NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Collaborating Centre for Mental Health (UK). Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care. Leicester (UK): British Psychological Society; 2006. (NICE Clinical Guidelines, No. 38.)

Cover of Bipolar Disorder

Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care.

Show details

10PSYCHOLOGICAL THERAPIES IN THE TREATMENT OF BIPOLAR DISORDER

10.1. INTRODUCTION: HISTORY OF TREATMENT FOR BIPOLAR DISORDER

Treatment for bipolar disorder traditionally has been predominantly pharmacotherapy. However, prophylactic agents such as lithium provide a long-term benefit for only about two thirds of patients with bipolar disorder (Goodwin, 2002; Prien & Potter, 1990). Lamotrigine may have a long-term role in delaying or preventing the recurrence of depressive episodes but lithium, antipsychotics and valproate semisodium remain first-line treatments (Calabrese, et al., 2002). In view of the limitations of pharmacotherapy alone to prevent relapses, there has been an emerging interest in developing psychological treatments specifically designed for bipolar disorder in recent years (Lam, 2002).

One of the first psychological treatments to be offered to people with bipolar disorder was psychoanalytic psychotherapy. There has been a longstanding clinical and theoretical interest in the treatment of bipolar disorder in the field of psychoanalysis. Over the past 70 years a number of case studies have reported treatment outcomes for people with bipolar disorder but there have been no systematic reviews or controlled trials that have evaluated the psychoanalytic treatment of bipolar disorder.

10.2. PRINCIPLES OF PSYCHOLOGICAL TREATMENT

10.2.1. Diathesis-stress model and combined treatment

As for most severe mental disorders, the diathesis-stress model applies to bipolar disorders. Biology predisposes individuals to be vulnerable to bipolar disorders. Yet, stress can both bring on the illness and affect its course. Hence, all randomised controlled psychological treatment studies cited below are combined treatments of medication and psychological therapy.

10.2.2. Aims of psychological intervention

The aims of psychological therapy are the prevention of relapses and the promotion of social functioning. Other aims may include the reduction of mood symptoms and mood fluctuations, promoting good coping skills, the enhancement of medication compliance and promoting communication within the family.

10.2.3. Time of recruitment

Bipolar disorder is a complex illness. Treatments for different phases of the illness are likely to be different. Psychological strategies designed for prevention of relapses may be minimally effective for an acute episode. In fact, strategies designed to target an acute episode may be different. Hence, it is important to be clear whether the goal of intervention is for the acute episode or relapse prevention for patients out of an acute episode. So far, the evidence for efficacy of combined drug and psychological treatment is mainly in relapse prevention for patients who are out of an acute episode (for example, Lam et al., 2003) or very stable patients (for example, Colom et al., 2003a).

10.2.4. Therapists’ variables

Psychological treatments for bipolar disorder are complex and require a high level of therapist expertise. These include psychological skills as well as sound knowledge about bipolar disorder and its pharmacological treatment. Such knowledge enables therapists to discuss treatment options intelligently with patients and gain credibility. Furthermore, it enables therapists to detect early stages of a manic relapse and institute strategies to prevent early stages escalating to full-blown episodes. Pharmacological intervention may also need to be instituted for patients with a history of rapid swings into mania. This is made much easier if therapists are familiar with the disorder and its pharmacological management.

10.2.5. Variation in delivery of psychological therapy

Efficacy evidence for psychological therapy in bipolar disorder has come from a variety of sources including individual work (Frank et al., 2005; Lam et al., 2000; Scott et al., 2001; Lam et al., 2003; Scott et al., 2006), group work (Colom et al., 2003a) and family work (Miklowitz et al., 2000). The choice of mode of delivery depends on patients’ preference, constraints of local services and patients’ mental state. For example, complex psychoeducational groups as conducted by Colom’s group should only be considered when patients have been stable for several months.

Psychological treatment approaches specific for bipolar disorder identified by the GDG to have some evidence of treatment efficacy include the following:

  • Cognitive behavioural therapy (CBT)
  • ‘Complex’ psychoeducation
  • Focused family therapy
  • Interpersonal and social rhythm therapy (IPSRT)
  • Identifying early warnings and seeking help.

