Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program

CONTEXT: Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder. OBJECTIVE: To examine the benefits of 4 disorder-specific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression. DESIGN: Randomized controlled trial. SETTING: Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder. Patients A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention. INTERVENTIONS: Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks. MAIN OUTCOME MEASURES: Outcome assessments were performed by psychiatrists at each pharmacotherapy visit. Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months. RESULTS: All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P = .01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P = .003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies. CONCLUSIONS: Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the cost-effectiveness of models of psychotherapy for bipolar disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00012558.     

Psychotherapy, symptom outcomes, and role functioning over one year among patients with bipolar disorder

OBJECTIVE: Randomized trials indicate that psychosocial interventions effective adjuncts to pharmacotherapy in bipolar disorder (1,2). A one-year naturalistic-prospective design was used to examine the association between psychotherapy use and the symptomatic and functional outcomes of patients with bipolar disorder. METHODS: Patients with bipolar disorder in a depressed phase (N=248) were drawn from the first 1,000 enrollees (November 1999 to April 2002) in the Systematic Treatment Enhancement Program (STEP-BD), a study of patients with bipolar disorder receiving best-practice pharmacotherapy. Patients were seen clinics and interviewed every three months over one year regarding of psychotherapy services, symptoms, and role functioning. Mixed-effects regression models were used to examine whether the amount of psychotherapy the patients received during each three-month interval was associated with symptomatic or psychosocial functioning during the same or a subsequent three-month interval. RESULTS: During the study year, percent of the patients had at least one psychotherapy session. Among patients who began an interval with severe depressive symptoms or low functioning, having more frequent sessions of psychotherapy was associated with less severe mood symptoms and better functioning in the same or a subsequent study interval. In contrast, among patients who began interval with less severe depressive symptoms or higher functioning, fewer psychotherapy sessions were associated with less severe depressive symptoms and greater functioning in the same or a subsequent interval. CONCLUSIONS: Intensive psychotherapy may be most applicable to severely ill patients with bipolar disorder, whereas briefer treatments may be adequate for less severely ill patients.     

A randomized controlled trial of cognitive therapy for bipolar disorder: focus on long-term change

BACKGROUND: This study reports the outcome of a randomized controlled trial of cognitive therapy (CT) for bipolar disorder. The treatment protocol differed from other published forms of CT for bipolar disorder through the addition of emotive techniques. METHOD: Fifty-two patients with DSM-IV bipolar I or II disorder were randomly allocated to a 6-month trial of either CT or treatment as usual, with both treatment groups also receiving mood stabilizers. Outcome measures included relapse rates, dysfunctional attitudes, psychosocial functioning, hopelessness, self-control, and medication adherence. Patients were assessed during treatment by independent raters blind to the patients' group status. RESULTS: At posttreatment, patients allocated to CT had experienced less severe depression scores (Beck Depression Inventory and Montgomery-Asberg Depression Rating Scale) and less dysfunctional attitudes. After controlling for the presence of major depressive episode at baseline, there was a statistical trend toward a greater time to depressive relapse (p=.06) for the CT group. At 12-month follow-up, the CT group showed a trend toward lower Young Mania Rating Scale scores and improved behavioral self-control. The Clinical Global Impressions-Improvement scale, comparing the 18 months prior to treatment to the severity of illness status at follow-up, showed a substantial difference between groups in favor of CT. CONCLUSION: Our findings corroborate previous bipolar disorder research in demonstrating the value of CT, particularly immediately post-treatment, and indicate some continuation (albeit diminishing) of benefits in the succeeding 12 months. These findings suggest that psychological booster sessions may be crucial for maintaining the beneficial effects of cognitive therapy.     

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

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.     

Family-focused treatment of bipolar disorder: 1-year effects of a psychoeducational program in conjunction with pharmacotherapy.

