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

Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder

Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.

Cognitive behavioral therapy for rapid-cycling bipolar disorder: a pilot study

Bipolar disorder is characterized by depressive and/or manic episodes that interfere with daily functioning. Between 10%-24% of bipolar patients experience a rapid-cycling course, with 4 or more mood episodes occurring per year. Characterized by nonresponse to standard mood stabilizing medications, patients with rapid-cycling bipolar disorder are particularly in need of effective, adjunctive treatments. Adjunctive cognitive-behavioral therapy (CBT) has been shown to improve adherence to medication and reduce relapse rates in patients with bipolar disorder. However, no published trials to date have examined the application of CBT to the treatment of patients with a rapid-cycling course of illness, with only a single case study published in the literature. We recently developed a CBT protocol that addresses the specific needs of bipolar patients with rapid cycling. The present study was designed to investigate outcomes with this CBT protocol. Study participants were 10 patients with rapid-cycling bipolar disorder, 6 of whom completed the study. Completers showed significant decreases in depressive mood, and improvements remained stable during the 2-month follow-up. This suggests that CBT for rapid cycling may have beneficial effects.

Non-pharmacological treatments in the management of rapid cycling bipolar disorder

BACKGROUND

Rapid cycling (RC) bipolar disorder is often treatment-resistant to pharmacotherapy. Non-pharmacological methods, however, are reasonable considerations in treatment refractory cases of bipolar patients. Thus, such methods may be useful in the management of RC, especially when drugs are not shown to be effective.

METHOD

This review is based on studies of all major non-pharmacological methods which are used in the management of bipolar disorder, by focusing on data regarding patients with a RC pattern of the illness.

RESULTS

Regarding biological treatments, for electroconvulsive therapy and sleep deprivation, there exists some evidence that they might be efficacious in RC patients for acute treatment as well as for prophylaxis from recurrences. Light therapy has not been shown to be efficacious in RC, while no published data exist for transcranial magnetic stimulation and vagus nerve stimulation. The non-biological treatments include psychotherapeutic and psychosocial interventions; these have not been tried particularly on RC patients, but their use should be expected to contribute to the overall management of the RC pattern as it does to that of mood disorder in general.

LIMITATIONS

Many data on which this review is based are drawn from case reports or non-randomised trials.

CONCLUSIONS

Non-pharmacological methods, either biological or non-biological (psychotherapies and psychoeducation), may be applied in the management of RC patients. These methods might be used in combination with the administration of drug treatment, based on the clinical experience of the physician and the individual characteristics of the patient.

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

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.

Psychotherapy of bipolar disorder: a review

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-behavioural, 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 standardised 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.

The influence of successful prophylactic drug treatment on cognitive dysfunction in bipolar disorders

BACKGROUND

Cognitive variables such as negative self-evaluations have been discussed as vulnerability factors for depressive syndromes. In the context of bipolar disorders dysfunctional cognitive structures have received little interest as these patients seem to be less disturbed during the euthymic interval than patients with major depression.

METHODS

In the present study, the self-esteem of remitted patients with DSM-III-R diagnosis of major depression (n=20), bipolar disorder (n=20) and healthy controls (n=20) was measured with the Frankfurt Self-concept Scale (FSKN).

RESULTS

1) Statistical analysis by analysis of variance (ANOVA) showed no significant differences as to age, sex, etc. between the psychiatric groups. The clinical groups showed lower self-esteem ratings in comparison to healthy controls. 2) Four groups (T1-T4) of remitted patients with bipolar disorders (20 in each group) were successfully maintained on mood stabilizers (lithium or carbamazepine) and classified by the duration of their episode-free period. T1 included those who were episode-free for only the week before discharge from hospital. T2 were symptom-free for <30 months. T3 were episode-free for >30 months and <60 months. T4 were episode-free for >60 months. The comparison of their FSKN self-esteem ratings by ANOVA suggests that self-esteem improves during successful prophylactic treatment. A posteriori contrasts indicate a normalized self-esteem after a bipolar episode-free period of at least 47 months.

CONCLUSIONS

Dysfunctional cognitions can be demonstrated in unipolar as well as in bipolar patients. Successful episode-preventive medication with mood stabilizers seems to counteract lowered self-esteem. Adjunctive cognitive therapy might help to optimize the long-term course of bipolar disorder.