Lifting the burden of bipolar disorder: The role of psychotherapies

Bipolar disorder is a severe, chronic and recurrent condition that can be linked to impairment in psychosocial functioning, even during periods of remission. Bipolar patients are frequently treated solely with pharmacotherapy; however, this strategy is not always effective in preventing further relapses and in decreasing morbidity, especially when illness awareness is reduced and medication adherence is compromised (Vieta, 2014). Adjunctive psychosocial interventions can be useful bridging this gap.

Early research on psychotherapy in bipolar disorder dates back to the early 1980s, but some of these studies lacked well-designed, blinded, randomized controlled designs. However, research into psychological interventions for bipolar disorder has progressed considerably over the last two decades. The majority of psychosocial studies that were adjunctive to medication report favorable results regarding reduction of episodes, mood symptoms and episode length (Reinares et al., 2014). Key elements include enhancing the patient’s therapeutic adherence and illness awareness, promoting an active attitude to treatment and a focus on improving quality of life and functioning. Nevertheless, it has to be noted that methodological differences regarding patient characteristics, the target clinical population for psychotherapy and follow-up periods impede study comparability. There is little evidence that any particular therapy has a unique mechanism of action or any specific advantages over any other approach. There is preliminary support for the notion that the best candidates for most psychological therapies may be those with relatively few previous episodes, those who are assessed as being at above-average risk of a further relapse, who are not taking medication or where there is potential ineffectiveness of prescribed medication (Reinares et al., 2014).

Regardless of the diversity of psychosocial interventions, there is substantial convergent validity for the importance of a collaborative approach to illness management that includes education about the illness, identification of patient-specific symptom patterns and development of action plans for responding to early warning signs of relapse. Despite the well-documented efficacy of adjunctive psychotherapy for bipolar disorder, it is still an underutilized treatment option, as illustrated by a recent study in this Journal (Sylvia et al., 2015). This study aimed to examine the characteristics of bipolar patients who sought psychotherapy versus those who did not. Only 31% of the patients reported having used psychotherapy services. Patients who received psychotherapy had greater medication side effects, higher overall bipolar illness severity and a higher prevalence of reported suicide risk. It appears that more impaired people are more likely to actively seek psychotherapy. The authors suggest that there remains a need for further systematic clinical research on psychotherapy in bipolar disorder in order to clarify its true usefulness and that further research focusing on making the interventions sustainable in general clinical practice should be a priority.

Efforts to further improve the utility of psychotherapy to augment the benefits provided by current optimal pharmacological treatment regimens will require a renewed focus on particular clinical uncertainties such as (1) to clarify which, if any, sub-populations may be most likely to benefit from a specific psychotherapeutic approach; (2) what is the best timing to implement them and how long should treatments last; (3) to elucidate whether or not there exists a relative aggregate advantage of one psychosocial approach over another; (4) to identify specific treatment components for particular phases of the bipolar illness course, for example, to test whether psychotherapy serves as a preventative agent in the early stages of the disorder; (5) and finally, to attempt to classify the interventions according to their ability to prevent manic versus depressive episodes.

In sum, the next generation of psychotherapeutic studies should focus on methodological improvement. Recent studies seem to favor group formats, which may be pragmatically sensible and in line with economic constraints and may allow peer-to-peer interaction (Torrent et al., 2013). The finding by Sylvia et al. (2015) that patients who seek psychotherapy may be those who are the most functionally impaired is noteworthy; it may also be influenced by triaging and prioritization by public healthcare services. However, this practice highlights the contradiction that therapies may work better if provided in the early stages. Effective prevention of illness morbidity and progression is crucial, and this suggests that further effort to implement psychotherapy at the earliest stages of bipolar disorder is necessary. There is also a clear need to reconcile prevention and remediation strategies (Popovic et al., 2014). Complicating this, people in the early stages of a bipolar illness might not have enough illness awareness and acceptance to seek psychotherapy, despite the fact that its efficacy may be better at that particular stage highlighting the particular need to target these factors. Conversely, people who have relapsed repeatedly and who may be particularly functionally impaired may have enough illness awareness to seek psychological support. Unfortunately, the array of available interventions for them is much more limited, although emerging evidence suggests cognitive and functional remediation may help.

See Research by Sylvia et al., 49(5): 453–461.