BACKGROUND: Few studies have examined the combined effects of psychosocial treatment and pharmacotherapy for bipolar disorder. This study used a randomized, controlled design to examine a 9-month, manual-based program of family-focused psychoeducational treatment (FFT). METHODS: Bipolar patients (N = 101) were recruited shortly after an illness episode and randomly assigned to 21 sessions of FFT (n = 31) or to a comparison treatment involving two family education sessions and follow-up crisis management (CM; n = 70). Both treatments were delivered over 9 months; patients were simultaneously maintained on mood stabilizing medications. Patients were evaluated every 3 months for 1 year as to relapse status, symptom severity, and medication compliance. RESULTS: Patients assigned to FFT had fewer relapses and longer delays before relapses during the study year than did patients in CM. Patients in FFT also showed greater improvements in depressive (but not manic) symptoms. The most dramatic improvements were among FFT patients whose families were high in expressed emotion. The efficacy of FFT could not be explained by differences among patients in medication regimes or compliance. CONCLUSIONS: Family-focused psychoeducational treatment appears to be an efficacious adjunct to pharmacotherapy for bipolar disorder. Future studies should evaluate family treatment against other forms of psychotherapy matched in amount of therapist-patient contact.     

Interpersonal and social rhythm therapy for adolescents with bipolar disorder: treatment development and results from an open trial

Background: In adolescents and adults, bipolar disorder (BD) is associated with significant morbidity, mortality, and impairment in psychosocial and occupational functioning. IPSRT is an empirically supported adjunctive psychotherapy for adults with bipolar disorder, which has been shown to help delay relapse, speed recovery from a bipolar depressive episode, and increase occupational and psychosocial functioning in adults with BD. This study is designed to describe the adolescent‐specific developmental adaptations made to IPSRT (i.e., IPSRT‐A) and to report the results from an open trial of IPSRT‐A with 12 adolescents with a bipolar spectrum disorder. Method: Interpersonal and Social Rhythm Therapy was adapted to be developmentally relevant to adolescents with bipolar disorder. Twelve adolescents (mean age 16.5±1.3 years) diagnosed with a bipolar spectrum disorder participated in 16–18 sessions of adjunctive IPSRT‐A over 20 weeks. Manic, depressive, and general symptoms and global functioning were measured at baseline, monthly during treatment, and at post‐treatment. Adolescent satisfaction with treatment was also measured. Results: Feasibility and acceptability of IPSRT‐A were high; 11/12 participants completed treatment, 97% of sessions were attended, and adolescent‐rated satisfaction scores were high. IPSRT‐A participants experienced significant decreases in manic, depressive, and general psychiatric symptoms over the 20 weeks of treatment. Participants' global functioning increased significantly as well. Effect sizes ranged from medium‐large to large. Conclusions: IPSRT‐A appears to be a promising adjunctive treatment for adolescents with bipolar disorder. A current randomized controlled trial is underway to examine effects of adjunctive IPSRT‐A on psychiatric symptoms and psychosocial functioning. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Psychosocial and neurocognitive functioning in unipolar and bipolar depression: a 12-month prospective study

Previous studies have revealed psychosocial and cognitive impairments in patients during unipolar and bipolar depression, which persist even in subsyndromal and euthymic states. Currently, little is known about the nature and the extent of psychosocial and cognitive deficits during depression. The aim of the present study was to characterize psychosocial and cognitive profiles among unipolar (MDD) and bipolar (BD) patients during a major depressive episode and to compare the profiles of the patient groups. Depressed patients with MDD (n=13) and BD (n=11) were followed over a period of 12 months. Clinical, psychosocial and neuropsychological assessments were conducted at baseline and at 6-week, 4-month, 8-month and 12-month follow-ups. In the case of severe mood disorders, psychosocial and neurocognitive functioning seem similar among MDD and BD patients during a depressive episode. All MDD and BD patients had global psychosocial dysfunction, characterized by occupational and relational impairments. Furthermore, the neurocognitive profile was heterogeneous with regard to the nature and extent of cognitive deficits but attentional processes were frequently compromised. After 1 year of treatment, occupational and relational impairments, as well as neurocognitive dysfunction, persisted sufficiently to alter daily functioning.     

