Psychotherapeutic options for bipolar depression

My colleague, Dr. Michael Miller, wrote last week about the importance of adding psychotherapy to drug treatment in order to increase the chances of recovery from bipolar depression. This week, I’ll briefly describe four types of therapies which have the strongest evidence for being helpful.

Psychoeducation

This type of therapy may be delivered on its own, but it is also a key component of other psychosocial interventions for bipolar disorder. It is sometimes given in the context of larger programs of collaborative patient care. Psychoeducation can take place on an individual basis or as part of group therapy.

The goal is to provide social support and share information relevant to bipolar disorder so that a patient can adapt to living with a chronic illness and find ways to remain stable. Therapy may involve steps to reduce risk factors for relapse (by identifying and avoiding stressful people and events), to structure the day and normalize sleep/wake cycles, or to ensure access to emergency medication should symptoms escalate.

Cognitive behavioral therapy (CBT)

Several types of CBT for bipolar disorder exist, adapted from those used to treat unipolar depression. CBT encourages patients to recognize and change distorted thinking that may contribute to symptoms (often with the help of written assignments). In bipolar disorder, this involves challenging grandiosity and unreasonable risk taking, as well as pessimism.

This therapy also encourages patients to enjoy themselves and interact constructively with their environment, but to avoid the kind of stimulation — such as substance use or sleep deprivation — that could trigger a manic episode.

Family-focused therapy

Although many different forms of family therapy for bipolar disorder exist, the best studied is family-focused therapy, developed by psychologists David J. Miklowitz at the University of Colorado and Michael J. Goldstein at the University of California, Los Angeles.

The therapist educates family members about bipolar disorder so that they can better support a patient’s recovery. Over a period of nine months, clinicians teach the patient and family members how to recognize emerging symptoms of the disorder and prevent relapse, communicate productively, and resolve family and other interpersonal conflicts. A problem-solving component focuses on particular aspects of rebuilding a patient’s life after an acute episode, such as renegotiating intimate relationships, determining when it’s safe to return to work, and maintaining medication regimens while dealing with any side effects.

Interpersonal and social rhythm therapy

This therapy, developed by psychologist Ellen Frank and colleagues at the University of Pittsburgh, stresses the importance of establishing regular routines, such as going to bed and getting up at the same time every day, to avoid triggering a relapse. Therapists also help patients cope with grief over having a chronic illness. In addition, they focus on how interpersonal relationships affect mood and help patients renegotiate interpersonal roles in light of the illness.

Remaining challenges

One theme that is emerging from the research is that the most productive strategy is not to pit one type of therapy against another — as is usually the case in clinical trials. Instead, the best route to recovery may be to identify the most effective components common to all types of psychosocial therapy.

Have you ever tried one of these therapies? What was your experience?

Dr. Michael W. Kahn is an Assistant Professor in the Department of Psychiatry at Harvard Medical School, and is medical Director of Ambulatory Psychiatry at the Beth Israel Deaconess Medical Center in Boston.

Depression
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