Psychotherapies for the Treatment of Bipolar Disorder

Abstract

While minor mood swings are a natural part of life, excessive and persistent mood disturbances can lead to heightened stress levels and significantly impact one's quality of life. Notably, the majority of these studies, around 90%, focused on group or family interventions, with only 10 to 15% addressing individual psychotherapy. [...]a significant portion of these studies lacked randomization, and there were methodological challenges in their design (Stahl 2002). [...]in the last two decades, promising evidence has emerged highlighting the role of stress as a key factor in episodes of mental disorders. Stress vulnerability interactions across psycho-social and biological systems influence the periodicity of episodes.

Headnote

ABSTRACT

Bipolar disorder is one of the major mental disorders leading to disability. This review aims to highlight the most effective psychotherapies used in the treatment of bipolar disorder. Across diverse schools of psychology, five psychotherapeutic approaches have emerged as both highly utilized and effective. These are interpersonal social rhythm therapy, psychoeducation, cognitive-behavioral therapy, family-focused therapy and mindfulness therapy. Multiple randomized controlled trials focusing on these psychotherapeutic interventions have provided strong evidence of their effectiveness when delivered alongside standard care. The results suggest that these approaches have a constructive role to play as adjunctive models of psychotherapy in the management of bipolar disorder. While the available evidence is robust, further randomized clinical trials are needed. Expanding these studies to sub-areas such as geriatrics and adolescents would provide more detailed information on the feasibility and efficacy of these psychotherapies among different demographic groups.

Keywords: Bipolar disorder, interpersonal social rhythm therapy, cognitive behavioural therapy, psychoeducation, family focused therapy, mindfulness therapy

ÖZ

Bipolar bozukluk, yetiyitimine yol açan önemli ruhsal bozukluklardan biridir. Bu derleme, bipolar bozukluğun tedavisinde kullanılan en etkili psikoterapileri vurgulamayı amaçlamaktadır. Farklı psikoloji ekolleri arasında, beş psikoterapi yaklaşımının hem yüksek oranda kullanıldığı hem de etkili olduğu saptanmıştır. Bunlar; kişilerarası sosyal ritim terapisi, psikoeğitim, bilişsel-davranışçı terapi, aile odaklı terapi ve farkındalık terapisidir. Bu psikoterapötik müdahalelere odaklanan çok sayıda randomize kontrollü çalışma, standart bakımla birlikte uygulandıklarında etkinliklerine ilişkin güçlü kanıtlar sunmuştur. Sonuçlar, bu yaklaşımların bipolar bozukluğun yönetiminde yardımcı psikoterapi modelleri olarak yapıcı bir rol oynadıklarını göstermektedir. Mevcut kanıtlar sağlam olmakla birlikte, daha fazla randomize klinik çalışmaların yapılmasına ihtiyaç duyulmaktadır. Bu araştırmaların geriatri ve ergenler gibi alt alanlara genişletilmesi, bu psikoterapilerin farklı demografik gruplar arasında uygulanabilirliği ve etkinliği hakkında daha detaylı bir bilgi sağlayacaktır.

Anahtar sözcükler: Bipolar bozukluk, kişilerarası sosyal ritim terapisi, bilişsel davranışçı terapi, psikoeğitim, aile odaklı terapi, farkındalık terapisi

Introduction

Stressful life events and conflicts are inevitable occurrences that can cause fluctuations in an individual's mood (del Mar Bonnin et al. 2014). While minor mood swings are a natural part of life, excessive and persistent mood disturbances can lead to heightened stress levels and significantly impact one's quality of life. These problematic situations are collectively referred to as affective disorders, encompassing a spectrum from unipolar to bipolar II and bipolar I disorder. Bipolar disorder (BD), characterized by episodes of both depression and mania, has become a prominent mental health concern in the 21st century (Phillips and Kupfer 2013).

Individuals with bipolar disorder often experience chronic symptoms and recurrent episodes of depression or mania, leading to a challenging and unstable lifestyle. This condition is associated with various comorbidities, a high risk of self-harm, and diminished overall quality of life (Benazzi 2004, Karl et al. 2006, Scott et al. 2006). BD affects approximately 1% of the population, with a lifetime prevalence of 0.6% for bipolar I and 0.4% for bipolar II (Salvatore et al. 2007, Ferrari et al. 2011, Merikangas et al. 2011). While pharmacological treatments have been explored, standard medications have shown limited efficacy in controlling symptoms for a significant portion of patients (Falloon et al. 1997, Stahl 2002).

