Improving Outcomes in Bipolar Disorder
Although bipolar disorder is diagnosed largely on the basis of whether a manic or hypomanic episode has occurred, the condition's most painful burden may be depression and disability. In fact, bipolar disorder is the sixth leading cause of disability worldwide.
Disability is partly a consequence of the high rate of relapse for episodes of both mania and depression. For example, in a study of people with bipolar disorder type 1, characterized by episodes of mania (rather than hypomania) with or without depression, researchers followed patients after they suffered a manic or depressive episode. They found that 37% of patients experienced a recurrence of mania or depression within a year, 60% within two years, and 73% within five years.
Full recovery from a manic or depressive episode — if it is achieved — may take months, even years. One study of patients who had been hospitalized for a manic episode and were then followed after discharge found that 48% of patients recovered from symptoms by the end of a year, but only 24% returned to normal life functioning. Another study found that aftereffects of a manic episode continued to affect work, social, and family relations as long as five years later.
Work functioning is a major area of vulnerability. One study found that only 33% of patients with bipolar disorder worked full-time and 9% worked part-time, while 57% said they were unable to work at all, or could work only in some type of supportive (sheltered) environment.
Of course, it's important to remember that many people with bipolar disorder eventually rebuild their lives. But clinicians and patients alike want to find ways to better support and hasten recovery.
Depression a key factor in disability
Researchers believe that depression is the most significant predictor of disability from bipolar disorder. Patients generally take longer to recover from a depressive episode than a manic episode, tend to emerge from a depressive episode with greater impairment, and experience residual symptoms of depression between clinical episodes. Patients may spend as much as half the year feeling ill due to their symptoms, with depressive symptoms predominating. Symptoms of bipolar depression tend to compromise functioning more than symptoms of major depression or dysthymia.
Adding to the challenge, only two medications — quetiapine (Seroquel) and an olanzapine-fluoxetine combination (Symbyax) — are specifically approved to treat bipolar depression (compared with nine medications for mania). And there is growing evidence that using standard antidepressants as an adjunct to mood-stabilizing medications does not benefit patients with bipolar disorder.
Making matters worse, patients with bipolar disorder — like those with other types of chronic illnesses — often take their medications irregularly or stop taking them altogether. According to the research, anywhere from 18% to 52% of patients with bipolar disorder do not take medications as prescribed.
Finally, in bipolar disorder, the brain's ability to regulate emotion is probably compromised, so stress and conflict, which trigger negative emotions, tend to worsen symptoms, especially depression. Thus people with bipolar disorder are particularly vulnerable to inadequate social support, traumatic life events, and hostility or criticism from family members. High levels of neuroticism (a tendency to overreact or interpret situations negatively) or a dysfunctional cognitive style also increase (or may underlie) vulnerability.
Psychosocial therapies essential
Psychotherapy and social interventions offer an essential adjunct to drug treatment of bipolar disorder. A large body of research shows that such therapies, when combined with mood-stabilizing medications, help to alleviate symptoms, increase the number of months a patient feels well, hasten recovery, and decrease the risk of relapse. The evidence is strongest for four methods: psychoeducation, cognitive behavioral therapy (CBT), family-focused therapy, and interpersonal and social rhythm therapy.
Psychotherapies are probably useful because they address aspects of recovery that medications alone do not. Although individual psychotherapies have different theoretical foundations and address particular challenges, they also have a lot in common. All seek to enlist the patient as an active participant in recovery by providing information about bipolar disorder and its treatments, educate patients and families about early signs of relapse, and bolster their coping skills. They also encourage collaboration between patients, clinicians, and family members. The fact that these therapies tend to work in multiple ways at once supports the theory that different aspects of recovery from bipolar disorder need different interventions.
Researchers have begun to evaluate the impact of psychotherapy on social and vocational functioning — aspects of life such as being able to work or sustain supportive relationships — that may determine whether someone will recover fully or become disabled.
The latest evidence comes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a federally funded, multi-site investigation that enrolled patients typical of those treated in the community, so that the results are clinically relevant. STEP-BD researchers reported in 2007 that patients who received any of three types of intensive psychotherapy — 30 sessions of CBT, family-focused therapy, or interpersonal and social rhythm therapy delivered over nine months — functioned better overall, had more stable personal relationships, and reported enjoying life more, when compared with patients who received a briefer and less intensive psychoeducation intervention, consisting of three sessions over six weeks. The three intensive interventions were about equally effective. There was no effect, however, on ability to work or engage in recreational activities.
This type of therapy may be delivered on its own, but it is also a key component of other psychosocial interventions for bipolar disorder. It is sometimes given in the context of larger programs of collaborative patient care. Psychoeducation can take place on an individual basis or as part of group therapy.
