Adjunctive Psychotherapy for Bipolar Disorder: State of the Evidence

Department of Psychology, University of Colorado, Boulder, CO 80309-0345, USA.
American Journal of Psychiatry (Impact Factor: 12.3). 10/2008; 165(11):1408-19. DOI: 10.1176/appi.ajp.2008.08040488
Source: PubMed


Psychotherapy has long been recommended as adjunctive to pharmacotherapy for bipolar disorder, but it is unclear which interventions are effective for which patients, over what intervals, and for what domains of outcome. This article reviews randomized trials of adjunctive psychotherapy for bipolar disorder.
Eighteen trials of individual and group psychoeducation, systematic care, family therapy, interpersonal therapy, and cognitive-behavioral therapy are described. Relevant outcome variables include time to recovery, recurrence, duration of episodes, symptom severity, and psychosocial functioning.
The effects of the treatment modalities varied according to the clinical condition of patients at the time of random assignment and the polarity of symptoms at follow-up. Family therapy, interpersonal therapy, and systematic care appeared to be most effective in preventing recurrences when initiated after an acute episode, whereas cognitive-behavioral therapy and group psychoeducation appeared to be most effective when initiated during a period of recovery. Individual psychoeducational and systematic care programs were more effective for manic than depressive symptoms, whereas family therapy and cognitive-behavioral therapy were more effective for depressive than manic symptoms.
Adjunctive psychotherapy enhances the symptomatic and functional outcomes of bipolar disorder over 2-year periods. The various modalities differ in content, structure, and associated mediating mechanisms. Treatments that emphasize medication adherence and early recognition of mood symptoms have stronger effects on mania, whereas treatments that emphasize cognitive and interpersonal coping strategies have stronger effects on depression. The placement of psychotherapy within chronic care algorithms and its role as a preventative agent in the early stages of the disorder deserve investigation.

