Psychosocial Interventions for Bipolar Disorder: A Review of Recent Research
Bipolar disorder is an affective disorder characterised by mood episodes which can cause considerable impairment in everyday life. This study outlines recent research on psychosocial interventions for this illness, focusing on psychoeducation, interpersonal and social rhythm therapy, cognitive behaviour therapy and family focused treatments. The basic components of these interventions are discussed along with evidence for effectiveness and an examination of possible limitations. The current research suggests there are a number of different psychosocial interventions which appear to be effective for reducing relapse, alleviating affective symptoms and improving functioning. However, the evidence base for some of these is relatively limited at present.
Received: July 28, 2010;
Accepted: September 03, 2010;
Published: November 27, 2010
Symptoms and diagnoses: Bipolar disorder is an affective disorder, or
mood disorder, characterised by episodes of depression combined with episodes
of hypomania or mania. The American Psychiatric Associations Diagnostic and
Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR,
American Psychiatric Association, 2000) states that a
hypomanic episode consists of an elated or irritable mood over 4 days or more.
Within this change in mood are specific symptoms such as racing thoughts, a
reduced need for sleep, increased talkativeness and involvement in impulsive
activities such as reckless business investments and sexual promiscuity (American
Psychiatric Association, 2000). An individual who experiences episodes of
both hypomania and mania is diagnosed with bipolar II disorder. A manic episode
has similar symptoms but is more severe with disrupted functioning at work or
socially and the possibility of psychotic symptoms and hospitalisation. Those
who experience multiple episodes of mania and usually depressive episodes as
well are diagnosed with bipolar I disorder (American Psychiatric
Association, 2000). It is important to note that there are a number of controversies
in terms of the diagnostic criteria for bipolar disorder, such as the minimum
duration required for hypomania and the relatively unclear distinction between
hypomania and mania (Richardson, 2009). Mixed episodes
can also occur where manic or hypomanic symptoms occur alongside symptoms of
depression. However, it is important to note that the mixed episodes category
may be removed from the 5th edition of the DSM (see www.dsm5.org/ProposedRevisions/
for details). Individuals can also be diagnosed as rapid-cycling where there
is a particularly short time between affective episodes (American
Psychiatric Association, 2000).
Epidemiology: Bipolar disorder is usually diagnosed first in adults,
but is increasingly diagnosed in children and adolescents in the United States.
However, this diagnosis is controversial outside of the US, thus there are differences
in the estimates of its prevalence in young people in other countries (Soutullo
et al., 2005). Estimates of the prevalence of bipolar disorder in
adults vary; Ten Have et al. (2002) estimated
a lifetime prevalence of 1.9%, with a 12 month prevalence of 1.1%. Mitchell
et al. (2004) estimated lower at a 12 month prevalence of 0.5% whilst
Merikangas et al. (2007) estimated a lifetime
prevalence of 1% for bipolar I disorder and 0.8% for bipolar II disorder, with
an additional 2.4% of the population with subthreshold symptoms. Sub-clinical
symptoms of hypomania are relatively common in the general population and are
related to sub-clinical psychotic symptoms (Richardson and
Garavan, 2009a), traits of impulsivity and risk-taking propensity (Richardson
and Garavan, 2010a) and substance use (Richardson and
Garavan, 2010b). In addition many of those diagnosed with unipolar depression
may have undetected hypomanic symptoms suggestive of a diagnosis of bipolar
II disorder (Benazzi and Akiskal, 2003; Richardson
and Garavan, 2009b).
Impact of bipolar disorder: Bipolar disorder is associated with reduced
quality of life, impaired functioning and high rates of marital disruption as
well as an increased risk of suicide attempt (Mitchell et
al., 2004; Ten Have et al., 2002). In
addition, bipolar disorder has high levels of psychiatric co-morbidity (Merikangas
et al., 2007; Mitchell et al., 2004).
Bipolar disorder is also associated with particularly high levels of drug and
alcohol use, especially in certain sub sets of patients such as those who are
younger and those who have a co-morbid anxiety disorder (Richardson,
2010). The use of drugs such as cannabis may also increase the severity
of affective symptoms (Richardson, 2010).