Considering these challenges, adjunctive treatments such as psychotherapy have gained attention. Cognitive behavioural therapy (CBT), family-focused therapy (FFT), interpersonal social rhythm therapy (IPSRT), and psychoeducation (PE) have emerged as promising interventions (Mikiowitz et al. 2003, Basco and Rush 2005, Colom and Lam 2005, Provencher 2012). These therapies aim not only to address acute symptoms but also to target persistent psychosocial deficits that persist beyond the acute phases of the disorder (Frank et al. 2000). By helping individuals regain control and establish a balanced rhythm in their lives, these psychosocial interventions offer significant potential in managing bipolar disorder (Prien and Potter 1990, Frank et al. 2000, Rothbaum and Astin 2000). This study seeks to elucidate the most prevalent and current adjunctive psychological interventions utilized in the treatment of BD (Nivoli et al. 2011, Moon et al. 2012,).

Early Psychotherapy Studies for Bipolar Disorder

The literature on psychotherapies and treatments for BD spans several decades, with studies and randomized controlled trials conducted from 1959 to 1999. During this period, 35 studies incorporating psychotherapies and pharmacological treatments were carried out. However, it is important to note that most of these studies featured small and unique sample sizes, typically comprising 20 to 30 participants. In total, approximately 1000 individuals were involved in these studies, receiving experimental psychotherapy in addition to standard pharmacological treatment. Notably, the majority of these studies, around 90%, focused on group or family interventions, with only 10 to 15% addressing individual psychotherapy. Moreover, a significant portion of these studies lacked randomization, and there were methodological challenges in their design (Stahl 2002). Despite these limitations, a clear trend emerged: patients who received adjunctive psychotherapy in addition to standard treatment exhibited better outcomes compared to those receiving only standard treatment and medications. Consequently, these results paved the way for further randomized clinical trials with more standardized methodologies, concentrating specifically on the relapse of bipolar disorder (Scott et al. 2007).

The primary objective of psychotherapies for BD is to alleviate symptoms, restore psychological functionality, hinder relapses, and enhance overall coping mechanisms. While medication and pharmacology remain the cornerstone of treatment procedures, psychotherapy serves as a valuable adjunctive approach (Sublette et al. 2009). However, there has been a noticeable efficacy gap, particularly with mood stabilizers. Even under optimal controlled trials, studies indicated that preventive treatment protected against episodes in less than 50% of cases. Psychotherapy has been welcomed as a means to bridge this gap and offer additional support. Regrettably, progress in psychotherapeutic interventions for bipolar disorder has been relatively slow thus far (Scott 1995).

Historically, individuals with bipolar disorder were often not offered psychotherapy due to several reasons. The prevailing etiological models favoured genetics, leading to a predominant focus on medication-based treatment options. Additionally, there was a misconception that medication-only treatment could fully restore patients to their premorbid level of functioning (Swartz and Swanson 2014). Moreover, psychodynamic therapists expressed reservations, suggesting that bipolar disorder patients lacked introspection and were overly dependent, making them less amenable to psychotherapeutic interventions. Comparisons were even drawn with patients suffering from schizophrenia, further discouraging the use of psychotherapy for BD (Scott and Pope 2003).

However, in the last two decades, promising evidence has emerged highlighting the role of stress as a key factor in episodes of mental disorders. Stress vulnerability interactions across psycho-social and biological systems influence the periodicity of episodes. Notably, randomized controlled trials in schizophrenia and major depression, employing psychotherapies as adjunctive models with standard care, demonstrated significant reductions in symptoms. This evidence prompted a reconsideration of the use of psychotherapy for BD, potentially saving individuals from the dire consequences of refusing medication. Scott and colleagues lamented that "35 years had been lost" in the process (Scott et al. 2007).