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    • "Interpersonal and social rhythm therapy (IPSRT) is an empirically supported psychotherapy that combines a focus on interpersonal relationships with behavioral interventions designed to regulate timing of daily routines (Frank 2005a). IPSRT has demonstrated efficacy an adjunct to pharmacotherapy for the management of mood disorders (Miklowitz et al. 2008). Treatment with IPSRT is associated with reduced time to recovery from an episode of depression (Miklowitz et al. 2007) and improved psychosocial and occupational functioning (Frank et al. 2008) among patients "
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    ABSTRACT: Background: Telephone-administered psychotherapies (T-P) provided as an adjunct to antidepressant medication may improve response rates in major depressive disorder (MDD). The goal of this study was to compare telephone-administered social rhythm therapy (T-SRT) and telephone-administered intensive clinical management (T-ICM) as adjuncts to antidepressant medication for MDD. A secondary goal was to compare T-P with Treatment as Usual (TAU) as adjunctive treatment to medication for MDD. METHODS: 221 adult out-patients with MDD, currently depressed, were randomly assigned to 8 sessions of weekly T-SRT (n=110) or T-ICM (n=111), administered as an adjunct to agomelatine. Both psychotherapies were administered entirely by telephone, by trained psychologists who were blind to other aspects of treatment. The 221 patients were a posteriori matched with 221 depressed outpatients receiving TAU (controls). The primary outcome measure was the percentage of responders at 8 weeks post-treatment. RESULTS: No significant differences were found between T-SRT and T-ICM. But T-P was associated with higher response rates (65.4% vs 54.8%, p=0.02) and a trend toward higher remission rates (33.2% vs 25.1%; p=0.06) compared to TAU. LIMITATIONS: Short term study. CONCLUSIONS: This study is the first assessing the short-term effects of an add-on, brief, telephone-administered psychotherapy in depressed patients treated with antidepressant medication. Eight sessions of weekly telephone-delivered psychotherapy as an adjunct to antidepressant medication resulted in improved response rates relative to medication alone.
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    • "The treatment of BD focuses on stabilizing acute mood episodes and preventing relapse when euthymia is established. To this end, pharmacotherapy has generally been the main treatment strategy, but over the last decade, the additional value of psychotherapeutic interventions in the treatment of bipolar patients has become increasingly evident [3] [4]. Evidence based psychotherapies for BD are psycho-education (preferably with a significant other), family focused therapy (FFT), interpersonal social rhythm therapy (IPSRT) and cognitive behavioral therapy (CBT) [5]. "
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    ABSTRACT: Bipolar disorder (BD) is a chronic illness, and a great need has been expressed to elucidate factors affecting the course of the disease. Social support is one of the psychosocial factors that is assumed to play an important role in the course of BD, but it is largely unknown whether the depressive and/or manic symptoms also affect the patients' support system. Further, the perception of one's social support appears to have stronger effects on disease outcomes than one's enacted or received support, but whether this also applies to BD has not been investigated. The objective of this study is to examine temporal, bidirectional associations between mood states (depression and mania) and both enacted and perceived support in BD patients. The current study was conducted among 173 BD I and II outpatients, with overall light to mild mood symptoms. Severity of mood symptoms and social support (enacted as well as perceived) were assessed every 3months, for 2years (1146 data points). Multilevel regression analyses (linear mixed-models) showed that lower perceived support during 3months was associated with subsequent higher levels of depressive, but not of manic symptoms in the following 3months. Vice versa, depressive symptoms during 3months were associated with less perceived support in the following 3months. Further, manic symptoms during 3months were associated with less enacted support in the subsequent 3 months. The current study suggests that perceived, but not enacted, support is consistently related to depressive symptoms in a bidirectional way, while mania is specifically associated with a subsequent loss of enacted support. Clinical implications of the current findings are discussed. Copyright © 2015. Published by Elsevier Inc.
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    • "Furthermore, epidemiological studies report that many bipolar disorder patients are not receiving adequate medication for their condition (Mitchell et al., 2013) often due to poor adherence. A large body of evidence now exists demonstrating the efficacy of several forms of psychological intervention adjunctive to medications in patients with bipolar disorder (Miklowitz, 2008). The Internet provides one possible path for disseminating these targeted and standardized interventions, due to its accessibility, versatility and capacity to assist individuals who do not seek help, and provides a feasible means for increasing the rate of those with bipolar disorder receiving evidence-based psychological interventions. "
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    ABSTRACT: The Internet is used to deliver information on many psychiatric disorders such as bipolar disorder. This paper reports on the results of a 12-months randomised controlled trial, which examined the efficacy of an Internet-based preventive program for bipolar disorder, adjunctive to usual pharmacological management. Participants were recruited by completing an online screening questionnaire accessed through the Black Dog Institute and Sentiens websites based in Australia. The treatment was predominantly psycho-educational with cognitive behavioral therapy optional elements. The attention control treatment comprised directing subjects to a variety of websites focused on 'healthy living'. Time to recurrence was determined using Kaplan-Meier survival analysis. The main outcome measures were recurrence as defined by: (i) depressive and/or hypomanic symptomatology and functional capacity (using Beck Depression Inventory, Internal State Scale and Sheehan Disability Scale) and (ii) hospitalization. Two-hundred-and-thirty-three subjects were randomized to the active or control treatment groups. There were no significant differences between the active and control treatment groups on any of the definitions of recurrence. Reliance on an online self-report tool to confirm diagnosis and hospitalization rates may have potentially allowed for inclusion of individuals with other diagnoses such as borderline personality disorder. The 'attention control' treatment may have included more 'active' components than intended. This is the first report examining the efficacy of a randomized controlled web-based psychological intervention in a large sample of subjects with bipolar disorder. The potential reasons for failing to demonstrate a significant difference compared to the active control are discussed. Copyright © 2014 Elsevier B.V. All rights reserved.
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