Due to these negative outcomes associated with bipolar disorder, it is important
for clinicians to consider effective treatments. A number of pharmacological
treatments are available, however these are associated with a number of potential
side effects (Al-Omar, 2005; Malhi
et al., 2010). The aim of this study is therefore to review recent
research on the effectiveness of psychosocial interventions for bipolar disorder.
Evidence for clinical efficacy: Psychoeducation aims to educate bipolar
disorder patients about the illness, usually in groups. Specific areas often
covered are medication, detecting early or prodromal symptoms, stress management
and relapse prevention techniques. A substantial body of evidence supports its
potential as an intervention, with structured group psychoeducation being more
effective than unstructured group support (Colom et al.,
2003b). Psychoeducation has been found to lead to reduce rates of relapse
(Colom et al., 2003a, b,
2009a) and increase the time between episodes (Colom
et al., 2003b, 2009a), as well as reduce
the time spent in affective episodes (Colom et al.,
2009a). It also appears to reduce the number and duration of hospital admissions
(Colom et al., 2003b, 2009a).
Group psychoeducation may also improve quality of life at least in terms of
physical functioning and general satisfaction (Michalak
et al., 2005). The effectiveness appears to be for hypomanic and
manic episodes and well as depressive episodes (Colom et
al., 2003b, 2009a) and benefits are maintained
up to 5 years later (Colom et al., 2009a). In
addition group psychoeducation appears to be cost-effective; though it costs
money to implement in the short term it saves money in the long run due to fewer
inpatient stays (Scott et al., 2001). Recent
work has tried to make psychoeducation more easily accessible: manualised interventions
have been developed which can be delivered by mental health professionals with
little experience in the area (Sorensen et al., 2007).
In addition, a number of research groups have begun to adapt psychoeducational
interventions for an online format such as beating bipolar (Smith,
2010) and recovery road (Barnes et al., 2007).
However, there is no evidence on the clinical effectiveness of these as of yet.
Mechanisms of change: Research is also beginning to demonstrate potential
mechanisms whereby psychoeducation improves outcomes for those with bipolar
disorder. Clients appear to appreciate the development of working relationships
with clinicians and being able to develop a personalised approach to illness
management which is in line with their beliefs about bipolar disorder (OConnor
et al., 2008). It also improves knowledge about medication (Colom
et al., 2003a), but goes beyond improving compliance with medication
as it enable healthy lifestyles to develop (Colom et
al., 2003a). Adding sessions on developing life goals appears to enhance
psychoeducational interventions (De Andres et al.,
2006), thus it may have a beneficial effect by creating targets for improvement
in patients. Psychoeducation may also increase the ability to notice warning
signs of oncoming episodes and cope with these effectively (Colom
et al., 2003a). As a result, it has been suggested that psychoeducational
interventions should include personalised manuals to help identify these early
warning signs and prevent relapse (Sorensen et al.,
2007). Psychoeducation appears to change locus of control such that clients
feel that health professionals can help them manage their illness (Even
et al., 2010). Similarly research has shown decreased hopelessness
and an increased perceived ability to cope with the illness after such interventions
(Sorensen et al., 2007). It may also change representations
of bipolar disorder into a conceptualisation as a medical illness (Even
et al., 2010), thus potentially reducing stigma and enhancing a sense
of control over the condition.
Limitations of psychoeducation: A number of studies have suggested potential
limitations of psychoeducation which need to been taken into account. Research
has found that illness severity affects outcomes; those with more episodes before
intervention have poorer outcomes (Colom et al.,
2010). An analysis of 5 year outcomes found that those with more than seven
episodes prior to treatment had no benefit in terms of duration between episodes
and those who had experienced more than 14 episodes did not have a reduced time
spent in affective episodes (Colom et al., 2010).
In addition, a greater number of previous episodes reduced the benefit of psychoeducation
on the risk of hypomanic, depressed and mixed episodes specifically (Colom
et al., 2010). There is also evidence that views about bipolar disorder
influence outcome from psychoeducation; Sorensen et al.