In the 21st century, the resurgence of psychotherapy and the substantiated evidence of its efficacy in managing mental disorders have led to the prominence of four common approaches in BD treatment. These approaches include psychoeducation, considered almost essential for bipolar disorder treatment; CBT, instrumental in restructuring cognition and behaviour; ISRT, extensively studied in clinical trials; FFT, acknowledging the pivotal role of family in the bipolar disorder treatment process; and mindfulness-based interventions, representing a new frontier in awareness-based psychotherapy. These approaches collectively represent a promising avenue in addressing the complexities of bipolar disorder (Karl et al. 2006).

Psychoeducation

PE stands as a structured and systematic approach involving the dissemination of educational information about a particular disease and its corresponding treatment methods (Stafford and Colom 2013). In essence, PE encompasses studies that employ educational techniques to induce desired behavioural changes in patients, serving both educational and psychosocial objectives (Çakır and Ozerdem 2010, Nehir 2011). Through well-designed psychoeducation programs, patients are equipped with fundamental knowledge about the disease and prescribed medications, fostering a heightened awareness among them. This approach aims not only to enhance adherence to treatment but also to facilitate the recognition of early symptoms, enable effective coping with the disease's challenges, improve social interactions, enhance overall functionality, and elevate the patient's quality of life (Colom and Lam 2005, Bordbar and Faridhosseini 2012).

Despite its seemingly basic premise of providing general information about the illness, PE transcends mere informative sessions. It operates as a cognitive training model that, first and foremost, guides patients to accept their illness and comprehend its consequences. PE assists patients in learning strategies to cope with the varied symptoms and fluctuations inherent in the disease. It is akin to a personalized training program, tailored to help patients understand the ongoing hidden dynamics of the disorder, enabling them to take proactive measures or seek assistance when they sense the onset of manic or depressive episodes (Vieta 2005).

PE serves as a comprehensive approach in managing BD, offering various essential components and benefits to empower both patients and their families in navigating the challenges associated with the disorder. One crucial aspect of PE is Monitoring and Symptom Management, where patients and their families are educated about recognizing disease precursors and formulating action plans for proactive symptom management (Gümüş 2006). Information Sharing forms a fundamental element, involving the dissemination of comprehensive disease information to foster deep understanding among patients and their families.

Skill Development is a pivotal component of PE programs, encompassing activities such as assertiveness training, problem-solving techniques, cognitive training, communication skills development, and stress management training. These skills are indispensable for effectively coping with the hurdles posed by bipolar disorder. Social isolation often affects individuals and families dealing with mental illness. PE initiatives facilitate Community Engagement, providing a platform for reconnecting with the community, thereby fostering renewed social connections and support networks (Bostancı 2008).

PE programs create opportunities for Emotional Catharsis and Support within supportive group settings. Patients and their relatives can share their experiences and feelings, enabling emotional catharsis and mutual support. Developing a Support Network is another crucial aspect of PE, fostering connections between families and providing a forum for sharing problems and solutions. This collective support emphasizes that individuals are not alone in their struggles (Bostancı 2008).

Incorporating Drug Education, PE educates patients about their prescribed medications, their effects, and potential side effects. Patients learn the importance of medication adherence even when symptoms subside. Families are also educated about medications and their role in supporting the patient's treatment journey. Improving General Health is emphasized through PE, highlighting factors such as rest, nutrition, exercise, abstaining from substance use, and overall healthcare. Understanding these aspects aids patients in coping with stress and preventing disease exacerbation (Worley et al. 2000).

Research underscores the enduring efficacy of PE interventions. Engaging in PE reduces time spent in depressive states, displaying lower rates of mania, hypomania, and mixed episodes (Colom et al. 2000). Long-term efficacy is evident, supported by a 5-year follow-up study (Colom et al. 2005). Cost-effectiveness studies further emphasize the benefits of PE, indicating reduced utilization of mental health care resources among patients enrolled in PE interventions (Scott et al. 2007).

However, a vital consideration is the patient's mood state. Effective implementation of PE interventions necessitates patients to be in a euthymic state. Concurrent pharmacological interventions are crucial, emphasizing the importance of combining PE with mood stabilizers for optimal results (Lam et al. 2003).

