Authors: David J. Miklowitz, Michael J. Gitlin
Categories: Article
Source: American journal of psychotherapy
Authors: David J. Miklowitz, Michael J. Gitlin
The broad acceptance of evidence-based psychosocial interventions as adjuncts to pharmacotherapy for bipolar disorder has been inhibited by the extensive training, supervision, and fidelity requirements of these approaches. Interventions that emphasize evidence-based strategies drawn from these modalities—rather than the full manualized protocols—may broaden the availability of psychotherapy for patients with bipolar disorder. In this article, psychosocial risk factors relevant to the course of bipolar disorder (stressful life events that disrupt social rhythms, lack of social support, family criticism and conflict, and lack of illness awareness or literacy) are reviewed, along with evidence-based psychosocial interventions (e.g., interpersonal and social rhythm therapy, cognitive-behavioral therapy, family-focused therapy, and group psychoeducation) to address these risk factors. The results of a component network meta-analysis of randomized psychotherapy trials in bipolar disorder are discussed. Manualized psychoeducation protocols—especially those that encourage active skill practice and mood monitoring in a family or group format—were found to be more effective, compared with individual psychoeducation or routine care, in reducing 1-year recurrence rates. Cognitive restructuring, regulation of daily and nightly routines, and communication skills training were core components associated with stabilization of depressive symptoms. The authors describe a novel psychoeducational approach—practical psychosocial management (PPM)—that integrates these core strategies into the personalized care of patients with bipolar disorder to reduce recurrences and enhance mood stability. PPM is designed to be implemented, without time-intensive training and oversight, by physician or nonphysician clinicians. Evaluating the efficacy and coverage of PPM will require implementation trials in community settings.
Pharmacotherapy is the mainstay of treatment for acute and maintenance care in bipolar disorder (1). Nonetheless, patients with bipolar disorder have high rates of recurrence (49%–60% in 2 years), even when taking mood stabilizers, anticonvulsants, or antipsychotics (2). Subthreshold symptoms often persist well after an episode has been controlled with medications (3, 4). Furthermore, patients are vulnerable to socioenvironmental stressors and contextual factors, including stressful life events (5), changes in sleep-wake rhythms (6), low levels of social support (7), high levels of familial conflict or expressed emotion (EE) (8), and lack of insight or information about the illness (9–11). Each of these risk factors has been associated with illness recurrence, symptom severity, lower functioning, and treatment nonadherence (12).
Psychosocial interventions—notably those that focus on educating patients about the nature and course of bipolar disorder and that teach skills for coping with stress—effectively augment pharmacotherapy in delaying recurrences and alleviating symptoms (1, 13). A variety of manual-based psychotherapies—including cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), group psychoeducation, and family-focused therapy (FFT)—have demonstrated efficacy as adjuncts to pharmacotherapy (13). Availability of these evidence-based approaches in community practice settings is limited, however. One survey (14) indicated that only 50.4% of adults with bipolar disorder were receiving psychotherapy (of any type) and medications. A 2013–2016 survey (15) indicated that psychiatrists offered psychotherapy in 35.7% of outpatient visits for bipolar disorder. How many of these visits included psychoeducation or other evidence-based strategies remains unclear.
The acceptance of evidence-based psychosocial interventions in routine practice has been inhibited by the extensive training, lengthy clinician manuals, and expert supervision needed to ensure treatment fidelity. Few practicing clinicians (physician or nonphysician) have time for, or access to, comprehensive training in evidence-based approaches, and few offer group treatments. These problems are compounded by the lack of research on the common elements of effective psychosocial the format, targets, and key strategies that are associated with clinical change. A core battery of evidence-based treatment strategies that could be tailored to patients with different illness presentations would enhance the goals of personalized medicine for patients with bipolar disorder (16).