(2007) found that those who saw their previous manic episodes as positive
took longer to improve. There may be certain types of bipolar patient who are
less likely to attend psychoeducation; Even et al.
(2007) found that inpatients were more likely to take part if they were
younger, more educated and had been ill for less time. In addition, those with
an external locus of control, i.e. they believed that they could not control
what happened to them, were less likely to take part (Even
et al., 2007). The majority of interventions have been developed
for use with both bipolar I and bipolar II disorder patients together. Whilst
psychoeducation appears to benefit bipolar II specifically, it has been suggested
that bipolar II patients need specifically designed interventions (Colom
et al., 2009b).
INTERPERSONAL AND SOCIAL RHYTHM THERAPY
Interpersonal and Social Rhythm Therapy (IPSRT) is based on theory and research
suggesting that relapse in bipolar disorder is often caused by disrupted social
routines or rhythms and stressful major life events (Goodwin
and Jamison, 1990; Shen et al., 2008). IPSRT
combines behavioural techniques with elements of interpersonal therapy in an
attempt improve medication adherence and assist in the development of regular
routines and sleep pattern, thereby reducing the risk of relapse (Frank
et al., 2000). A moderate body of evidence provides support for its
effectiveness with bipolar disorder. Frank et al.
(2005) found that those who received IPSRT during an acute affective episode
had longer in between episodes. IPSRT also led to more stable social rhythms,
which in turn reduced the risk of relapse (Frank et al.,
2005). Swartz et al. (2009) found reduced
depression and mania, with 29% achieving a full remission. IPSRT also appears
to improve occupational functioning (Frank et al.,
2008). Some research has found that IPSRT alone is effective without medication
(Swartz et al., 2009), whereas other authors
have suggested that it is combined with medication for treatment (Frank
et al., 2009). Recently, it has been adapted for use with adolescents,
focusing on issues around development at that age (Crowe
et al., 2008). Hlastala et al. (2010)
found high levels of completion and satisfaction with IPSRT in adolescents as
well as reduced severity of affective symptoms and improved functioning. However,
some research has emphasised the limitations of IPSRT; Frank
et al. (2008) found that the effects on functioning were not maintained
2 years later and that it is more effective for women than men.
COGNITIVE BEHAVIOUR THERAPY
Evidence for clinical efficacy: Cognitive Behaviour Therapy (CBT) has
only relatively recently been developed for bipolar disorder. It includes a
number of elements such as developing treatment goals and using cognitive-behavioural
techniques to address dysfunctional thoughts and beliefs, and the development
of emotional management and relapse prevention techniques (Scott
et al., 2001). A considerable body of evidence supports its effectiveness
as an intervention for bipolar disorder. Cognitive therapy has been found to
reduce the number of subsequent episodes (Lam et al.,
2000, 2003), with as much as a 60% reduction in
relapses (Scott et al., 2001). It also appears
to lead to a shorter duration of episodes (Lam et al.,
2003). Lam et al. (2005a) found that, over
30 months, those with bipolar I who had cognitive therapy spent 110 less days
in an affective episode. Similarly, Zaretsky et al.
(2008) found that CBT halved the number of days spent in an episode of depression
over the following year. It has also been shown to lead to fewer hospitalisations
(Lam et al., 2003) and improve affective symptoms
(Ball et al., 2006; Lam
et al., 2003, 2005b). In addition, there
appear to be reduced fluctuation between mood states (Lam
et al., 2000, 2003) and CBT may be effective
for those with rapid-cycling bipolar disorder (Reilly-Harrington
et al., 2007). It may also improve functioning (Lam
et al., 2000, 2003, 2005b;
Patelis-Siotis et al., 2001; Scott
et al., 2001), reduce hopelessness (Lam et
al., 2000) and increase the ability to cope with prodromal symptoms
(Lam et al., 2003, 2005b).