The goal is to provide social support and share information relevant to bipolar disorder so that a patient can adapt to living with a chronic illness and find ways to remain stable. Therapy may involve steps to reduce risk factors for relapse (by identifying and avoiding stressful people and events), to structure the day and normalize sleep/wake cycles, or to ensure access to emergency medication should symptoms escalate.
The results of psychoeducation studies are difficult to aggregate because they examine different comparison groups. The bulk of the evidence indicates that psychoeducation is effective at reducing episodes and relapses of mania — though not depression.
Cognitive behavioral therapy
Several types of CBT for bipolar disorder exist, adapted from those used to treat unipolar depression. CBT encourages patients to recognize and change distorted thinking that may contribute to symptoms (often with the help of written assignments). In bipolar disorder, this involves challenging grandiosity and unreasonable risk taking, as well as pessimism.
This therapy also encourages patients to enjoy themselves and interact constructively with their environment, but to avoid the kind of stimulation — such as substance use or sleep deprivation — that could trigger a manic episode.
Studies of CBT's effectiveness on bipolar disorder have produced mixed results, and only a few have evaluated how well this therapy works for bipolar depression. Some researchers believe that CBT may be most useful for patients who are in the early stages of bipolar disorder or who have milder forms of the disorder.
Although many different forms of family therapy for bipolar disorder exist, the best studied is family-focused therapy, developed by psychologists David J. Miklowitz at the University of Colorado and Michael J. Goldstein at the University of California, Los Angeles.
The therapist educates family members about bipolar disorder so that they can better support a patient's recovery. Over a period of nine months, clinicians teach the patient and family members how to recognize emerging symptoms of the disorder and prevent relapse, communicate productively, and resolve family and other interpersonal conflicts. A problem-solving component focuses on particular aspects of rebuilding a patient's life after an acute episode, such as renegotiating intimate relationships, determining when it's safe to return to work, and maintaining medication regimens while dealing with any side effects.
Several randomized controlled trials have concluded that family-focused therapy, combined with medication, improves medication adherence, stabilizes symptoms, delays relapse, and enhances family relationships. One study found that 60% of patients who received individual therapy were rehospitalized within two years, compared with only 12% of those who received family-focused therapy. This therapy is particularly effective with depressive symptoms and relapses, but it's not clear whether it has the same effect on manic symptoms and relapses.
Interpersonal and social rhythm therapy
This therapy, developed by psychologist Ellen Frank and colleagues at the University of Pittsburgh, stresses the importance of establishing regular routines, such as going to bed and getting up at the same time every day, to avoid triggering a relapse. Therapists also help patients cope with grief over having a chronic illness. In addition, they focus on how interpersonal relationships affect mood and help patients renegotiate interpersonal roles in light of the illness.
Studies have reported that this therapy can help patients keep symptoms under control and avoid relapse, and may speed recovery from depression.
Colom F, Vieta E. Psychoeducation Manual for Bipolar Disorder (Cambridge University Press, 2006).
Frank E. Treating Bipolar Disorder: A Clinician's Guide to Interpersonal and Social Rhythm Therapy (Guilford Press, 2007).
Miklowitz D. The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (Guilford Press, 2002).
Miklowitz D. Bipolar Disorder: A Family-Focused Treatment Approach, 2nd ed. (Guilford Press, 2008).
Newman C., et al., eds. Bipolar Disorder: A Cognitive Therapy Approach (American Psychological Association, 2001).
Researchers don't yet know what the optimal combinations of medications and psychosocial interventions are, or when to introduce specific interventions. It's also unclear how to determine which patients are most likely to benefit. In the STEP-BD study, for example, intensive psychosocial interventions showed an overall advantage over briefer therapy, but there was a lot of individual variation in response.
The results of STEP-BD, which followed patients only for nine months, also suggest that recovering vocational function may require extra time and support. Two studies which reported that psychosocial interventions helped people recover their ability to work followed patients for at least 18 months.
One theme that is emerging from the research is that the most productive strategy is not to pit one type of therapy against another — as is usually the case in clinical trials. Instead, the best route to recovery may be to identify the most effective components common to all types of psychosocial therapy.
Mansell W, et al. "The Nature and Treatment of Depression in Bipolar Disorder: A Review and Implications for Future Psychological Investigation," Clinical Psychology Review (Dec. 2005): Vol. 25, No. 8, pp. 1076–1100.
Miklowitz DJ, et al. "The Psychopathology and Treatment of Bipolar Disorder," Annual Review of Clinical Psychology (2006): Vol. 2, pp. 199–235.
Sachs GS, et al. "Effectiveness of Adjunctive Antidepressant Treatment for Bipolar Depression," New England Journal of Medicine (April 26, 2007): Vol. 356, No. 17, pp. 1711–22.
For more references, please see www.health.harvard.edu/mentalextra.
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