Cognitive impairment in later life in patients with early-onset bipolar disorder

OBJECTIVES: Cognitive impairment may interfere with psychosocial functioning in bipolar disorder (BD). There is limited information regarding the cognitive function of elderly bipolar patients with onset at a young age. The present study aimed to investigate the frequency and the determinants of cognitive impairment in elderly early-onset bipolar patients. METHODS: Using the Clock-drawing Test (CDT), the Mini Mental State Examination (MMSE), and the Cognitive Abilities Screening Instrument (CASI), we examined euthymic patients with bipolar I disorder in Taiwan, aged 60 years and older. Clinical data were obtained by reviewing medical records and personal interviews with patients and their family members. The onset of BD prior to the age of 40 years is defined as 'early-onset'. RESULTS: Of the 52 early-onset patients, 42.3% were determined to have cognitive impairment by exhibiting either abnormal CDT or education-adjusted MMSE scores. In a multiple regression model, years of education and the age at the last manic/hypomanic (but not depressive) episode accounted for the greatest variance in both MMSE and CASI scores. While educational level and the age at the last manic/hypomanic episode were not considered in the regression model, onset with depressive syndrome and current age explained 21.5% of the variance in MMSE scores. Age at the first depressive episode, the first manic episode before the age of 40 years, and comorbid diabetes accounted for 16.7% of the variance in CASI scores. CONCLUSIONS: There appeared to be a sizable proportion of elderly early-onset bipolar patients having cognitive impairment. It is suggested that clinical manifestation of first-onset affective episode and impact of medical comorbidity affect the cognition of early-onset BD in later life.     

Efficacy of electroconvulsive therapy in treatment-resistant bipolar disorder: a case series

The response to electroconvulsive therapy for six bipolar patients after pharmacotherapy failure is discussed. METHODS: Inclusion criteria were as follows: (1) bipolar mood disorder, manic, depressive or mixed episode (DSM-IV); (2) failure of pharmacotherapy, that is, for mania, manic episode unresponsive to at least 2 adequate antimanic trials for 6 weeks; and for bipolar depression, bipolar depressive episode unresponsive to at least 2 adequate antidepressant trials for 8 weeks. The patients underwent 12 bilateral sessions of ECT 3 times per week. Clinical response was considered a reduction of 50% or greater in the Young Mania Rating Scale (YMRS) and in the Hamilton Rating Scale for Depression-21 items (HAMD-21). Final YMRS <6 and HAMD-21 <8 defined remission. RESULTS: Six of the 9 referred patients consented to be submitted to ECT. Four were male, with ages ranging from 29 to 61 years, and their age at onset ranged from 19 to 49 years. Four showed psychotic features. All responded to ECT.     

Symptoms predicting inpatient service use among patients with bipolar affective disorder.

OBJECTIVE: Symptoms that were risk factors for hospital readmission among psychiatric inpatients diagnosed as having bipolar affective disorder were evaluated. METHODS: Subjects were 100 persons consecutively admitted to a psychiatric inpatient unit at a university-affiliated hospital who met Research Diagnostic Criteria for bipolar I or II disorder or schizoaffective disorder, manic type. Patients were assessed using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) and the Brief Psychiatric Rating Scale (BPRS) within one week of discharge, and their hospitalization status was documented by monthly phone contacts over a period of 15 months. RESULTS: Twenty-four patients (24 percent) were rehospitalized within six months of discharge, and 44 (44 percent) were readmitted within 15 months. Survival analysis using the Cox proportional hazard regression model demonstrated that patients with high scores on a BPRS-derived mania factor were at significantly decreased risk of rehospitalization, whereas those scoring high on a factor consistent with neurovegetative depression were at significantly increased risk. A greater number of previous psychiatric admissions and younger age were also associated with significantly increased risk of rehospitalization. CONCLUSIONS: The findings suggest that patients with bipolar disorder presenting with a depressive episode characterized by prominent neurovegetative features should be treated more aggressively with both pharmacotherapy and intensive outpatient services to reduce the relatively high risk of rehospitalization that appears to be associated with this type of depression.     