10.2.6. Shared common features

Irrespective of differences in theoretical frameworks and mode of delivery, there are some common features in psychological work in relapse prevention in bipolar disorders. These include:

  • Psychoeducation about the illness
  • Promoting medication adherence
  • Promotion of regular daily routine and sleep
  • Monitoring mood, detection of early warnings and strategy to prevent early stages from developing into full-blown episodes
  • General coping strategies including problem-solving techniques

10.3. THE EARLY WARNING APPROACH

The interest in studying early warnings of relapse in bipolar disorder is based on the assumption that if patients can detect early warnings, actions may be taken to prevent the development of a full episode. Studies have found that bipolar patients can report early warnings of relapses reliably (Molnar et al., 1988; Lam et al., 2001) and are better at reporting early warnings of mania than early warnings of depression (Lam & Wong, 1997). However, the patterns of early warnings and the length of early warning periods are different for different patients (Smith & Tarrier, 1992; Jackson et al., 2003; Lam & Wong, 2005). Only one study investigated the effect of adaptive coping with early warnings on the course of the illness in bipolar disorder. A cross-sectional study reported that bipolar patients’ level of functioning was highly related to how well they coped with the early warning signs (Lam & Wong, 1997). It was also found that adaptive cognitive and behavioural coping strategies for early warnings predicted fewer manic symptoms, good functional outcomes and reduced relapses 18 months later (Lam & Wong, 2001). Common early warning signs of mania include decreased need for sleep, increased activity, being more sociable and racing thoughts, while common early warning signs of depression are loss of interest, not being able to put worries aside and interrupted sleep (Lam et al., 2001).

10.4. OVERVIEW OF CLINICAL REVIEW

10.4.1. Definitions of psychological therapies reviewed

Cognitive behavioural therapies (CBT)

Cognitive behavioural therapies were defined as discrete, time limited, structured psychological interventions derived from the cognitive behavioural model of affective disorders and where the patient:

  • works collaboratively with the therapist to identify the types and effects of thoughts, beliefs and interpretations on current symptoms, feelings states and/or problem areas
  • develops skills to identify, monitor and then counteract problematic thoughts, beliefs and interpretations related to the target symptoms/problems
  • tackles dysfunctional assumptions, which may maintain some high-goal attainment behaviour
  • learns a repertoire of coping skills appropriate to the target thoughts, beliefs and/or problem areas.

Family interventions

Family sessions with a specific supportive or treatment function based on systemic, cognitive behavioural or psychoanalytic principles, which must contain at least one of the following:

  • psychoeducational intervention
  • problem solving/crisis management work
  • intervention with the identified patient.

Complex psychoeducation

Complex psychoeducation was defined as any group programme involving an explicitly described educational interaction between the information provider and the patient/carer as the prime focus of the intervention. Patients/carers should be provided with information, support and different management strategies, including:

  • illness awareness
  • treatment compliance
  • early detection of prodromal symptoms and relapse
  • lifestyle regularity.

Interpersonal and social rhythm therapy (IPSRT)

IPSRT was defined as discrete, time limited, structured psychological intervention derived from an interpersonal model of affective disorders that focuses on:

  • working collaboratively with the therapist to identify the effects of key problematic areas related to interpersonal conflicts, role transitions, grief and loss, and social skills, and their effects on current symptoms, feelings states and/or problems
  • seeking to reduce symptoms by learning to cope with or resolve these interpersonal problem areas
  • seeking to improve the regularity of daily life in order to minimise relapse.

10.4.2. Evidence search

The review team conducted a new systematic search for RCTs that assessed the efficacy of psychological interventions for people with bipolar disorder, both in an acute illness phase and as long-term treatment for people who have recovered from an acute episode. Databases searched are in Table 74.

Table 74. Databases searched and inclusion/exclusion criteria for clinical effectiveness of psychological interventions.