In the first section of this article, we review the evidence on psychosocial risk factors in bipolar disorder and describe the disorder-specific psychosocial interventions that have been developed to modify these risk factors. In the second section, we review a component network meta-analysis of randomized psychotherapy trials that identified distinct therapy strategies associated with reduced recurrence and severity of mood symptoms. In the third section, we describe how these treatment strategies can be integrated into a less formal psychotherapeutic approach—called practical psychosocial management (PPM)—that can be implemented by most psychiatrists or nonphysician clinicians experienced in treating bipolar disorder. A case study (a composite with details disguised to protect patients’ identities) illustrating the approach is available in the online supplement to this article.
Life events and stressors play an important role in the timing, polarity, and severity of mood recurrences. Goal attainment events, such as a job promotion or a new romantic relationship, lead to increases in self-confidence, impulsivity, goal pursuit, and manic or hypomanic symptoms (17). Conversely, stressful life events (e.g., loss of a valued relationship) may interact with preexisting negative self-referent attitudes (e.g., self-criticism, rumination, or perfectionism), resulting in increases in depressive symptoms (18, 19). These and other observations are the basis for CBT, which has been shown to reduce acute depressive symptoms in bipolar disorder (20–22).
Stressful life events can also disrupt a patient’s diurnal routines related to sleeping, eating, working, exercising, and socializing (social rhythms). Social rhythm–disruptive events, such as taking a transatlantic flight or staying up late to study for an exam, are often antecedents to manic episodes (6). Protection in the context of these events can be provided by IPSRT, which emphasizes the tracking and regulating of social rhythms (23, 24). In a randomized trial involving adults with bipolar I and II disorders, Frank and colleagues (25) showed that weekly IPSRT with medications, administered acutely, was associated with a longer period without recurrence and better vocational functioning during maintenance care than was a comparably intensive supportive therapy with medications.
Patients with highly recurrent or treatment-resistant illnesses are often socially isolated, having lost or become disconnected from their families of origin, spouses, friends, and occupational networks (26). Low levels of social support among patients with bipolar disorder are associated with longer times to remission from depressive episodes and more severe depressive symptoms (7), increased risk for recurrence (27, 28), poorer medication adherence (29), and more severe dysregulation of biological rhythms (30). IPSRT identifies interpersonal problems that are often correlated with depressive episodes and the loss of social grief, role disputes, interpersonal conflicts, or interpersonal deficits. The IPSRT clinician assists patients in recognizing interpersonal patterns that have had negative effects on social relationships and in exploring alternative interpersonal behaviors that may enhance social support and self-esteem (23, 24).
Interacting with other patients with bipolar disorder in a group context can increase patients’ awareness of the importance of social support and decrease self-stigmatization (31). Among patients experiencing remission from bipolar I or II disorder, structured psychoeducational groups have been associated with lower recurrence, better functioning, and lower service use costs compared with unstructured support groups over 5 years (32). In the UK National Health Service’s Improving Access to Psychological Therapies study (33), a 10-session group-based CBT was associated with improvements in personal recovery, quality of life, and depressive symptoms among adults with bipolar disorder.
Patients with parental or spousal caregivers who have high levels of EE (highly critical, hostile, emotionally overinvolved attitudes) have two to three times higher risk for recurrence over 1–2 years compared with patients whose caregivers have low levels of EE (34–36). Negativity in caregiver-patient interactions has also been associated with increased risk for recurrence in bipolar disorder (37, 38). Research on EE (i.e., criticism, overinvolvement, and family conflict) forms the empirical basis of FFT. FFT relies on three patients and relatives who recognize early warning signs of new episodes are better able to access emergency services and illness management techniques to prevent recurrences; caregivers who have received psychoeducation about the nature, causes, and treatment of bipolar disorder are less prone to blame the patient for dysfunctional behaviors; and patients and caregivers with training in communication and problem-solving skills have alternatives to critical or hostile interchanges that are aversive to all parties. In randomized trials of adults and adolescents with bipolar disorder, FFT with pharmacotherapy has been found to be more effective than individual supportive therapy or brief family education with pharmacotherapy in delaying recurrence and in stabilizing depressive symptoms over 1–2 years (22, 39–41).