Clozapine in treatment-resistant patients with schizophrenia,schizoaffective disorder,or psychotic bipolar disorder: a naturalistic 48-month follow-up study

BACKGROUND: The aim of this study was to evaluate the long-term efficacy and safety of clozapine in patients with treatment-resistant schizophrenia, schizoaffective disorder, or bipolar disorder with psychotic features. METHOD: 101 patients with a DSM-III-R diagnosis of schizophrenia (N = 34); schizoaffective disorder, bipolar type (N = 30); or bipolar disorder with psychotic features (N = 37) were naturalistically treated with clozapine at flexible doses over a 48-month period. Data were collected from 1994 to 2000. The Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impressions-Severity of Illness scale total predicted scores over time were estimated with random-effects regression models. Time to response to clozapine, defined as 50% reduction of BPRS score, was analyzed in the 3 diagnostic groups using the Kaplan-Meier method. Survival curves were compared using the log-rank test. RESULTS: The BPRS total predicted score halved its baseline value in 3 months for bipolar disorder patients, in 6 months for schizoaffective disorder patients, and in 24 months for schizophrenia patients. The proportion of subjects who satisfied the criterion for response to clozapine after 48 months of follow-up was significantly (p <.01) higher in the schizoaffective and bipolar disorder groups (90.0% and 83.8%, respectively) than in the schizophrenia group (64.7%). Baseline scores on the Global Assessment of Functioning (GAF) showed low levels of psychosocial and occupational functioning in all 3 groups. After 48 months of treatment, GAF scores showed a functional improvement in all 3 groups, with significantly (p <.01) greater improvement in the bipolar disorder group compared with the other groups. CONCLUSION: The findings of this study confirm the efficacy and safety of clozapine for treatment-resistant patients with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder with psychotic features. Patients with schizoaffective disorder and those with bipolar disorder show greater clinical improvement than those with schizophrenia. Patients with bipolar disorder have the shortest time to response and the highest psychosocial and occupational functioning levels. Patients with schizoaffective disorder have the lowest treatment discontinuation rate.     

Subsyndromal depression is associated with functional impairment in patients with bipolar disorder

BACKGROUND: The purpose of this study was to assess whether a relationship exists between mild depressive symptoms and overall functioning in subjects with bipolar disorder. METHOD: Twenty-five male subjects with bipolar I disorder (DSM-III-R criteria), who had not experienced a DSM-III-R episode of mania, hypomania, or major depression for 3 months as determined using the Structured Clinical Interview for DSM-III-R, were evaluated for degree of depressive symptoms using the Hamilton Rating Scale for Depression (HAM-D) and for overall functional status using the Global Assessment of Functioning (GAF, DSM-IV Axis V). RESULTS: GAF scores were significantly negatively correlated with HAM-D scores (r = -0.61, df = 23, p = .001), despite the fact that no patient had a HAM-D score high enough to be considered clinically depressed. CONCLUSION: The results of this study support a relationship between subsyndromal depressive symptoms and functional impairment in bipolar subjects, despite their not meeting threshold criteria for a major depressive episode. These findings raise the possibility that in some patients with bipolar disorder subsyndromal depressive symptoms might contribute to ongoing functional impairment.     

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

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.     

Psychosocial disability in the course of bipolar I and II disorders: a prospective, comparative, longitudinal study