Table 74

Databases searched and inclusion/exclusion criteria for clinical effectiveness of psychological interventions.

10.4.3. Presenting the evidence

Systematic reviews of the evidence are based on the searches described above, supplemented with additional narrative as necessary. Relevant characteristics of all included studies are in Appendix 22, together with a list of excluded studies with reasons for exclusion, and full references for both included and excluded studies. These are presented for each topic covered in this chapter. To aid readability, summaries of the study characteristics are included below, followed by the critical outcomes from the evidence profiles, together with a summary of the evidence profile.

In all of these, studies are referred to by a study ID (primary author in capital letters and date of study publication, except where a study is in press or only submitted for publication, then a date is not used).

Based on the GRADE methodology outlined in chapter 3, the quality of the evidence is summarised in the evidence profiles and summary of the evidence profiles as follows:

  • high = Further research is very unlikely to change our confidence in the estimate of the effect
  • moderate = Further research is likely to have an important impact on our confidence in the estimate of the effect and may change the estimate
  • low = Further research is very likely to have an important impact on our confidence in the estimate of the effect and is likely to change the estimate
  • very low = Any estimate of effect is very uncertain.

10.4.4. Search results

Twenty-one trials were identified from searches of electronic databases, 11 of which met the eligibility criteria set by the GDG (COCHRAN1984; COLOM2003; COLOM2003A; FRANK1997; LAM2000; LAM2003; MIKLOWITZ2000; PERRY1999; REA2003; SCHMITZ2003; SCOTT2001), and pre-publication copies of a further four trials were sourced directly from known researchers in the field, one of which has been subsequently published (MILLER2004; SCOTT2006; MEYER unpub; BALL, in press). Three of these met inclusion criteria (BALL, in press MILLER2004; SCOTT2006) (see section on CBT below). Excluded studies with reasons for exclusion can be seen in Appendix 22. See tables below for a summary of the characteristics of included studies. Further details are available in Appendix 22.

10.4.5. Review strategy

There are very few studies of psychological therapy in bipolar disorder. In addition, there are no studies of psychological therapy where all participants are in an acute episode, although some studies recruited during acute-phase treatment (for example, REA2003) and others included some acute-phase patients (for example, SCOTT2006). In the main, it was not possible to combine studies using meta-analysis because of heterogeneity in study populations and interventions. Therefore, the review team calculated effect sizes for study outcomes for each study individually (see evidence profiles). The studies are presented below by intervention, with particular issues with individual studies discussed as appropriate.

10.5. OVERVIEW OF HEALTH ECONOMICS REVIEW

The systematic literature search for economic studies identified one study that assessed the cost-effectiveness of CBT combined with pharmacological treatment for long-term maintenance of patients with bipolar disorder (LAM2003). The full reference and characteristics of the study are presented in the evidence tables for economic studies in Appendix 14.

10.6. FAMILY INTERVENTIONS

10.6.1. Clinical studies considered for family interventions

Three studies were of family interventions (REA2003; MIKLOWITZ2000; MILLER unpub) all undertaken in the US. These recruited patients during an acute episode, with treatment starting either whilst the acute phase was still ongoing (MILLER2004, MIKLOWITZ2000) or once participants were stabilised (REA2003). See Table 75.

Table 75. Summary of study characteristics for family interventions (all adjunctive to medication).

Table 75

Summary of study characteristics for family interventions (all adjunctive to medication).

10.6.2. Overview of clinical findings

An evidence profile detailing results from these trials is in Appendix 23, and a summary is provided in Table 76.

Table 76. Summary evidence profile for family interventions.

Table 76

Summary evidence profile for family interventions.

The three studies of family interventions provide some evidence of effectiveness of family interventions, although the overall quality is moderate. Patients in all studies were taking prophylactic medication.

REA2003 included a young patient population (average age 26 years), recruited during an acute manic episode (40% in a first episode), with treatment starting once patients were stabilised. There were no details of the randomisation process. For this population, there is evidence that compared with individual interventions, a family intervention resulted in better outcomes as measured by relapse and hospitalisation at 1 year follow-up, although this evidence is of moderate quality. Other outcomes were inconclusive.

