module was added. The idea behind social rhythm therapy is that mood episodes are triggered and/or maintained by deranged scheduling, particularly disruptions of sleep/wake cycles. The goal of the therapy is both to regularize activities, and to improve interpersonal relationships.
- Regularize sleep and activities: if nothing else, have the patient get up at the same time every morning
- Help the patient find the right balance between rest and activity
- Plan for disruptions in scheduling
(Frank E. Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy. New York: Guilford Press; 2006)
Most of us think of psychoeducation as something we provide to our patients in our individual sessions. However, as studied by Colom and Vieta, it consists of 21 ninety-minute sessions that systematically review topics such as awareness of the disorder, medications, mood monitoring, and prodrome awareness. Formal psychoeducation groups provide a level of systematic teaching about bipolar disorder that we are unlikely to be able to provide during regular visits. If such a group is not available in your community, the following tips involving bibliotherapy might be useful.
- Recommend that your patient read a consumer book on bipolar disorder; I usually recommend Miklowitz’s Bipolar Survival Guide (Guilford Press, 2nd Edition, 2010)
- Assign a specific chapter for homework
- Review the key points with your patient at the next visit
(Colom F and Vieta E. Psychoeducation Manual for Bipolar Disorder. Cambridge, UK: Cambridge University Press; 2006)
In addition to these therapy techniques, I encourage you as practitioners to reflect on this question: How many hospitalizations would it take to convince you to take lithium (or Seroquel or Depakote or Zyprexa) for the rest of your life? One study found that around 40% of first episode patients with bipolar disorder experience a relapse within just the first two years on an index hospitalization for a manic or mixed episode. Almost all subjects (95.2%) received at least one psychotropic agent at discharge, but at two-year follow-up, 35.6% were taking no medication (the authors did not evaluate treatment status as a predictor of relapse) (Tohen M et al, Am J Psychiatry 2003;160(12):2099–2107).
Given this data, when I honestly answer this question for myself, I can see that I would need at least two hospitalizations to convince me that I really needed to be on a lifelong medication regimen. Thus, when a patient asks some variation on the theme of, “Do I still have bipolar disorder? Do I really need to be on medications for the rest of my life?” I might say something like, “I’ve often thought that I myself would need to be hospitalized at least twice to convince me that I needed to be on meds indefinitely. At some point, you may be tempted to go off your meds, and when that time comes, I hope you’ll come to me and we can talk about it. That way, if you go off your meds, and you start experiencing symptoms, maybe we can prevent anything really bad from happening.”
Understanding that patients are often in a process of accepting an illness helps us to maintain a vision of a healthy future despite setbacks. Each setback can then at least be viewed as a learning experience. My attitude is that each person has his/her own path to accepting who they are, and that our role as healers is to help the patient to stay on that path.
TCPR’s VERDICT: From a clinical point of view, the patient who accepts an illness is able to stay on beneficial medications, avoid extreme lifestyles, and realistically prepare for potential relapses. From there, a person with bipolar disorder can stay out of the hospital, stay out of mania or depression, and move forward in fulfilling their life goals.