CONTEXT: Evidence of psychosocial disability in bipolar disorder is based primarily on bipolar I disorder (BP-I) and does not relate disability to affective symptom severity and polarity or to bipolar II disorder (BP-II). OBJECTIVE: To provide detailed data on psychosocial disability in relation to symptom status during the long-term course of BP-I and BP-II. DESIGN: A naturalistic study with 20 years of prospective, systematic follow-up. SETTING: Inpatient and outpatient treatment facilities at 5 US academic centers.Patients One hundred fifty-eight patients with BP-I and 133 patients with BP-II who were followed up for a mean (SD) of 15 (4.8) years in the National Institute of Mental Health Collaborative Depression Study. MAIN OUTCOME MEASURES: The relationship, by random regression, between Range of Impaired Functioning Tool psychosocial impairment scores and affective symptom status in 1-month periods during the long-term course of illness from 6-month and yearly Longitudinal Interval Follow-up Evaluation interviews. RESULTS: Psychosocial impairment increases significantly with each increment in depressive symptom severity for BP-I and BP-II and with most increments in manic symptom severity for BP-I. Subsyndromal hypomanic symptoms are not disabling in BP-II, and they may even enhance functioning. Depressive symptoms are at least as disabling as manic or hypomanic symptoms at corresponding severity levels and, in some cases, significantly more so. At each level of depressive symptom severity, BP-I and BP-II are equally impairing. When asymptomatic, patients with bipolar disorder have good psychosocial functioning, although it is not as good as that of well controls. CONCLUSIONS: Psychosocial disability fluctuates in parallel with changes in affective symptom severity in BP-I and BP-II. Important findings for clinical management are the following: (1) depressive episodes and symptoms, which dominate the course of BP-I and BP-II, are equal to or more disabling than corresponding levels of manic or hypomanic symptoms; (2) subsyndromal depressive symptoms, but not subsyndromal manic or hypomanic symptoms, are associated with significant impairment; and (3) subsyndromal hypomanic symptoms appear to enhance functioning in BP-II.     

RESEARCH: Cognitive Rehabilitation for Bipolar Disorder: An Open Trial for Employed Patients with Residual Depressive Symptoms

Bipolar disorder is characterized by recurrent episodes of depression and/or mania along with interepisodic mood symptoms that interfere with psychosocial functioning. Despite periods of symptomatic recovery, individuals with bipolar disorder often continue to experience impairments in psychosocial functioning, particularly occupational functioning. Two determinants of psychosocial functioning of euthymic (neither fully depressed nor manic) individuals with bipolar disorder are residual depressive symptoms and cognitive impairment (i.e., difficulties with executive functioning, attention, and memory). The present study explored whether a new cognitive remediation (CR) treatment designed to treat residual depressive symptoms and, for the first time to the best of our knowledge, address cognitive impairment would be associated with improvement in psychosocial functioning in individuals with bipolar disorder. Following a neuropsychological and clinical assessment 18 individuals with DSM‐IV bipolar disorder were treated with 14 individual sessions of CR. Results indicated that at the end of treatment, as well as at the 3‐months follow‐up, patients showed lower residual depressive symptoms, and increased occupational, as well as overall psychosocial functioning. Pretreatment neuropsychological impairment predicted treatment response. Improvements in executive functioning were associated with improvements in occupational functioning. These findings suggest that treating residual depressive symptoms and cognitive impairment may be an avenue to improving occupational and overall functioning in individuals with bipolar disorder.     

Psychoeducation and interpersonal and social rhythm therapy for bipolar disorder

In treating bipolar disorder, specific psychotherapies in adjunct to pharmacotherapy have been shown to be effective in preventing new episodes and treating depressive episodes. Among those, interpersonal and social rhythm therapy (IPSRT) developed by Frank, amalgamation of interpersonal psychotherapy (IPT) with behavioral therapy focused on social rhythm has been shown to be an efficacious adjunct to mediation in preventing new episodes in bipolar I patients and in treating depression in bipolar I arid II disorder. IPSRT has also been shown to enhance total functioning, relationship functioning and life satisfaction among patients with bipolar disorder, even after pretreatment functioning and concurrent depression were covaried. IPSRT was designed to directly address the major pathways to recurrence in bipolar disorder, namely medication nonadherence, stressful life events, and disruptions in social rhythms. IPT, originated by Klerman et al., is a strategic time-limited psychotherapy focused on one or two of four current interpersonal problem areas (ie, grief, interpersonal role disputes, role transitions, and interpersonal dificits). In IPSRT, the fifth problem area "grief for the lost healthy self" has been added in order to promote acceptance of the diagnosis and the need for life-long treatment. Social rhythm therapy is a behavioral approach aiming at increasing regularity of social rhythms using the Social Rhythm Metric (SRM), a chart to record daily social activities including how stimulating they were, developed from observation that disruptions in social rhythms often trigger affective episodes in patients with bipolar disorder. IPSRT also appears to be a promising intervention for a subset of individuals with bipolar II depression as monotherapy for the acute treatment.     