Poor insight into the disorder and lack of mental health literacy—the patient’s understanding of the causes, prognosis, treatment, and self-care of bipolar disorder—are associated with medication nonadherence and likelihood of symptom recurrence (42, 43). Illness literacy among caregivers (e.g., understanding why patients need postepisode psychiatric care) may contribute to patients’ treatment adherence and reduce the likelihood of rehospitalization (9).
Each of the abovementioned treatments acknowledges that patients’ understanding of bipolar disorder has an important role in their acceptance of its treatment. The treatments differ, however, in how psychoeducation is given. For example, clinicians administering CBT help patients to identify and challenge pessimistic beliefs about pharmacological treatment through cognitive restructuring (44). Group psychoeducation and FFT include the perspectives of other patients with bipolar disorder and of patients’ caregivers, respectively, in encouraging illness awareness and treatment consistency.
Few head-to-head comparisons of adjunctive psychotherapy protocols have been conducted. Because of heterogeneity in sample sizes, patient populations, and follow-up durations, individual trials are rarely able to answer the question of what works best for whom.
Component network meta-analyses offer a different approach to this question. They enable investigators to synthesize evidence from randomized trials (so that differing treatment options can be compared with one another) and deconstruct complex treatment protocols into their constituent components, strategies, or formats (so that the effects of each component on outcomes can be estimated) (45). Efficacy results are expressed as incremental odds ratios (iORs) or incremental standardized mean differences (iSMDs) for comparisons between treatments that did or did not include a specific component (46, 47) (Tables 1 and 2).
A component network meta-analysis of data from 20 two-group randomized controlled trials (N>2,000 patients with bipolar disorder) indicated that pharmacotherapy with disorder-specific psychotherapy (CBT, IPSRT, family or conjoint therapy, individual or group psychoeducation) was associated with an almost 50% reduction in 1-year rates of recurrence (OR=0.56, 95% CI=0.43–0.74) compared with pharmacotherapy plus treatment as usual (i.e., symptom monitoring and support sessions; Table 1) (13). Psychoeducational treatments that involved active, guided practice of illness management skills and self-monitoring of moods and prodromal symptoms were associated with lower recurrence rates than were treatments without these components (Table 2). When guided practice of illness management skills and mood monitoring were administered in a family or group format, 1-year recurrence rates were much lower (OR=0.12, 95% CI=0.02–0.94) than they were when the components were administered in an individual format (Table 2). Importantly, protocols in which patients received didactic information passively (i.e., in lectures or workshops) were not associated with reduced rates of recurrence (13).
The treatment elements that emerged as potent in stabilizing depressive symptoms included cognitive restructuring, teaching patients to regulate daily social rhythms, and family or interpersonal communication training. The combination of these three components was significantly more effective in depression stabilization than was routine treatment without these components (Table 2). Similarly, cognitive restructuring and regulation of daily rhythms emerged as the most effective components in mania or hypomania stabilization. Finally, treatment in a family format was the only component associated with lower rates of study attrition (iOR=0.39, 95% CI=0.15–1.10) (13).
Some treatment guidelines (48) recommend that clinicians choose and adhere to one treatment manual, with its associated session plans, length, timing, and scripted homework assignments. PPM consists of the treatment elements that emerged as efficacious in the component network meta-analyses, enabling clinicians to adopt strategies from different protocols and offering increased flexibility to adjust treatment to individual patients.
The decision as to whether PPM should be given by the physician prescribing the medications or by an associated mental health clinician should be based on the needs of the patient, the structure and demands of the clinical setting, and the knowledge base of the practitioner(s). Concerns may arise in the delivery of split pharmacological and psychosocial care, as discussed elsewhere (49).