MIKLOWITZ2000 included a mix of people with more established morbidity in depressed, acute and mixed illness phases. It is not clear whether treatment started during the acute episode. However, the study provides some evidence of efficacy of family interventions compared with crisis management at follow-up.

MILLER2004 provides evidence of family interventions compared with pharmacotherapy with clinical management or multi-family psychoeducation groups. Evidence was inconclusive compared with multi-family psychoeducation groups. Compared with pharmacotherapy plus clinical management family interventions showed some efficacy, although the overall quality of evidence is low.

10.7. PSYCHOEDUCATION

10.7.1. Clinical studies considered for psychoeducation

There were two studies of ‘complex’ psychoeducation (COLOM2003; COLOM2003A), with one further study classified as psychoeducation (PERRY1999). Only COLOM2003 and COLOM2003A were combined in meta-analysis. All these studies recruited euthymic patients. See Table 77.

Table 77. Summary of study characteristics for psychoeducation (all adjunctive to medication).

Table 77

Summary of study characteristics for psychoeducation (all adjunctive to medication).

10.7.2. Overview of clinical findings

An evidence profile detailing results from these trials is in Appendix 23 and a summary is provided in Table 78.

Table 78. Summary evidence profile for psychoeducation.

Table 78

Summary evidence profile for psychoeducation.

COLOM2003 and COLOM2003A compared group complex psychoeducation (which included psychoeducation about bipolar disorder, communication enhancement training and problem-solving skills training) with group non-directive support in patients who were euthymic at baseline and, in COLOM2003, had been compliant to medication in the previous 6 months. Both studies were undertaken in a specialist centre in Spain and all participants were maintained on medication. There was a high dropout rate. Group complex psychoeducation was more effective than group non-directive support at 2-year follow-up based on the number relapsed. However, other outcomes were inconclusive and the overall quality of evidence is moderate.

PERRY1999 compared psychoeducation with no additional treatment in euthymic patients maintained on medication and was undertaken in the UK. The intervention focused on helping patients to identify early warning signs. The intervention was effective in helping to prevent relapse into manic episodes, but not depressed episodes. Other primary outcomes were inconclusive. The overall quality of evidence is moderate.

10.8. COGNITIVE BEHAVIOURAL THERAPY (CBT)

10.8.1. Clinical studies considered for CBT

Four studies of CBT (LAM2000, LAM2003, SCOTT2001, SCOTT2006), all undertaken in the UK, met inclusion criteria. The majority of these studies recruited euthymic patients maintained on prophylactic medication, two being of patients liable to relapse (LAM2000, LAM2003) and one study, SCOTT2006, which included a proportion of patients in the acute phase as well as some unmedicated patients. For SCOTT2006, data were obtained from the trial authors that excluded these acute patients. In addition, the GDG secured initial data from an unpublished study undertaken in Germany (MEYER unpub). However, this study was not included in the analyses since the relevant outcomes could not be reliably extracted. An additional study, BALL unpub, was also secured and included in the analysis. A summary of study characteristics of included studies is in Table 79.

Table 79. Summary of study characteristics for CBT (all adjunctive to medication).

Table 79

Summary of study characteristics for CBT (all adjunctive to medication).

10.8.2. Overview of clinical findings

An evidence profile detailing results from these trials is in Appendix 23, and a summary is provided in Table 80.

Table 80. Summary of evidence profile for CBT in preventing relapse.

Table 80

Summary of evidence profile for CBT in preventing relapse.

There were some quality issues in the SCOTT2001 trial (randomisation method not clear, and not clear if assessors blinded). However, there was some evidence of the efficacy of CBT compared with no psychological therapy based on relapse data at follow-up, although there was considerable heterogeneity in the dataset. The SCOTT2006 and LAM2003 studies produced consistently different effect sizes, with LAM2006 producing an effect favouring CBT and the SCOTT2006 result either favouring neither CBT nor treatment as usual, or favouring treatment as usual but with wide 95% CIs leading to a categorisation of inconclusive. This is likely to be due to the different populations in the trials. SCOTT2006 included patients with a history of multiple recurrences, substance use and other psychiatric diagnoses. The trial was removed in sensitivity analyses to reduce or remove heterogeneity.

