Michael E. Thase, MD Bipolar affective disorder is commonly thought of as the most "biological" form of mood disorder and, perhaps for this reason, the role of psychotherapy historically has received relatively short shrift.[1] However, several factors came together in the 1990s that fueled a renewed interest in examining the role of psychotherapy in bipolar affective disorder, particularly if used in combination with pharmacotherapy.[1-3] Perhaps of greatest importance, there was a recognition that even medications with well-established preventive efficacy, such as lithium salts, often failed to protect patients from relapse and recurrence.[4,5] Other research established that psychosocial risk factors, including inadequate social support, adverse life events, and medication nonadherence, were often linked to the relapse risk.[6-8] It was proposed that psychosocial interventions that targeted these risk factors could have the potential to complement the effects of pharmacotherapy. Although development of even more effective and better-tolerated pharmacotherapies remained a high public health priority, the time is ripe to evaluate the utility of focused forms of psychotherapy in combination with the existing standard medications.
It was not necessary to develop psychotherapies for bipolar disorder from scratch. Drawing upon research conducted in patients with schizophrenia, therapies focusing on improving family support and psychoeducation were available.[9-11] Likewise, in the area of nonbipolar depression, there were well-developed, procedurally specified interventions that focused on cognitive, behavioral, and interpersonal aspects of depression.[12,13] Thus, in relatively short order, manuals for psychoeducational,[14] family-dyadic,[15] cognitive-behavioral,[16] and interpersonal[17] models of treatment for bipolar affective disorder were developed. A number of studies evaluating these therapies now have been completed and, in the following sections, the evidence pertaining to each of these models will be examined.
Randomized controlled trials (RCTs) have been completed evaluating 4 forms of psychotherapy for adjunctive treatment of bipolar disorder. These empirically validated interventions include: (1) psychoeducation, (2) cognitive behavioral therapy (CBT), (3) family focused therapy (FFT), and (4) interpersonal and social rhythm therapy (IPSRT). Despite some conceptual and procedural overlap, these interventions differ with respect to the frequency and duration of sessions and use of specific interventions. Thus, although all 4 interventions might be expected to capitalize on similar nonspecific therapeutic ingredients, they also might be expected to differentially affect selected aspects of bipolar illness.
The first study of psychoeducation was conducted by Perry and colleagues.[18] These investigators evaluated the impact of 7 to 12 individual psychoeducational sessions addressing medication adherence, early recognition of prodromal symptoms and impending relapse, and rapid intervention to forestall relapse. The 69 remitted bipolar I patients taking mood stabilizers were randomized to receive either treatment as usual (TAU) or "add on" psychoeducational sessions. When compared with the TAU group, patients receiving psychoeducation had a significantly lower risk of manic relapse (18% vs 46%) and significantly better social and vocational functioning. Patients receiving therapy also were at somewhat lower risk for depressive relapse (ie, 31% vs 48%), although this difference was not statistically significant.