CBT appears to improve compliance with medication (Lam et
al., 2000, 2005b) and reduce the amount of medication
needed (Zaretsky et al., 2008). Although cognitive
interventions may be costly to implement, they appear to save money in the long
term due to reduced service use (Lam et al., 2005a).
Attempts to make CBT more cost-effective have led to the development of computerised
interventions with elements of CBT, however there is no outcome data available
at this time (Barnes et al., 2007).
Age and culturally sensitive CBT: Recent work has begun to examine the
potential for CBT to assistant in the management of bipolar disorder in children
and adolescents. Pavuluri et al. (2004) developed
an intervention consisting of CBT for the child individually as well as family-focused
CBT, finding reduced severity of manic, depressive and psychotic symptoms, as
well as improved aggression and functioning. West et
al. (2009) developed a similar intervention for children as young as
12, finding improved functioning and mania. However, there was no effect on
depressive symptoms and little impact on parental stress (West
et al., 2009). Other work has found that CBT reduces parent rated,
but not self-reported symptom severity (Feeny et al.,
2006). There has been little work trying to develop CBT for use with older
adults with bipolar disorder, though case studies appear to support its effectiveness
(Nguyen et al., 2007). The majority of work has
used CBT in a Western context and there has been little work trying to make
CBT culturally sensitive. However, Masoudi et al.
(2009) recently used CBT for women in Iran with bipolar disorder, finding
reduced mania and improved awareness of signs of relapse.
Limitations of traditional CBT: Despite a strong evidence base, research
has indicated that CBT can be limited in certain ways. For example, Lam
et al. (2005b) observed that the effects of CBT only reduce relapse
rates in the first year after treatment, with no long term benefit. It is also
unclear which specific type of affective episode is reduced by CBT; Lam
et al. (2003) found an impact on depressive and manic episodes, but
not hypomanic episodes, whereas, Lam et al. (2000)
found improvements in hypomanic episodes, but not manic or depressive episodes.
Other work has failed to find a reduction in long term service use (Lam
et al., 2005b; Zaretsky et al., 2008).
There may also be certain subtle characteristics which influence whether CBT
will be effective; Lam et al. (2005c) found that
cognitive therapy was less effective for those who believed that they had personal
attributes similar to hypomania. These individuals did not see hypomanic symptoms
as part of their illness, and thus these symptoms were resistant to change.
In recent years new Third Wave therapies of Dialectical Behaviour Therapy and
Mindfulness-Based cognitive therapy have attempted to provide a different approach
to bipolar disorder than that offered by traditional CBT.
Dialectical behaviour therapy: Dialectical Behaviour Therapy (DBT) is
a development from CBT which uses insights from behavioural science, Zen Buddhism
and dialectical philosophy in order to address interpersonal problems and suicidal
behaviours (Salsman and Linehan, 2006). This was originally
developed for the treatment of borderline personality disorder, but in recent
years has been applied to other conditions (Lynch et
al., 2007). Two self-help books have been published on how to use DBT
skills to help regulate emotions in bipolar disorder (Van
Dijk, 2009; Van Dijk and Guindon, 2010). However,
at present there has been little research to support its effectiveness. Goldstein
et al. (2007) used DBT with adolescents aged 14 to 18 with bipolar
disorder. The sessions were delivered with families and individually over a
year. Completion and satisfaction were high and there were reductions in suicidal
ideation and self-harm, as well as improvement in affect control and depression
(Goldstein et al., 2007). DBT aims to enhance
emotional regulation, so, it may hold potential for bipolar disorder. However,
there is little evidence to support its effectiveness at present.
Mindfulness-based cognitive therapy: Mindfulness Based Cognitive Therapy
(MBCT) incorporates elements of traditional CBT with mindfulness meditation
and was originally developed in an attempt to reduce relapse rates for unipolar
depression (Segal et al., 2002). It has been suggested
that mindfulness meditation may be especially helpful for bipolar disorder as
relapse rates are high and often due to anxiety and stress (Ball
et al., 2007). Mindfulness aims to help regulate thoughts, feelings
and reduce stress, therefore it may help prevent relapse in bipolar disorder.
