Psychosocial Interventions for Bipolar Disorder

Psychosocial I
Bipolar

Jenifer L. C

Stanford

Interventions for
Disorder

Culver, PhD

University

“At this point in my existence, I
normal life without both taking l
benefit of psychotherapy. Lithiu
disastrous highs, diminishes my
wool and webbing from my diso
from ruining my career and rela
hospital, alive, and makes psych
ineffably, psychotherapy heals.
confusion, reins in the terrifying
some control and hope and poss
But, always, it is where I have b
believe – that I might someday
this.”

cannot imagine leading a
lithium and having had the
um prevents my seductive but
y depressions, clears out the
ordered thinking…keeps me
ationships, keeps me out of
hotherapy possible. But,
It makes some sense of the
g thoughts and feelings, returns
sibility of learning from it all…
believed – or have learned to
be able to contend with all of

Kay Jamison

An Unquiet Mind

2

Treatment of B

• Basic goals of treatm

– Alleviate acute mood
– Restore psychosocia
– Prevent relapse of m

• Psychopharmacology
treatment

• Relapse and subsynd
may occur even with
treatment

Bipolar Disorder

ment:

d symptoms
al functioning
mood episodes

gy as foundation of

ndromal symptoms
h optimal medication

3

Targets of P
Interventions in

• Psychoeducation abou
its treatment

• Medication understand
• Social and work functi
• Recognition of early w

early intervention
• Reduce impact of psyc

related to relapse

Psychosocial
Bipolar Disorder

ut bipolar disorder and

ding and adherence
ioning
warning symptoms and

chosocial factors

4

Evidence-Base
Treatments for B

• Psychoeducation
• Family-focused the
• Interpersonal and s
• Cognitive-behavior

*Zaretsky A. Bipolar Disord. 2003;5:80-87.

ed Psychosocial
Bipolar Disorder

erapy
social rhythm therapy
ral therapy

5

Psychoe

• Provides informatio
disorder and treatm

• Teaches early-warn
recognition and cop
relapse

• Individual, group, or

• Key element across
psychotherapies for

education

on about bipolar
ment

ning symptom
ping skills to prevent

r family formats

s all evidence-based
r bipolar disorder

6

Effects of Psy

Results from controlled

• Longer time to manic relap
• Increased knowledge of a

pharmacotherapy2
• Fewer hospitalizations,3,4
• Fewer relapsed patients, f

patient4
• Longer time to depressive

mixed recurrence4

1Perry A, et al. BMJ. 1999;318:149-152; 2Peet M
200; 3Cochran SD. J Consult Clin Psychol. 1984
Psychiatry. 2003;60:402-407; 5Colom F, et al. Bip

ychoeducation

studies:

apse, fewer manic relapses1
and improved attitude toward

shorter hospitalizations4,5
fewer recurrences per

e, manic, hypomanic, and

M, Harvey NS. Br J Psychiatry. 1991;158:197- 7
4;52:873-878; 4Colom F, et al. Arch Gen
ipolar Disord. 2004;6:294-298.

Psychoeducatio
Adjunctive Maint

% of Patients Remaining Well 100

Psyc

• Tim
80 • Num

• Num

60

40

N=120
20 P<.003

0 6 12
0

Time to Recurren

Colom F, et al. Arch Gen Psychiatry. 2003;60:40

on Is an Effective
tenance Therapy

choeducation Superior to Control for:

me to recurrence (graph)
mber of relapsed patients
mber of recurrences/patient

18 21-week
Psychoeducation
nce (months) Group

21-week
Nonstructured
Group

24

02-407. 8

Family Tr

• High expressed emotio
increased risk of relap
in bipolar disorder1

• Miklowitz and colleagu
focused therapy, which
in schizophrenia, for u

1Miklowitz DJ, et al. Psychopharmacol Bull. 1986
1990;18:17-28; 3Clarkin JF, et al. Psychiatr Serv
J Affect Disord. 1991;21:15-18;

reatments

ion is associated with
pse and poor outcomes

ues adapted family-
ch has been successful
use in bipolar disorder

6;22:628-632; 2Clarkin JF, et al. J Affect Disord.
v. 1998;49:531-533; 4van Gent EM & Zwart FM.

9

Family-Focus

• Assessment of family
• Psychoeducation abou

(symptoms, early reco
treatment, self-manag
• Communication skills t
rehearsal of effective s
strategies)
• Problem-solving skills

Miklowitz DJ, Goldstein MJ. Bipolar Disorder: A
Guilford Press; 1997.

sed Treatment

or couple
ut bipolar disorder
ognition, etiology,
gement)
training (behavioral
speaking and listening

training

Family-Focused Treatment Approach. New York:

10

FFT + Medication Dela
Crisis Managemen

1.0

Cumulative Survival Rate 0.8

0.6

0.4

0.2 FFT + medication
CM + medication
0.0
0 10 20 30 40

Weeks

Mean survival = FFT, 73.5 weeks; CM, 53.2 wee
Miklowitz DJ, et al. Arch Gen Psychiatry. 2003;60

ays Relapse More Than
nt (CM) + Medication

(N=101)
p = .003

n

50 60 70 80 90 100 110

s of Follow-up

eks. 11
0:904-912.