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.     

Long-term treatment of bipolar disorder in adults

Bipolar disorder is a common, chronic, multidimensional syndrome that appears to be a progressive illness, in that each episode substantially increases the risk that another episode will occur and will be less responsive to treatment than previous episodes. The biphasic and episodic nature of bipolar disorder substantially contributes to its negative impact on patients' quality of life as well as their physical, social, and occupational functioning. Patients with bipolar disorder often have co-occurring conditions, particularly medical comorbidities, and, unfortunately, several psychotropic medications prescribed to treat bipolar disorder may increase the risk of developing certain medical illnesses. Although the recommendation in psychiatric care is to regularly assess patients' physical health, many clinicians are not yet implementing this strategy in their clinical practice. When making evidence-based medication choices, clinicians can select from several FDA-approved agents for the treatment of acute manic and depressive episodes as well as for maintenance therapy. Additionally, psychotherapies are effective when used in combination with pharmacotherapy.     

Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial

OBJECTIVE: To describe an adapted version of dialectical behavior therapy for adolescents with bipolar disorder. METHOD: The dialectical behavior therapy intervention is delivered over 1 year and consists of two modalities: family skills training (conducted with individual family units) and individual therapy. The acute treatment period (6 months) includes 24 weekly sessions; sessions alternate between the two treatment modalities. Continuation treatment consists of 12 additional sessions tapering in frequency through 1 year. We conducted an open pilot trial of the treatment, designed as an adjunct to pharmacological management, to establish feasibility and acceptability of the treatment for this population. Participants included 10 patients (mean age 15.8 +/- 1.5 years, range 14-18) receiving treatment in an outpatient pediatric bipolar specialty clinic. Symptom severity and functioning were assessed quarterly by an independent evaluator. Consumer satisfaction was also assessed posttreatment. RESULTS: Feasibility and acceptability of the intervention were high, with 9 of 10 patients completing treatment, 90% of scheduled sessions attended, and high treatment satisfaction ratings. Patients exhibited significant improvement from pre- to posttreatment in suicidality, nonsuicidal self-injurious behavior, emotional dysregulation, and depressive symptoms. CONCLUSIONS: Dialectical behavior therapy may offer promise as an approach to the psychosocial treatment of adolescent bipolar disorder.     

A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder

BACKGROUND: Bipolar patients are at risk for relapses of their illness even when undergoing optimal pharmacotherapy. This study was performed to determine whether combining family-focused therapy (FFT) with pharmacotherapy during a postepisode interval enhances patients' mood stability during maintenance treatment. METHODS: In a randomized controlled trial, 101 bipolar patients were assigned to FFT and pharmacotherapy or a less intensive crisis management (CM) intervention and pharmacotherapy. Outcome assessments were conducted every 3 to 6 months for 2 years. Participants (mean +/- SD age, 35.6 +/- 10.2 years) were referred from inpatient or outpatient clinics after onset of a manic, mixed, or depressed episode. FFT consisted of 21 sessions of psychoeducation, communication training, and problem-solving skills training. Crisis management consisted of 2 sessions of family education plus crisis intervention sessions as needed. Both protocols lasted 9 months. Patients received pharmacotherapy for 2 study years. Main outcome measures included time to relapse, depressive and manic symptoms, and medication adherence. RESULTS: Rates of study completion did not differ across the FFT (22/31, 71%) and CM groups (43/70, 61%). Patients undergoing FFT had fewer relapses (11/31, 35%) and longer survival intervals (mean +/- SD, 73.5 +/- 28.8 weeks) than patients undergoing CM (38/70, 54%; mean +/- SD, 53.2 +/- 39.6 weeks; hazard ratio, 0.38; 95% confidence interval, 0.20-0.75; P =.003; intent to treat). Patients undergoing FFT showed greater reductions in mood disorder symptoms and better medication adherence during the 2 years than patients undergoing CM. CONCLUSION: Combining family psychoeducation with pharmacotherapy enhances the postepisode symptomatic adjustment and drug adherence of bipolar patients.