Psychosocial interventions should begin with a thorough illness history and diagnostic assessment, with evaluation of discrete life events or chronic stressors that were antecedents to prior episodes. Events that preceded manic escalations (e.g., a new romantic relationship) and that may have provoked dramatic changes in sleep-wake routines are given special consideration. Inquiring as to whether caregiving relatives (parents, spouse, siblings) are available for conjoint sessions opens the door to family psychoeducation. The clinician can explore the patient’s anxieties about family involvement, emphasizing to the patient that “it will give you a chance to clarify your point of view without their interruption.”
Anecdotally, we have observed that psychiatrists often assume that patients understand more about bipolar disorder than they actually do. Soliciting patients’ (and where possible, their caregivers’) understanding of the most recent illness episode and its precipitants is important. Basic and vital information should be provided to patients, such as the recurrent course of bipolar disorder without pharmacological care, the expected struggles with adherence, and ways to manage the side effects.
Exploring the meaning of the diagnosis to the patient usually bolsters the therapeutic alliance. Simple questions, such as “What does the term ‘bipolar’ mean to you?” and “What do you think it means to other people?” can provide a window into the patient’s health beliefs, illness literacy, and fears about stigma. Patients and caregivers often have mistaken beliefs about the side effects of psychiatric medications (e.g., “They destroy brain cells”) that are likely to influence treatment adherence (42, 43).
In early sessions, the clinician can introduce daily mood tracking as “one of the things you can do besides taking medications to help manage your disorder” and “a way for us to identify early warning signs before they worsen.” The ready availability of mobile apps for mood tracking makes this task easier (e.g., eMoods [https://emoodtracker.com], Moodfit [https://www.getmoodfit.com], and MoodTools [https://moodtools.org]). Patients can be encouraged to bring in app-generated graphs showing their recent symptom fluctuations, sleep and wake hours, and medication-taking habits—all of which can inform treatment planning. Caregivers’ observations about prodromal symptoms (e.g., “He stands too close to me and talks in a loud voice”) are important supplements to the patient’s report.
In relapse prevention planning, patients make lists of coping strategies to implement when they experience (or their mood chart indicates) a distinct change in mood. For manic escalations, the strategies usually include contacting the physician to review and adjust medications and limiting use of activating substances. For the early stages of depression, patients often list exercise, supportive communication with others, and meditation. An example of a depression prevention plan (with information disguised to protect patients’ identities) is available in Figure S1 of the online supplement).
A key issue for patients is the regularity of sleep-wake cycles, which can vary considerably from one night to the next and can contribute to mood instability. The Social Rhythm Metric (50) from IPSRT provides a systematic record for patients to chart their bedtimes and wake times, exercise, meals, caffeine or alcohol intake, social interactions, and mood. With information from these daily diaries, clinicians work with patients on regulating sleep-wake cycles and other routines, including anticipating and coping with events (e.g., expected travel with changes in time zones) that are likely to disrupt social rhythms (23, 24).
Early in the care of new patients, and often throughout maintenance care, practitioners need to be vigilant about medication inconsistencies or changes in patients’ willingness to adhere to their medication regimen. Physicians often learn of nonadherence through family members. Several interventions are suggested.
First, normalize inconsistency and, without endorsing it, make it safe to discuss (e.g., “Most people miss their medications once in a while; how has it been for you?”). Second, take a directive but supportive stance by providing psychoeducation about medications—what they are designed to do and what kinds of benefits and side effects to expect. Problem solving around the pros and cons of stopping versus adjusting dosages or changing agents helps patients feel more in control of the process.
Finally, when treating younger patients, clinicians can predict that nonadherence will eventually occur. Adolescents are especially likely to experiment with discontinuation during the first year after an acute manic episode (51, 52). Clinicians can say, “I know you’re being consistent with your mood stabilizer right now, but I predict that in a few months when you start feeling better, you’ll want to stop taking it. Will you agree to talk with me before you do that?” When the patient later considers discontinuation, he or she may recall the agreement.
