Cognitive therapy for clients with bipolar disorder

New Psychosocial Interventions for Bipolar Disorder: A Review of Literature and Introduction of the Systematic Treatment Enhancement Program

What is the evidence that psychosocial treatment adds to the efficacy of pharmacotherapy in forestalling episodes of bipolar disorder (BPD)? This article gives the rationale for including psychosocial intervention in the outpatient maintenance of BPD. Attention is placed on 4 psychosocial modalities that have achieved empirical support in randomized trials: family-focused psychoeducational treatment (FFT), cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), and group psychoeducation. FFT, CBT, and IPSRT are being contrasted with a psychosocial control condition in the context of the ongoing, multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The objectives, design, and potential contributions of the STEP-BD study are explained. Future directions for the evaluation and dissemination of manual-based psychosocial interventions are discussed.

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

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.

Psychotherapy for bipolar depression: a phase-specific treatment strategy?

OBJECTIVES

The depressive phase of bipolar disorder is particularly difficult to treat. Pharmacologic strategies for bipolar depression are often inadequate. We therefore review the literature on the role of psychotherapy as an adjunct to medication in the treatment of bipolar depression.

METHODS

With one exception, there are no descriptions of psychotherapies employed specifically for the treatment of bipolar depression. We therefore reviewed published reports of psychotherapy for bipolar disorder in general and extracted from these reports relevant data or impressions about the specific effects of the therapies on the depressive phase of the disorder.

RESULTS

Described psychosocial approaches to bipolar disorder include psychoeducation, group therapy, cognitive-behavioral therapy, couples therapy, family therapy, and interpersonal psychotherapy. Only cognitive-behavioral therapy has been tested in a pilot study for the treatment of bipolar depression specifically. Results from randomized controlled trials of family therapy and interpersonal and social rhythm therapy suggest that these treatments may be more efficacious in the treatment and prevention of depression relative to mania.

CONCLUSIONS

A limited number of well-designed studies and preponderance of case reports limit definitive conclusions about the role of psychotherapy in the treatment of bipolar depression. However, converging reports suggest that cognitive-behavioral therapy, family therapy, and interpersonal and social rhythm therapy may be particularly useful for bipolar depression. We propose a novel approach to the treatment of bipolar disorder that includes the use of phase-specific sequenced psychotherapies delivered in variable patterns and linked to fluctuating mood states.

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

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.