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Psychotherapy for Bipolar Disorder 
(revised 5/2007; original August 2003)

At least 5 psychotherapy approaches for bipolar disorder have been been shown to be of benefit when added to medications for the treatment of bipolar disorder, compared to medications alone.  This essay will introduce you to each of these psychotherapies and show you some evidence of their success.  

Update 5/2007:
You will find the original 2003 essay below, which includes data on and links to all five approaches.  However, in April 2007 a major research program publish their results testing three out of these five versus a 3-session.education program.  When any of these three were added to mood stabilizer treatment for patients with bipolar disorder experiencing significant depression, patients recovered more quickly and more were likely to stay well.  The three psychotherapies, all of which are described below, were:

• Bipolar-specific Cognitive Behavioral Therapy
• Interpersonal Therapy with Social Rhythm Therapy
• Family-Focused Therapy (for patients with family who could join in treatment)

Here is a link (full text) to this important study, in the Archives of General Psychiatry, April 2007.

The rest of the material originally organized here in 2003 is still very relevant.  See in particular the program called Psychoeducation, which now has very striking five-year follow-up showing a lasting benefit relative to their control treatment.

This is a long essay.  You might want to skip right to the summary.  A briefer overview of this same topic, in medical lingo, was published on Medscape in June 2003; register and then enter this URL :  http://www.medscape.com/viewarticle/457054_1 ).  Or you may skip to a particular technique from the links for the five programs to be discussed: 

None of these bears much resemblance to traditional "psychoanalytic" psychotherapy (the modern version of Freudian technique), which has not been shown to be of use in bipolar disorder.  They are specific approaches developed to address known needs of bipolar patients and families.  As you'll see, all the therapies emphasize similar ingredients:

• Identifying signs of relapse and making plans for early detection and response;
• Using education to increase agreement between doctor, patient and family about what it being treated and why;
• Emphasis on the need to stay on medications even when well;
• Stress management, problem-solving, and focus on improving relationships; and
• Regular daily "rhythms" for sleep, exercise, eating, activities

We will look at each in turn, starting with the simplest.

1. Prodrome Detection: Perry and colleagues (Bipolar I or Bipolar II not specified; emphasis seems on BPI)

In this study, a psychologist "with little previous clinical experience" met with patients up to 12 times (average 9) while the rest of the clinical team proceeded as usual.  She discussed with the patient her/his personal experience of bipolar disorder and the signs preceding manic and depressive episodes in the past.  They planned and rehearsed a plan for action should those symptoms appear again.  The plan was written on a laminated card, carried by the patient.  The therapist helped the patient keep a weekly diary, increasing to daily notes if symptoms were appearing.  She informed the rest of the treatment team (a psychiatrist and mental health worker and primary care physician) of the plan.  That was it, nothing any fancier than that, although it looks like she is a very smart person from the style of the write-up, of which she is the primary author. 

Here are the striking results for prevention of manic episodes (prevention of depression was much less dramatic).  The lines show the total number of patients having some sort of manic recurrence (so, as time goes on, the number grows and grows).  If we watched long enough, and everyone had a relapse of some sort, the line would eventually flatten way up to the right at 1.0, meaning 100% of the patients had finally relapsed.  As you can see, in the control group that didn't get to meet with the psychologist, 50% of the group (the 0.5 line from left to right) had relapsed in some way in about a year).  

By comparison, in the group who met with the psychologist, in one year only about 20% relapsed.  We have to wonder if just anybody could get these results, besides Ms. Perry, but still, it's pretty impressive.  I'm planning on adding some of her tricks, like the card thing, to my approach, based on this result -- for patients who have clearly identifiable "episodes" and pre-episode warning signs.  

2.  Psychoeducation: Colom and colleagues (BPI and BPII)

This research team (including Dr. Vieta, who provided much of the material for this entire essay) added 21 sessions of education about bipolar disorder, in groups of 8-12 patients each, to routine treatment in their clinic.  A control group received 21 sessions of "nonstructured" meetings with the same two therapists, but in these groups, they tried not to teach about bipolar disorder (think about it: this was a very rigorous test of the theory that education itself is the active ingredient in the different outcomes shown below).   