In the aftermath of a manic episode, patients often experience lengthy, unremitting, and impairing depressive states (2, 4). Patients may bring in a weekly mood chart that is essentially a flat line of negative mood values. Negative cognitions about the self, world, or future can be addressed with classic cognitive therapy techniques, such as weekly thought records in which patients record instances of pessimistic or self-defeating thoughts and evaluate the evidence for and against these thoughts. Learning to generate and rehearse adaptive cognitions is often met with skepticism at first (e.g., “You don’t know what it’s like”), but as patients begin to see mood improvement, they become more willing to practice these skills on their own. Self-guided cognitive restructuring programs (53) are often a useful supplement to treatment. Some patients respond better to mindfulness-based adaptations of cognitive therapy, in which patients learn to observe negative moods, thoughts, and physiological states from a meditative, nonjudgmental, and “decentered” stance (54).
Frequent criticism of the patient (i.e., high EE) is often associated with a caregiver’s unexpressed belief that the patient is depressed because of a lack of effort or laziness (55). When caregivers insist on greater effort from the patient, the patient often feels inadequate, self-critical, and resentful. Patients contribute to this dynamic by expressing equally critical remarks to their caregivers, often leading to escalating and damaging conflicts (56).
Learning about the biological and genetic underpinnings of bipolar disorder can help family members to reevaluate their assumption that the patient’s aversive behaviors are purposeful. Clinicians can also engineer role-played exchanges, in which caregivers are asked to rephrase critical comments (e.g., “You are lazy and don’t care”) directed toward the patient as positive requests for change (e.g., “I’d like you to put more effort into job seeking”). In turn, patients are encouraged to paraphrase caregivers’ feelings or beliefs (active listening) before making their counterarguments. Patients’ perceptions of caregivers as allies rather than as enemies can go a long way toward bolstering mood states.
This article has described the strategies of PPM: psychoeducation with active skill training, self-monitoring of moods and prodromal symptoms, regulation of daily and nightly rhythms, mental health literacy and pharmacological adherence, cognitive restructuring to reduce depression, and communication skills training to address family or other interpersonal conflicts. These treatment components can be helpful adjuncts to pharmacotherapy, even when psychiatrists have limited time with patients. Adapting these strategies in ways that fit patients with different illness presentations is consistent with personalized medicine.
Most practicing psychiatrists do not have the time or resources to learn full treatment protocols, such as FFT, IPSRT, or CBT, nor do they have space within brief pharmacotherapy sessions to implement these full protocols. Few practicing psychiatrists are equipped, in terms of training or physical space, to conduct psychoeducation groups. Familiarity and confidence with the techniques involved in PPM may require additional training for clinicians who have been trained in other models, but the training need not be extensive. One study (57) found that nonspecialist therapists who attended an initial training workshop, followed by weekly group supervision, were able to administer a five-session individual psychoeducational therapy with high levels of adherence. Patients with bipolar I and II disorder who were randomly assigned to this brief therapy showed greater improvements in knowledge of their illness and increases in their number of well weeks over 1 year compared with patients assigned to self-administered psychoeducation.
Systematic research is needed to determine the most economic and time-efficient methods for training clinicians in PPM or in similar psychosocial interventions. For example, comparisons between prerecorded and live clinician training workshops, followed by different intensities of case supervision, may help to clarify the level of commitment and training necessary for clinicians to achieve treatment fidelity (58). Future research should also aim to clarify which therapy components lead to the greatest clinical gains among patients encountered in general practice. Implementation trials with dismantling designs can be used, in which treatments based on one element (e.g., social rhythm regulation) are compared with treatments consisting of multiple elements (e.g., the full IPSRT protocol). In the interim, administering individual elements of longer protocols may be the most feasible way to deliver evidence-based therapies in practice.