Cognitive Behavioural Therapy

CBT constitutes a comprehensive approach that integrates behavioural and cognitive factors, culminating in a holistic therapeutic paradigm (Şirin 2013). The evolution of CBT involves the fusion of behavioural and cognitive components, rooted in distinct philosophical and theoretical underpinnings, shaping the foundation of this approach (Stone et al. 2018). To comprehend CBT, it is essential to delve into the origins of its constituent elements, beginning with behaviourism as a counterpoint to psychoanalysis in the 1960s. Behaviourism, rejecting the mind-body dualism, emphasizes behaviour over mental content and is grounded in classical and operant conditioning theories, pioneered by Pavlov, Thorndike, and Skinner (Ozcan and Çelik 2017). However, the rigid determinism of behaviourism was later challenged, acknowledging the significant role of cognitive mechanisms in shaping human behaviour (Falloon et al. 1984, Türkçapar and Sargın 2012).

In cognitive theory, influenced by philosophers like Epictetus, behaviours and emotions are shaped by perceptions, meanings, and cognitions. According to this perspective, individual experiences are interpreted through the lens of personal beliefs and thoughts, with external events being secondary to the meanings ascribed to them (Şafak et al. 2014). CBT, emerging in the 1970s under Beck and Ellis, challenged prevailing psychoanalytic views. Beck's research on dreams of depressed individuals revealed themes of self-deficiency, loss, and deprivation, leading to the formulation of cognitive theories (Stone et al. 2018, Domic-Siede et al. 2023). In CBT, emotions and behaviours are not directly caused by events but are influenced by individual perceptions and interpretations (Çelebi and Odacı 2018, Dent et al. 2004).

CBT, initially developed for unipolar depression, has been adapted for various mental disorders, including bipolar disorder. However, due to the complex stages and fluctuations inherent in bipolar disorder, designing CBT protocols for bipolar disorder, especially during manic or depressive phases, has proven challenging. Consequently, many CBT approaches for bipolar disorder focus on the euthymic stage (Basco and Rush 1996a). Moreover, successful CBT implementation hinges on patient acceptance of their condition, family understanding, and active patient involvement in treatment processes, emphasizing medication adherence and self-awareness of symptoms (Juruena 2012).

Several CBT manuals have been developed for bipolar disorder, with diverse emphases. One such manual, by Basco and Rush (1996), consists of 20 sessions focusing on psychoeducation, cognitive restructuring, and psychosocial issues. Lam et al. (2003) introduced a 20-session model emphasizing self-awareness, cognitive restructuring, and future planning. Perry and colleagues (1999) devised an action-oriented CBT approach focusing on prodromal symptoms, leading to reduced manic episodes. Studies have highlighted CBT's efficacy in managing comorbid conditions, such as anxiety disorders and post-traumatic stress disorder (PTSD), often present in bipolar disorder patients (Rosenberg et al. 2004, Provencher et al. 2011). Nevertheless, limitations exist, including limited access to professional therapists, the necessity for patient euthymia, and diminishing effects over time (Lam et al. 2003, Ball et al. 2006, Abreu 2016). While CBT holds promise, continuous research is imperative to optimize its long-term efficacy and address these challenges (Maçkah and Tosun 2011).

Interpersonal Social Rhythm Therapy

IPSRT offers a unique blend of interpersonal psychotherapy and social rhythm therapy, specifically tailored for individuals dealing with BD. Developed by Frank and colleagues (2005), IPSRT incorporates the social Zeitgeber model, emphasizing the crucial role of maintaining consistent social and biological rhythms to manage BD symptoms effectively. The therapy posits that disruptions in sleep and social routines disturb the circadian system, leading to manic and depressive relapses (Hlastala 2005).

In IPSRT, potential triggers for mood episodes, such as interpersonal disputes arising from nonreciprocal expectations within relationships, are identified (Weismann et al. 2017). By focusing on balancing patients' social rhythms and promoting regular daily routines, IPSRT aims to stabilize circadian systems and prevent episodes (Weissman et al. 2017). The therapy consists of three modules: exploring the patient's history and relationships, analysing social rhythm, providing psychoeducation about BD, and addressing interpersonal conflicts (Monk et al. 1990).