Miklowitz et al. (2009) used 8 weeks of MBCT
and found improved symptoms of depression and mania as well as reduced suicidal
ideation and anxiety. However, this appeared to be more effective for depression
than mania. Williams et al. (2008) similarly
found reductions in anxiety and depression and Bonvalot
et al. (2010) found that adding mindfulness to traditional CBT reduced
drop out. However, Weber et al. (2010) found
that although MBCT was rated highly, there was no overall improvement in depression.
FAMILY FOCUSED TREATMENTS
Family psychoeducation: Family focused treatments aim to involve the
caregivers and family of those with bipolar disorder. These are often psychoeducational;
they attempt to educate family members about the symptoms of bipolar disorder,
treatment options and management techniques. Such psychoeducation has been found
to improve knowledge about bipolar disorder in families, as well as reduce the
sense of burden on caregivers and consequently relieve stress (Reinares
et al., 2003). Reinares et al. (2008)
gave 12 sessions of psychoeducation to family members without the patients present,
finding that this led to fewer relapses and longer between affective episodes.
Similarly, D'Souza et al. (2010) gave psychoeducation
to patients and their partner, finding a reduced likelihood of relapse and improved
manic symptom severity. There was also longer between episodes, an effect which
was mediated by enhanced medication compliance (D'Souza
et al., 2010). Whilst many of the psychoeducational interventions have
been developed and tested in Western countries such as the U.S., they are beginning
to be adapted cross culturally. For example, Ozerdem et
al. (2009) adapted a 21 session psychoeducational intervention designed
in the US for use in Turkey. Recent research has also developed a psychoeducational
intervention for the parents and a families of children with bipolar disorder,
finding that it improved self-reported knowledge and coping skills and led to
more positive attitudes (Fristad et al., 2002).
Family focused therapy: As well as psychoeducational approaches, interventions
have been developed which more actively involve the family members. Such interventions
are known as family focused therapy. In addition to psychoeducation, these interventions
include elements such as communication and problem skill training for families
(Miklowitz et al., 2003). Research suggests that
family focused therapy is more clinically effective than family psychoeducation
alone, with reductions in the number of relapses and longer between episodes
(Miklowitz et al., 2000, 2003;
Reinares et al., 2008). Family focused interventions
also appear to be more effective than individually administered interventions;
Rea et al. (2003) found that 28% of those in
a family intervention relapsed compared to 60% in an individual intervention.
In addition, only 12% were hospitalised compared to 60% who had individual work
(Rea et al., 2003). Solomon
et al. (2008) similarly found that actively involving all members
of the patients family reduced rates of hospitalisation. There is however,
evidence to suggest that the effect on relapse rates is seen for hypomanic or
manic episodes, but not for depressive or mixed episodes (Reinares
et al., 2008). Similarly, Solomon et al.
(2008) found no effect on type of episode. Additional work has documented
that such interventions have also been found to reduce affective symptom severity
(Miklowitz et al., 2003). However, some work
suggests that this is the case for depressive symptoms but not manic or hypomanic
symptoms (Miklowitz et al., 2000). They may also
increase adherence to medication treatments (Miklowitz
et al., 2003), though other work has failed to find such an effect (Reinares
et al., 2008). A limited body of research has tried to develop family
therapy interventions for children and adolescents with bipolar disorder, finding
improvements in the severity of manic, depressive and psychotic symptoms (Miklowitz
et al., 2004; Pavuluri et al., 2004).
These interventions with young people have also been shown to improve functioning
and reduce problematic behaviour (Miklowitz et al.,
2004; Pavuluri et al., 2004).
Limitations of family interventions: It is important to note that some
research has failed to find a benefit of family focused treatments; Miller
et al. (2004) found that family therapy or family psychoeducation
in addition to medication did not improve recovery more than medication alone.