10.8.3. Health economics evidence

One study assessing the cost-effectiveness of CBT as part of prophylactic treatment for patients with bipolar disorder met the eligibility criteria for inclusion in the systematic review of economic literature (LAM2003). The economic analysis was undertaken alongside an RCT conducted in the UK. The study population consisted of adult patients with bipolar I disorder who experienced frequent relapses despite being prescribed commonly used prophylactic agents. Patients experiencing an acute episode or with high residual symptoms at the beginning of the study were excluded from the trial. CBT comprised an average of 14 sessions over 6 months plus two booster sessions in the following 6 months. CBT was added to standard care, defined as treatment with prophylactic medication at a recommended level combined with regular psychiatric outpatient follow-up. Therefore, the CBT group received CBT added to standard care, whereas the control group received standard care alone. The time frame of the analysis was 30 months overall, with results over the first 12 months of the trial also being analysed. The perspective of the analysis was that of health and social care; estimated costs included costs associated with hospital care (inpatient, outpatient, day hospital, accident and emergency attendances), mental health services (psychiatrists, psychologists, community mental health nurses, and so on), contact with GPs, social workers, support groups, and residential care. The primary outcome measure of the analysis was the number of days free from acute bipolar episode per patient.

CBT added to standard care was demonstrated to be more effective than standard care alone. Patients in the CBT group spent on average significantly fewer days in acute bipolar episodes compared with the control group over 12 months and also over the whole follow-up period of 30 months. In addition, mean total costs per patient in the CBT group were lower than those in the control group for both periods of time examined, as costs associated with provision of CBT were offset by a reduction in costs of other health and social services. However, this difference in costs between the two groups was not statistically significant (mean total cost per patient over 30 months £10,352 in the CBT group and £11,724 in the control group, 1999/2000 prices).

A probabilistic analysis based on a regression model by applying bootstrapping techniques on the trial results was also carried out. Results were presented in the form of CEACs, which showed the probability of CBT added to standard care being cost-effective for a range of potential values placed on the WTP for an additional day free from bipolar episode. The analysis demonstrated that, even with zero WTP for an additional day free from episode, the probability of CBT being cost-effective was 0.85 for the first 12 months and 0.80 for the whole 30-month study period. At a WTP equal to £10 per additional day free from episode, the probability of CBT being cost-effective rose to 0.90 for the first 12 months and 0.85 for the overall 30-month time frame of the analysis.

Despite the limitations of the study, such as the small study size (n = 103 at randomisation; cost data available for n = 83 subjects at 30 months) and the method of collection of costing data, which was based on self-report and hospital records, the analysis suggests that addition of CBT to standard prophylactic pharmacological treatment is likely to be a cost-effective option in the UK for patients with bipolar I disorder: it is significantly more effective than prophylactic pharmacological treatment alone at no extra total cost.

10.9. PSYCHOLOGICAL THERAPY FOR PEOPLE WITH COMORBID SUBSTANCE USE DISORDER

10.9.1. Studies considered for review

There was one study of psychological therapy for people with comorbid substance use disorder (SCHMITZ2003). See Table 81.

Table 81. Summary of study characteristics for CBT for comorbid substance use versus medication alone.

Table 81

Summary of study characteristics for CBT for comorbid substance use versus medication alone.

10.9.2. Overview of clinical findings

There were no extractable efficacy data and therefore it was not possible to assess this treatment.

