Lithium, the first drug treatment used for bipolar disorder, was considered so effective when it was introduced that medication has been the primary focus of bipolar treatment ever since. Relatively little attention has been paid to psychosocial treatments for bipolar disorder, a condition characterized by alternating depression and mania.
While psychotherapy was routinely used during the 20th century, it had little to offer manic patients who suffer from marked impairments in insight, said Holly A. Swartz, M.D., associate professor of psychiatry at the University of Pittsburgh School of Medicine in Pennsylvania.
Writing in the journal Focus, Swartz states, “Toward the end of the 20th century, it became increasingly apparent that medication offered only partial relief from bipolar disorder. Treatment with pharmacologic interventions alone was associated with disappointingly low rates of remission, high rates of recurrence, residual symptoms, and psychosocial impairment.”
But she adds, “Gradually, the field moved from conceptualizing bipolar disorder as a disorder requiring only medication to an illness that, like many chronic disorders, is best treated using a combination of pharmacotherapy and psychotherapy.”
Talk therapies for bipolar disorder, such as cognitive-behavioral therapy, are potentially very useful because the condition involves psychosocial and interpersonal dysfunction, as well as a low rate of adherence to medication.
“Each of these domains is reasonably addressed by psychotherapeutic interventions, especially when delivered in combination with pharmacotherapy,” Swartz writes.
She outlines several clinical trials, beginning in the 1990s, that found evidence that bipolar-specific psychotherapies are effective.
“Contemporary bipolar-specific psychotherapies utilize directive and symptom-focused strategies such as encouragement of medication adherence, provision of psychoeducation, involvement of family members, development of strategies for relapse prevention, exploration of the reciprocal relationship between mood and either cognitions or interpersonal relationships, and establishment of regular sleep-wake cycles,” she explains.
The studies show that, in general, psychotherapy has a bigger impact on depressive symptoms than manic symptoms. This may be because many bipolar disorder psychotherapies were originally developed for treatment of unipolar depression. The researchers say this may also be due to the fact that depressive symptoms are much more common than manic symptoms. So unless patients are specifically recruited on the basis of mania symptoms, clear improvements in mania may not be found.
Nevertheless, one study did suggest that psychotherapies had more of an effect on depressive symptoms even among patients who were recruited to the study in a euthymic state (non-depressed, reasonably positive mood). A further study of Integrated Care Management, which utilizes the strategies of case management with psychotherapy, led to a reduced time in manic or hypomanic episodes, but had no effect on depressive symptoms.
“These studies suggest the possibility that more intensive interventions targeting more severely ill patients may have preferential effects on mania,” writes Swartz.
She adds that “interestingly, there is considerable overlap among the bipolar disorder-specific psychotherapies.” She believes that much of the benefit of psychotherapies is due to “nonspecific factors.” “There are several core strategies that are common to most, if not all, of the efficacious treatments for bipolar disorder,” she writes. These core strategies include psychoeducation and self-rated mood charts.
Swartz concludes, “Psychotherapy, when added to medication for the treatment of bipolar disorder, consistently shows advantages over medication alone.” Those who receive bipolar disorder-specific psychotherapy fare better than those who do not, whether it is delivered in a group or individual format, she adds.
Overall, the evidence suggests that psychotherapy hastens the recovery from depressive episodes, and helps to improve functioning and quality of life. It has low-level risks and “robust” benefits, so should be considered an important component of bipolar disorder illness management.
“How then should a patient decide which bipolar disorder-specific psychotherapy is best for him or her?” asks Swartz. Most reliable trials that compare psychotherapies show little difference between them, “suggesting that any of the bipolar disorder-specific psychotherapies will help.”
She adds that, “Unfortunately, the availability of evidence-based psychotherapy in routine practice settings has not kept pace with the increasing demand for these services,” hence “the choice of treatment may be primarily driven by the availability of trained therapists and preference for individual versus group treatment.”
It may be that a stepped approach for bipolar disorder may be most effective. (That is, short-term interventions delivering the core components of psychotherapy, followed by longer, more specific treatments if necessary.) This could “help the field to allocate efficiently relatively scarce psychotherapy resources, improve outcomes, and ensure that as many people as possible have access to bipolar disorder-specific psychotherapies,” but more studies of this approach are needed, Swartz concludes.
Swartz, H. A. and Swanson, J. Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence. Focus (American Psychiatric Publishing). Summer 2014, Volume 12, issue 3, pp. 251-66.