Why psychosocial therapies may help alleviate bipolar depression

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.

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.

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.

That is why 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.

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.

Next week my colleague, Dr. Michael Kahn, will write in more detail about particular therapies. For now, it’s important to remember that psychotherapies provide an important adjunct to drug treatment in bipolar depression—and help many people to recover.

Tell us about your experience with psychotherapy, medication or both for bipolar depression. What combination of treatments have you tried? What is your take on what helps you and what doesn’t?

Dr. Michael Miller has been on staff of the Beth Israel Deaconess Medical Center, a large teaching hospital in Boston, for more than 25 years. He is also an Assistant Professor of Psychiatry at Harvard Medical School.

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