Look at the difference between these groups (this is the same kind of graph as shown above, except in reverse -- it shows the total proportion of patients remaining well, so a curve that falls down more slowly means that more patients are staying well):

 What did these education groups study?  Here is their 21-week topic list:

1. Introduction

2. What is bipolar illness?

3. Causal and triggering factors

4. Symptoms (I): Mania and Hypomania

5. Symptoms (II): Depression and mixed episodes

6. Course and outcome

7. Treatment (I): mood stabilizers

8. Treatment (II): antimanic agents

9. Treatment (III): antidepressants

10. Serum levels: lithium, carbamazepine, valproate

11. Pregnancy and genetic counseling

12. Psychopharmacology vs alternative therapies

13. Risks associated with treatment withdrawal

14. Alcohol and street drugs: risks in bipolar illness

15. Early detection of manic and hypomanic episodes

16. Early detection of depressive and mixed episodes

17. What to do when a new phase is detected?

18. Regularity [presumably similar to "social rhythm therapy" emphasis; see below]

19. Stress management techniques

20. Problem-solving techniques

21. Final session

Over the next 2 years the education group had about one third as many hospitalizations as the control group.As of December 2006, their treatment manual for this program is available in English thanks to diligent work on the translation by Dr. Colom. You can buy it on Amazon.

3. Cognitive Therapy:  Lam and colleagues, 2003  (Bipolar I)

This technique was introduced in 1996 by Drs. Basco and Rush (Ph.D. and M.D. respectively) in their book Cognitive Therapy for Bipolar Disorder.   For psychologists seeking training in this method -- or patients and families seeking the most thorough treatment possible and willing to teach their therapists while both patient and therapist learn by working through the a training manual -- another more recent book describes the technique used by the authors of the largest research study of this method:  Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice, by Dominic Lam and colleagues.

They too have shown a strikingly lower relapse rate in patients who had 14 sessions of this therapy added to their regular treatment.  Note that this is not quite as rigorous a test as the PsychoEducation method above, since the control group here is getting no additional treatment, whereas Colom and colleagues conducted an identical group for the controls, without the education.  Thus there is a chance that the improvement we're seeing here is simply due to 14 sessions with skilled, caring therapists, and not necessarily due to the treatment described in their book.  However, in any case, the results are still impressive:  

Again the results are shown as a total number of patients remaining well, so the slower decrease in the treatment group (green) means more patients are staying well longer with the additional treatment. 

Here are some of the main focus points in this therapy (from an excellent summary by Otto and colleagues): 

The Harvard program makes extensive use of written plans, with a separate "treatment contract" for each of the following:  

1. Building a Support team

2. Depressive Symptoms

3. Personal Triggers of Depression

4. Coping with Depression

5. Personal Triggers of Mood Elevation

6. Mood Elevation Symptoms

7. Coping with Mood Elevation

8. Agreement

For details of the treatment contract, see the Harvard Bipolar Research website, www.manicdepressive.org.   They also share all their tools, including their monitoring forms. 

There is even a free, online CBT for depression that is worth looking at if you can't find a good, live CBT therapist. 

4.  Interpersonal and Social Rhythm Therapy (IPSRT) :  Frank and colleagues  (BP subtype not specified)

The data supporting this method are not as strong for the other methods described in this essay.  We will skip quickly on to another method which incorporates this approach.  Professionals may recognize the following graph from the 1999 publication by Frank et al, which primarily shows that if you start with one method, be it IPSRT or regular clinical management with interpersonal therapy (ICM), you're better off if you stick with it:

5. Family-Focused Therapy (FFT) and Integrated FFT/IPSRT: Miklowitz and colleagues (BP I and BPII)

As far back as 1990, Dr. Miklowitz and his research team at the University of Colorado were at work adapting a Behavioral Family Management technique, previously studied in patients with schizophrenia and their families, to bipolar disorder.^Miklowitz 

How does Family-Focused Therapy work?  As described in his book by that title (1997), FFT includes:

• the same kind of "psychoeducation" found in method #2 above;

• a "relapse drill" similar to method # 1 above; and

• ways to make the diagnosis easier to accept, a big part of the cognitive method #3 above.

However, this therapy also includes the family in a major way, which is not a feature of any of the above approaches.  In addition to involving family members in all the steps just listed, it also focuses on communication within the family, teaches communication skills, and prepares the entire family for relapse episodes so that all members (not just the patient) have a plan for what to do when symptoms start to reappear. 

In the research studies below, this method consisted of 21 therapy sessions over 9 months.  Using this technique, his team reduced relapse rates in patients who'd been hospitalized for mania.^{Rea 2003}   Another study using this method was published in 2000^Miklowitz(c) with the following results:

As before, this shows the total number of patients staying well.  Over a year, many relapse, but the treatment group (red line) does so more slowly.  Unlike previous methods, this one shows the same pattern but for depressive relapse, which has been more difficult to address in most of the studies shown here (the PsychoEducation method is an exception, also showing as much or more benefit in preventing depressive relapse). 

