The depressive phase of bipolar disorder is particularly difficult to treat. Pharmacologic strategies for bipolar depression are often inadequate. We therefore review the literature on the role of psychotherapy as an adjunct to medication in the treatment of bipolar depression.
With one exception, there are no descriptions of psychotherapies employed specifically for the treatment of bipolar depression. We therefore reviewed published reports of psychotherapy for bipolar disorder in general and extracted from these reports relevant data or impressions about the specific effects of the therapies on the depressive phase of the disorder.
Described psychosocial approaches to bipolar disorder include psychoeducation, group therapy, cognitive-behavioral therapy, couples therapy, family therapy, and interpersonal psychotherapy. Only cognitive-behavioral therapy has been tested in a pilot study for the treatment of bipolar depression specifically. Results from randomized controlled trials of family therapy and interpersonal and social rhythm therapy suggest that these treatments may be more efficacious in the treatment and prevention of depression relative to mania.
A limited number of well-designed studies and preponderance of case reports limit definitive conclusions about the role of psychotherapy in the treatment of bipolar depression. However, converging reports suggest that cognitive-behavioral therapy, family therapy, and interpersonal and social rhythm therapy may be particularly useful for bipolar depression. We propose a novel approach to the treatment of bipolar disorder that includes the use of phase-specific sequenced psychotherapies delivered in variable patterns and linked to fluctuating mood states.
"Indeed, despite relative effectiveness in a majority of patients, pharmacological treatments are insufficient on a functional level, as well as on residual depressive, dysthymic and dysphoric symptoms (Tohen et al., 2000; Huxley and Baldessarini, 2007). Consequently, in parallel with pharmacological progress, psychosocial interventions have recently undergone great development (Swartz and Frank, 2001; Zaretsky, 2003; Colom and Vieta, 2004; Miklowitz, 2008). Most of these interventions target emotional and cognitive processes in order to improve adaptive processes and reach functional recovery (Honig et al., 1997; Bernhard et al., 2006). "
[Show abstract][Hide abstract] ABSTRACT: Bipolar disorders (BD) are mainly characterized by emotional and cognitive processing impairment. The cerebral substrate explaining BD impairment and the action mechanisms of therapies are not completely understood, especially for psychosocial interventions. This fMRI study aims at assessing cerebral correlates of euthymic bipolar patients (EBP) before and after psychoeducation therapy. Sixteen EBP and 16 matched healthy subjects (HS) performed a word-face emotional Stroop task in two separate fMRI sessions at 3-month interval. Between fMRI sessions, EBP underwent psychoeducation. Before psychoeducation, the comparison of EBP vs. HS in fMRI data revealed (a) significant decreased activity of cognitive control regions such as bilateral inferior and left superior frontal gyri, right insula, right fusiform gyrus and bilateral occipital gyri and (b) significant increased activity of emotion-related processing regions such as bilateral hippocampus, parahippocampal gyri and the left middle temporal gyrus. After psychoeducation, EBP showed significant clinical improvement, increased activity of inferior frontal gyri and a tendency toward decreased activity of right hippocampus and parahippocampal gyrus. These results suggest that the imbalance between cognitive control and emotion processing systems characterizing BD acute episodes may persist during euthymic periods. Moreover, this imbalance may be improved by psychoeducation, which enhances the cognitive control and modulates emotional fluctuations in EBP.
"Cohen and colleagues  also found that perceived social support from a best friend, parent, and romantic partner independently predicted depressive, but not manic, episode recurrence. In addition, psychosocial interventions such as family therapy and interpersonal and social rhythm therapy tend to be more efficacious in the treatment and prevention of depression relative to mania . These considerations assume that the participants in this study had supportive marriages despite the increased risk for marital problems that exists when one partner has bipolar disorder. "
[Show abstract][Hide abstract] ABSTRACT: Despite the importance of marriage as a source of social support, it has been largely neglected in studies of bipolar disorder; and differential effects on men and women have not been explored.
Data on episodes of depression, mania, and mixed states were collected for the previous 2 years from a sample of 282 bipolar individuals using the National Institute of Mental Health Life Chart Methodology.
Effects unique to women included the following: Bipolar women were significantly more likely to be married. Married women had fewer episodes of depression during the past 2 years than never-married women, and the cumulative severity of depression was lower. There were no differences in diagnostic subtype or age of onset between married and never-married women. Among men, never-married men were more likely to have bipolar I disorder and had an earlier age of onset compared with married men. There were no differences between married and never-married men in frequency, duration, or severity of mood episodes.
Partner selection processes as they relate to bipolar disorder may be different for men and women. The bipolar I diagnostic subtype and early age of onset were associated with a lower likelihood of being married for men, but not for women. Marriage was associated with less depression in women during a 2-year period; but marital status was not associated with disease course differences in men, suggesting that women may be more sensitive to the positive effects of social support available within a stable marital relationship.
"In all of these trials, psychotherapeutic approach was investigated as adjunctive to pharmacotherapy. Psychotherapeutic interventions in bipolar disorder were found to have some effects on depressive symptoms (Swartz and Frank, 2001; Miklowitz et al., 2007) and reported positive results in maintenance treatment when used as adjunctive to pharmacotherapy (Perlis and Keck, 2005). Some psychosocial therapies were started immediately after acute mood episodes (Miklowitz et al., 2003; Miller et al., 2004; Simon et al., 2006). "
[Show abstract][Hide abstract] ABSTRACT: Aim of this systematic review was critical presentation of psychosocial approaches in bipolar disorders with regard to their fundamentals and impact on the clinical course and outcome of the illness.
PubMed, Medline, PsycINFO and Turkish databases between 1980 and 2009 were searched by using keywords "bipolar disorder" and "psychotherapy", "psychosocial approaches", "psychological intervention". Randomized controlled trials, reviews and meta analysis were included.
Fifty studies met the inclusion criteria where four types of interventions -psychoeducation, family focused, cognitive behavioral and interpersonal psychosocial rhythm therapy-were studied. Twenty two of 24 original research papers were randomized controlled trials, 23 were reviews and 3 were meta analysis. In almost all studies psychotherapeutic approach was applied as adjunctive to pharmacotherapy. Group psychoeducation was more effective in preventing manic relapses, whereas cognitive behavioral and family focused therapies showed efficacy in preventing depressive episodes. Additional benefits on such secondary outcomes as medication compliance, number and duration of hospitalizations, time to recurrence were reported. Effects on functionality and quality of life were assessed rarely, but reported to be beneficial. Cultural adaptation studies are scarce and needs exploration.
Psychosocial interventions adjunctive to pharmacotherapy in bipolar disorder seem to be effective in relapse prevention. Stage of illness where the therapy is initiated and the targeted episode for prevention varies between interventions. Future studies are needed to strengthen the place of psychosocial interventions in treatment guidelines and would contribute to narrow the gap between effectiveness of pharmacotherapy and functional improvement.
Turk psikiyatri dergisi = Turkish journal of psychiatry 06/2010; 21(2):143-54. DOI:10.5080/u6157 · 0.43 Impact Factor
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