It has also been noted that whilst family interventions may reduce relapse,
they have no impact on recovery from an acute affective episode (Solomon
et al., 2008). There is evidence to suggest that providing psychoeducation
for caregivers and families is more beneficial if provided earlier on in the
course of the illness, and it may be that there is limited or no impact if intervention
is delayed (Reinares et al., 2010). It is also
possible that only certain families will benefit from such interventions: Miller
et al. (2008) found that family therapy or psychoeducation for those
with bipolar I disorder only led to improvements in patients who were part of
a dysfunctional family. Similarly, Miklowitz et al.
(2000) showed that improvements were more pronounced where there were high
levels of expressed emotion. Family interventions have been developed which
try to reduce such expressed emotion, but it seems relatively resistant to change.
Eisner and Johnson (2008) found that a family intervention
improved knowledge about bipolar disorder, but families still have high levels
of blame, criticism and anger (Eisner and Johnson, 2008).
Alternative therapeutic approaches: In addition to the psychosocial
interventions for bipolar disorder mentioned previously, there are studies which
have examined the potential of alternative therapeutic approaches. Goldner-Vukov
et al. (2007) used group therapy with elements of existential therapy
and found preliminary evidence to support its effectiveness. Gonzalez
and Prihoda (2007) also found that group psychodynamic therapy improved
depression and reduced episode duration. Relapse prevention interventions which
focus on early warning signs and prodromal symptoms have also been developed
(Lobban et al., 2007). Similarly, Castle
et al. (2010) recently developed a group intervention using a stress-vulnerability
approach. This was found to reduce the number of depressive and hypomanic or
manic episodes (Castle et al., 2010). Interestingly
however, the severity of these affective symptoms was not significantly reduced.
This suggests that the intervention did not improve symptoms per se, but rather
increased the patients ability to cope with the symptoms and therefore
reduce the likelihood of relapse and hospitalisation (Castle
et al., 2010).
Commonalities between approaches: Research has shown that many different
psychosocial interventions for bipolar disorder share a number of specific components
such as teaching problem solving skills (Miklowitz et
al., 2008). In addition research suggests that there is often little
difference between these types of specific interventions in terms of clinical
effectiveness. For example, Miklowitz et al. (2007a)
found that psychoeducation, family focused interventions and CBT with IPSRT
were equally effective. Similarly, Miklowitz et al.
(2007b) found no difference in terms of recovery between IPSRT, CBT or family
focused interventions. As a result, it is likely that in the future there will
be increased research on collaborative approaches which combine elements from
a number of different interventions.
Recent research has begun to highlight the potential of a number of different psychosocial interventions for bipolar disorder. Group psychoeducation appears to be effective with improvements in relapse rates, hospitalisation and functioning, which appear to be the result of improved awareness of the illness and an enhanced sense of control. However, beliefs about the illness, as well as the number of previous affective episodes may affect outcome. Interpersonal and Social Rhythm Therapy also appears to reduce the risk of relapse and improve functioning, however the long term benefits are unclear. Cognitive behaviour therapy has been shown to reduce relapse rates and duration of episodes, as well as reduce service use and improve affective symptoms. Whilst CBT has been adapted for use with younger clients, it has rarely been applied to older adults or those from different cultures. There is controversy over the long-term benefits of CBT and its effect on specific affective episodes, thus in recent years new third wave approaches have developed. Dialectical Behaviour Therapy has been applied to bipolar disorder in adolescents but there is little evidence on its effectiveness at present. There is however a growing evidence base for the use of mindfulness-based cognitive therapy as a way to reduce symptom severity.
Family focused treatments offer potential with psychoeducation for family members leading to a number of improvements. Family focused therapy appears to be more effective than psychoeducation alone, with reduced rates of relapse and hospitalisation. However, such interventions are most effective in the early stages of an illness and with dysfunctional families and expressed emotion in these families seems resistant to change. In recent years research has begun to highlight the common components of these therapies and in the future there may be attempts to combine them. In conclusion, there are a number of psychosocial interventions which appear to be effective for bipolar disorder, with reduced rates of relapse, improved functioning and reduce symptom severity and service use. However, there are a number of approaches where the evidence base is still relatively small and thus future research needs to help demonstrate the efficacy of these therapies in order to help inform mental health professionals as to the best course of intervention.
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