10.10. INTERPERSONAL AND SOCIAL RHYTHM THERAPY (IPSRT)

10.10.1. Studies considered for review

There was one study of IPSRT (FRANK1997). This compared IPSRT with ICM. Participants were recruited during an acute episode and randomised to treatment or control. When their illness had stabilised (defined as 4 consecutive weeks with HRSD <= 7 and Bech-Rafaelsen Mania Scale (BRMS) <= 7), they were randomised to either continue with their acute treatment or switch to the other treatment. The different papers published from this trial give slightly different accounts of how this was done. From earlier papers it appears that participants were randomised to acute treatment and then re-randomised on stabilisation, but the later paper implies that both randomisation procedures were undertaken at the study start, but that the second allocation was not made known until stabilisation. An overview of the study’s characteristics is in Table 82.

Table 82. Summary of study characteristics for IPSRT.

Table 82

Summary of study characteristics for IPSRT.

10.10.2. Overview of clinical findings

There were few extractable efficacy data from this trial, so the evidence profile is based on recurrence rates – see Table 83 for a summary. Also, since participants were re-randomised to maintenance treatment, it is not appropriate to calculate effect sizes from groups at the level of acute-maintenance treatment, since this violates the principle of independent data points. Additionally, only those who had stabilised were entered into the maintenance phase. Therefore, acute-phase treatments and maintenance-phase treatments were compared separately regardless of allocation in the other phase of the trial.

Table 83. Summary of evidence profile for IPSRT.

Table 83

Summary of evidence profile for IPSRT.

On raw recurrence rates at 2 years, based on separate analyses of allocation acute-and maintenance-phase data, and including all those randomised in the analysis based on acute-phase allocation, there is an effect for acute-phase IPSRT.

10.11. PSYCHOLOGICAL THERAPY FOR MEDICATION ADHERENCE

10.11.1. Studies considered for review

There was one study of psychological therapy aimed specifically at medication adherence (COCHRAN1984). See Table 84.

Table 84. Summary of study characteristics for psychological therapy for medication adherence.

Table 84

Summary of study characteristics for psychological therapy for medication adherence.

10.11.2. Overview of clinical findings

See Table 85 for a summary. All outcomes were inconclusive.

Table 85. Summary of evidence profile for psychological therapy for medication adherence.

Table 85

Summary of evidence profile for psychological therapy for medication adherence.

10.12. Clinical summary

10.12.1. Psychological treatments aimed at preventing relapses of bipolar disorder

In common with many other treatment interventions for bipolar disorder, there is relatively little research in this area, with only a few promising studies largely undertaken by specialist research groups. Therefore, it is uncertain whether the results generated by these studies, which show some effect of treatment, are generalisable to the wider clinical situation. Although there is a slightly wider base for CBT compared with other therapies, there are problems in the research base, such as population comparability. Overall, there are considerable methodological problems relating to the illness phase during which people are recruited into trials and there are problems with inconsistent outcomes. In addition, there is no evidence for populations such as adolescents and older adults, and no evidence for people in the acute illness phase (in particular, depression, where evidence from unipolar populations indicates that psychological therapy is effective). Future research should focus on which populations are likely to gain benefit from psychological therapy, for example, based on whether patients are more liable to depressed or manic relapses.

10.12.2. Psychological approaches aimed at substance misuse

There is no evidence for psychological therapies in the treatment of bipolar disorder with comorbid substance use disorder.

10.12.3. Psychological approaches aimed at improving adherence

There is one low-quality study where the intervention is specifically aimed at improving medication adherence using basic CBT techniques and on no outcome is there convincing evidence in favour of the treatment. However, there is some evidence from other studies reviewed in this section that psychological therapies in general, rather than specific compliance therapy, improve compliance.

10.13. SUMMARY OF ECONOMIC EVIDENCE

There is evidence suggesting that CBT added to pharmacological treatment is a cost-effective option for the long-term maintenance of patients with bipolar I disorder in the UK.