IPSRT concentrates on five key areas: establishing connections between life events and mood changes, establishing regular daily routines, identifying factors disrupting social and biological rhythms and interpersonal relationships, addressing the loss of the "healthy self" due to the disease, and recognizing and managing affective symptoms. The therapy initiates with a comprehensive history-taking process, focusing on past triggers, relationship challenges, and rhythm disruptions. Psychoeducation covers various aspects of BD, including symptoms, medication effects, chronicity, and the importance of regular drug use. The third phase involves helping the patient develop a daily social routine while monitoring circadian rhythms, striving for balance and a euthymic mood. Therapists actively observe the patient's daily routine and address conflicts that might disrupt the flow of the day (Frank et al. 2022).

However, despite its potential, IPSRT faces challenges. Limited randomized controlled trials, primarily conducted by Frank et al. (2007) in the US, have been carried out. Comparisons with other therapies like CBT, and mindfulness-based therapies are essential to determine IPSRT's efficacy relative to other approaches. While promising, ongoing research is crucial to validate IPSRT's effectiveness and elucidate its comparative advantages in the treatment of BD (Malkoff-Schwartz et al. 1998).

Family Focused Therapy

FFT is a specialized psychotherapy designed to involve the family members of individuals with BD in the treatment process. Originally adapted from Family Behavioral Management for schizophrenic patients, FFT operates on the principle that the family functions as a system, where each member's actions and emotions impact the individual with BD. The therapy focuses on several core principles, including psychoeducation, where family members learn about bipolar disorder, its symptoms, triggers, and treatment options, enabling them to offer informed support. Communication skills are taught to foster empathy and active listening, ensuring open communication to prevent misunderstandings and conflicts. FFT equips families with problem-solving skills to collaboratively address challenges related to bipolar disorder, promoting collaborative decision-making, and developing contingency plans. Setting healthy boundaries defines family roles, preventing emotional burnout and ensuring balanced support. Stress-reduction techniques are introduced to cope with the unpredictable nature of bipolar disorder, while emotional support is encouraged within the family, creating a safe space for expressing feelings and fostering acceptance (Deckersbach et al. 2012).

FFT sessions are structured, including psychoeducation sessions that provide detailed information about the disease and strategies to identify and manage episodes. Communication skills training involves active listening and empathetic reflections, addressing specific communication conflicts within the family. Problem-solving skills training equips families with techniques to handle challenges related to bipolar disorder, emphasizing collaborative decision-making and contingency planning.

However, FFT faces challenges, such as changing the family's perception of the patient and overcoming stigma, which can hinder progress. In some cases, family dynamics may inadvertently perpetuate the patient's problematic situation to divert attention from other family issues, posing obstacles in the therapeutic process.

Despite these challenges, FFT has demonstrated promising results in enhancing family relationships and supporting individuals with BD in managing their condition effectively. Ongoing research and further refinement of the FFT approach are crucial to address these limitations and maximize its effectiveness in treating bipolar disorder within a family context.

Mindfulness Therapy

Mindfulness therapy, rooted in the present moment, offers a holistic approach for individuals grappling with bipolar disorder. This practice encourages deliberate attention without judgment, enabling profound emotional regulation and resilience. By integrating mindfulness into treatment regimens, individuals can develop self-awareness, effectively navigate mood swings, and build a foundation for lasting well-being. The benefits of mindfulness therapy in the context of BD are multifaceted. Firstly, mindfulness enhances emotional regulation by enabling individuals to observe manic energy and depressive thoughts without impulsivity, fostering emotional control and self-awareness. It encourages acceptance of depressive feelings and curiosity about one's mental state, reducing negative emotional amplification. Additionally, mindfulness breaks rumination cycles by redirecting focus from past events or future worries, thereby fostering emotional stability and resilience (Goldberg et al. 2018).

Moreover, mindfulness equips individuals with effective coping mechanisms to manage stressors, enhancing composure and reducing impulsivity during challenges. It is seamlessly integrated into therapeutic approaches such as CBT and dialectical behaviour therapy (DBT), providing a comprehensive toolkit for navigating the complexities of bipolar disorder. Within support networks, mindfulness enhances communication by heightening self-awareness, enabling individuals to express their needs effectively and fostering empathy and understanding among family members. Furthermore, caregivers practicing mindfulness can manage the emotional toll of supporting someone with BD creating a more supportive environment (Hanssen et al. 2020).