Interpersonal an
Therapy

• Integrates:

– Psychoeducation

– Social rhythm therap
rhythms (eg, sleep, s
modifying routines

– Interpersonal psycho
quality of interperson
satisfaction with soci

nd Social Rhythm
(IPSRT)

py – to regulate social
social) by monitoring and

otherapy – to improve
nal relationships and
ial roles

12

Social Rhythm Metric ScoreIPSRT Increases
Rhythms O

6

5

4

3

2
0 10 20 30
Weeks

ICM = intensive clinical management.
Frank E, et al. Biol Psychiatry. 1997;41:1165-117

Stability of Social
Over Time

P=.006 IPSRT
(n=18)

ICM
(n=20)

40 50 60 70 80 13
ks of Treatment

73.

Cognitive Beha

• Psychoeducation
• Enhancing Medication C
• Monitoring of mood and
• Monitor behavior to prev

(e.g., routine and sleep)
• Challenge thoughts and

mood disturbance
• Dealing with long-term v

Lam DH, et al. Arch Gen Psychiatry. 2003;60:14

avioral Therapy

Compliance 14
d early warning signs
vent mood escalation
)
d beliefs contributing to

vulnerability issues

45-152.

CBT Effective for B
and Relapse

• In early controlled stud
(vs meds alone) yielde

– Fewer

• Relapses1,2
• Hospitalizations2,3
• Subsyndromal fluctua

– Improved

• Medication adherence
• Global functioning1
• Social functioning2
• Coping with depressio

1Scott J, et al. Psychol Med. 2001;31:459-467; 2L
503-520; 3Cochran SD. J Consult Clin Psychol. 1

Bipolar Depression
e Prevention

dies, CBT plus meds
ed:

ations2 15

e1,2

on and mania prodromes2

Lam DH, et al. Cognit Ther Res. 2000;24:
1984;52:873-878.

Adjunctiv
Enhanced Outcome

60

% of Patients With Events 50

40

30

20

10

0 Mania

Depression (P<.002)

(P<.001)

Lam DH, et al. Arch Gen Psychiatry. 2003;60:145

ve CBT
es Over 12 Months

CBT + medication
management

Medication
management

Mixed Admission

5-152. (P<.003)

16

Mean Days in Episode Adjunctive CB
Days in Bipo

End of

45

40

35 CBT + medica
management

30 Medication ma

25

P<.01

20

15

10

5
0

Intention to Treat

Lam DH, et al. Arch Gen Psychiatry. 2003;60:145

BT Decreases
olar Episodes

f therapy

ation CBT group had
anagement fewer days in bipolar
episodes (p<.01)
even after covarying
for number of
previous episodes.

5-152. 17

Future D
Dialectical Beh

• Skills Modules

– Distress Tolerance
– Emotion Regulation
– Interpersonal Effectiv

• Format of group

– Lecture
– Didactic discussion
– Homework
– Mood monitoring

Directions:
havior Therapy?

veness

18

Stanford DBT

• Retrospective chart re
receiving DBT skills gr

– Decreased

• Days with sadness
• Days with anhedoni
• Severity of anhedon
• Distractibility

– Increased:

• GAF scores

Culver et al. (2005)

T Skills Group

eview (n=16) of patients
roup at Stanford:

ia
nia

19

Which T

• Almost all studies sho
psychosocial intervent

• No definitive evidence

• Therapies overlap in t

• Treatment choice influ

– Patient choice
– Availability of therapist
– Individual characteristic

Therapy?

owed some benefit of
tions
e comparing key therapies
targets for change
uenced by:

t
ics

20

Where to

• Psychoeducation

– Consider asking your
therapist and/or
psychiatrist for more
education about the
disorder

– Read structured
psychoeducational
materials

to Start?

21

Where to

• Monitoring of mood sym

– NIMH Lifechart availab
www.bipolarnews.org
(click on “Lifecharting”)

• Plan for early interventio

– Work with your therapis
develop a plan to help y
warning symptoms and

to Start?

mptoms

ble online at:
g
)

on

st and/or psychiatrist to
you recognize early
d take action

22



23



24

Conclu

• Even with optimal pharm
with bipolar disorder ma
symptoms and/or proble
functioning

• Adjunctive psychosocial
clinical outcomes and ps

• Structured, evidence-ba
helpful even when mood

usions

macotherapy, individuals
ay have subsyndromal
ems with psychosocial

l treatments can improve
sychosocial functioning
ased therapy can be
d is stable

25