10.14. PSYCHOLOGICAL TREATMENTS FOR CHILDREN AND ADOLESCENTS

There are no formal evaluations of psychological interventions for children and adolescents with bipolar disorder, despite the fact that broad psychological approaches to their treatment and management are common. In most cases psychologically informed care management services are offered to children with bipolar disorder. This would include a comprehensive multidisciplinary assessment and a range of individual psychological and family interventions. In most cases this also involves significant liaison with school, home (including home visiting where necessary) and primary care. Rarely will formal therapy such as cognitive behavioural or psychodynamic psychotherapy be offered to children with these. The most likely psychological approach is an eclectic one aimed at elaborating and formulating the individual’s problems with an attempt at interventions that are perceived as reducing the individual’s vulnerability to further episodes. In these circumstances, considerable caution should be exercised before offering formal psychological therapies but it seems likely that the individual structured psychological therapies, for which there is evidence from adults that they are potentially effective, would have application in particular for developmentally advanced adolescents.

Of paramount importance in the management of children with severe mental illness such as bipolar disorder, is the involvement of their families. Again, there is very little evidence to support the use of formal interventions, although a number of detailed intensive interventions aimed at families have been developed (MIKLOWITZ2000, REA2003). Again, with more developmentally advanced adolescents the offer of these structured formal family interventions may be of benefit.

10.15. CLINICAL RECOMMENDATIONS

Recommendations for psychological therapy during an acute depressive episode are included in the relevant section of Chapter 9.

General principles of the management of people with bipolar disorder

10.15.1.1.

Healthcare professionals should aim to develop a therapeutic relationship with all patients with bipolar disorder, and advise them on careful and regular self-monitoring of symptoms (including triggers and early warning signs), lifestyle (including sleep hygiene and work patterns) and coping strategies.

Psychological therapy following recovery from an acute episode

10.15.1.2.

Individual structured psychological interventions should be considered for people with bipolar disorder who are relatively stable, but may be experience mild to moderate affective symptoms. The therapy should be in addition to prophylactic medication, should normally be at least 16 sessions (over 6 to 9 months) and should:

  • include psychoeducation about the illness, and the importance of regular daily routine and sleep and concordance with medication
  • include monitoring mood, detection of early warnings and strategies to prevent progression into full-blown episodes
  • enhance general coping strategies.
10.15.1.3.

Structured psychological interventions should be delivered by people who are competent to do this and have experience of patients with bipolar disorder.

10.15.1.4.

Healthcare professionals should consider offering a focused family intervention to people with bipolar disorder in regular contact with their families, if a focus for the intervention can be agreed. The intervention should take place over 6–9 months, and cover psychoeducation about the illness, ways to improve communication and problem solving.

Harmful drug/alcohol use in bipolar disorder

10.15.1.5.

For people with bipolar disorder and comorbid harmful drug and/or alcohol use, a psychosocial intervention targeted at the drug and/or alcohol use (for example, psychoeducation and motivational enhancement) should be considered. This should normally be delivered by general mental health services, working with specialist substance use services where appropriate.

Early warnings

10.15.1.6.

Healthcare professionals, in collaboration with patients, should develop a plan to identify the symptoms and indicators of a potential exacerbation of the disorder, and how to respond (including both psychosocial and pharmacological interventions)

Personality disorder

10.15.1.7.

People with bipolar disorder and comorbid personality disorder should receive the same care as others with bipolar disorder, because the presence of a personality disorder does not preclude the delivery of effective treatments for bipolar disorder.

Special considerations for children and adolescents

10.15.1.8.

When planning the care of children and adolescents with bipolar disorder, healthcare professionals should consider:

  • stressors and vulnerabilities in their social, educational and family environments, including the quality of interpersonal relationships
  • the impact of any comorbidities, such as attention deficit hyperactivity disorder (ADHD) and anxiety disorders
  • the impact of the disorder on their social inclusion and education
  • their vulnerability to exploitation, for example, as a result of disinhibited behaviour.
10.15.1.9.

Parents or carers (and possibly other family members) should be involved in developing care plans so that they can give informed consent, support the psychological goals of treatment, and help to ensure treatment adherence.

10.15.1.10.

Children and adolescents should be offered separate individual appointments with a healthcare professional in addition to joint meetings with their family members or carers.

Copyright © 2006, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Bookshelf ID: NBK55366

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (2.5M)
  • Disable Glossary Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...