However, it's essential to acknowledge individual variability in the effectiveness of mindfulness therapy. Tailored guidance from mental health professionals ensures personalized mindfulness practices. Additionally, mindfulness therapy complements medication by addressing the psychological and emotional aspects of bipolar disorder, enhancing the overall treatment approach. In conclusion, mindfulness therapy offers a promising pathway for individuals with bipolar disorder, providing stability, resilience, and lasting emotional wellness through embracing the present moment and observing thoughts non-judgmentally. Integrated into comprehensive treatments, mindfulness therapy transforms the management of bipolar disorder, offering hope and empowerment to those seeking emotional well-being. As mindfulness continues to evolve, its potential to reshape bipolar disorder treatment remains significant, offering a beacon of hope for individuals on their journey toward improved emotional health and overall quality of life.

Conclusion

Bipolar disorder is indeed a multifaceted condition that requires a nuanced approach, and the combination of psychoeducation, CBT, IPSRT, FFT, and mindfulness therapy provides a holistic framework for addressing its various aspects. The importance of personalized treatment plans cannot be emphasized enough. Every individual with bipolar disorder is unique, and their experiences, symptoms, and responses to therapies can vary significantly. Tailoring the approach based on the individual's specific needs, circumstances, and preferences ensures a more effective and meaningful intervention.

Additionally, the collaborative aspect of treatment is vital. Involving mental health professionals, individuals with bipolar disorder, and their families in the treatment process fosters a supportive and understanding environment. This collaborative effort enhances treatment adherence, improves communication, and strengthens the overall support system.

Remaining open to new research and evidence-based interventions is crucial in the field of mental health. As our understanding of bipolar disorder deepens, it may lead to the development of more targeted and efficient therapies. Staying updated with the latest advancements ensures that individuals with BD have access to the most effective and innovative treatments available. Ultimately, the goal of these therapeutic approaches is to enhance the quality of life for individuals with bipolar disorder. By empowering them with coping strategies, emotional resilience, and a strong support system, individuals with bipolar disorder can effectivelymanage their symptoms, navigate challenges, and lead fulfilling lives.

Further research suggestions involve several key areas of focus. Firstly, examining the effect sizes during different phases of BD-both acute phases with standard medication and maintenance phases with adjunctive psychotherapy-can offer valuable insights into treatment effectiveness. These insights can help clinicians tailor treatments to meet the specific needs of patients at different stages of their illness. Additionally, investigating the relationship between bipolar disorder and comorbid conditions such as substance use, suicide, and insomnia in the context of adjunctive psychotherapies is crucial. Given the significant impact these comorbidities can have on the course of the illness, understanding how psychotherapeutic interventions affect these conditions can lead to more comprehensive and effective treatment strategies (Rosenberg et al. 2004).

Moreover, addressing the unique challenges presented by special populations, including adolescents, geriatric individuals, and those with Bipolar II disorder, is essential (Judd et al. 2003). These groups have distinct physiological and psychological differences, necessitating specialized approaches in their treatment. Tailoring psychotherapeutic interventions specifically for these populations through empirical testing can significantly improve outcomes and enhance their overall quality of life (Roth and Fónagy 2005).

Furthermore, rigorous randomized controlled trials (RCTs) are fundamental to establishing the efficacy and safety of adjunctive psychotherapies. RCTs provide the gold standard for evaluating intervention effectiveness, ensuring that treatments are evidence-based and replicable. Finally, researching the long-term outcomes of adjunctive psychotherapies is vital. Understanding the sustained effects of these interventions can inform the development of maintenance strategies, enabling individuals to manage bipolar disorder as a chronic condition effectively. These research areas collectively contribute to advancing our understanding of bipolar disorder treatment and improving the lives of those affected by this complex condition.

Sidebar

Address for Correspondence: Metin Çınaroǧlu, Istanbul Nişantaşı University, Department of Psychology, Istanbul, Türkiye

E-mail: [email protected]

Received: 26.07.2023 | Accepted: 30.10.2023

Authors Contributions: The author(s) have declared that they have made a significant scientific contribution to the study and have assisted in the preparation or revision of the manuscript

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared.

Financial Disclosure: No financial support was declared for this study.

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