Like almost all the others, this therapy also focuses on the importance of "adherence" -- staying on medications -- and showed a specific benefit there (it's a little unnerving to note that the control patients, shown below in yellow, were not taking medications as directed half the time, and that even when improved by treatment, shown in red, that was still a problem 25% of the time): 

I hope, my readers, if you're still with me here, that you're already seeing the main point:  all these treatment have common ingredients.  As a final demonstration of that point, here are results Dr. Miklowitz and his team obtained when they combined FFT with IPSRT.  IFIT is the combined therapy, in red; the comparison group received treatment as usual plus 2 family education sessions and crisis management (CM): 

Summary

1. All five treatments shown here have solid evidence demonstrating their effectiveness (for the moment, no other psychotherapies have this and to my knowledge, no others are being researched in this way).

2. Most have a strong education component.

3. Most emphasize looking for, and planning for, signs of relapse.

4. Most include some way of looking at "illness acceptance", including what's getting in the way of that.

5. Several include some emphasis on regular rhythms of sleep and activity.

6. One emphasizes involving the family very directly.
   
   (Some are more intensive (time, energy, and presumably money) than others. )

Remaining Questions, and Implications

A. Which therapy is best?
To answer this properly, with the same kind of emphasis on evidence, will take additional research.  Since these studies cost a lot and take years of work, I doubt we'll see "head-to-head" comparisons (we don't have that for many medications, either).  For now it looks simpler to conclude that they all have some merit and that elements of each, at minimum the simpler ones, should be part of a treatment package that most patients with bipolar disorder receive. 

Unfortunately, at least in my area, money problems are driving treatment programs in the opposite direction (e.g public mental health programs).  So once again I think it may be up to people like you, who have managed to read all the way to this point, to get these treatments for yourself or your family member. 

You can buy the books and teach yourself from them (here they are again with a link to Amazon.com so you can see more about each -- but watch out for getting sucked into buying something you didn't need while you're there!)

#1.  Prodrome Detection -- no manual for this to my knowledge (the paper is linked in full text though)

#2. PsychoEducation  -- the manual is now available in English: The Psychoeducation Manual for Bipolar Disorder. This is a remarkable text.  It details each of the 20 sessions from a group leader's point of view, including tips on opening the session, specific tools used in each session, things to watch out for in that particular session -- and all with a very amusing sense of humor.

#3. Cognitive Therapy for Bipolar Disorder
    Do you like to learn from the version written for patients? 
    Update 12/2007: I just bought this, but I think this might be a great way to get started
        The Bipolar Workbook: Tools for Controlling Your Mood Swings by Monica Basco

    Dr. Basco is one of the originators of bipolar-specific CBT, as evidenced by her comprehensive book on the subject: 
        Cognitive Therapy for Bipolar Disorder by Basco and Rush

    There is also a textbook from another research team whose results were presented above, Dr. Lam and colleagues: 
    Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice

#4. IPSRT -- this treatment approach is described by Ellen Frank, one of the developers of this method, in her book entitled Treating Bipolar Disorder.  There is no other treatment manual available to my knowledge.  Here is a review of the book.

#5. FFT
   Bipolar Disorder: Family-Focused Treatment Approach (for therapists) 
  The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (for patients and families)

Perhaps you can recruit some local therapist -- one that your insurance might pay for; and one that may be easier to find than a psychiatrist who knows and is willing/able to use all this stuff -- to work through the book with you. (This may be a pie-in-the-sky idea, I should warn you.  I learned some methods this way, but I'm not sure it's typical of what other therapists do). 

B. Is there one therapy that is better for bipolar II?
Some of the research did not include Bipolar II patients, and none focused on this subtype.  The emphasis of most methods on relapse prevention is, I presume, a reflection of an emphasis on Bipolar I, as most of my patients with Bipolar II do not have discrete "episodes" in the fashion these methods are designed to detect. 

However, in my experience, the emphasis on regular rhythms; on stress reduction; on involving the family; and on education about bipolar disorder, are all very appropriate for bipolar II.  Based on the research shown here, I would expect that a study with only bipolar II patients would show positive results. 

C. Does this mean that all patients with bipolar disorder should have one of these psychotherapies? 
I hope you've been thinking "hey, this website is "psychoeducation" and so you've already been getting some!  Beyond that,  if you look at the summary, you'll see that all these elements are appropriate to any treatment.  However, I believe they should be individualized, so that some patients would notice an emphasis more on one than another. 

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