Academic journal article Journal of Cognitive Psychotherapy

New Psychosocial Interventions for Bipolar Disorder: A Review of Literature and Introduction of the Systematic Treatment Enhancement Program

Academic journal article Journal of Cognitive Psychotherapy

New Psychosocial Interventions for Bipolar Disorder: A Review of Literature and Introduction of the Systematic Treatment Enhancement Program

Article excerpt

What is the evidence that psychosocial treatment adds to the efficacy of pharmacotherapy in forestalling episodes of bipolar disorder (BPD)? This article gives the rationale for including psychosocial intervention in the outpatient maintenance of BPD. Attention is placed on 4 psychosocial modalities that have achieved empirical support in randomized trials: family-focused psychoeducational treatment (FFT), cognitive-behavioral therapy (CBT), interpersonal and social rhythm therapy (IPSRT), and group psychoeducation. FFT, CBT, and IPSRT are being contrasted with a psychosocial control condition in the context of the ongoing, multicenter Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The objectives, design, and potential contributions of the STEP-BD study are explained. Future directions for the evaluation and dissemination of manual-based psychosocial interventions are discussed.

Keywords: psychosocial treatment; expressed emotion; pharmacology; psychotherapy, family therapy

Pharmacotherapy is the first-line treatment for bipolar symptoms during the acute, stabilization, and maintenance phases of the disorder. There is increasing evidence, however, that adjunctive psychosocial treatment offers more positive outcomes for bipolar disorder (BPD) than medication with routine clinical care alone (Bauer, 2002; Craighead & Miklowitz, 2000; Huxley, Parikh, & Baldessarini, 2000; Miklowitz & Craighead, 2001). The purpose of this article is to (1) explain the rationale for the use of psychosocial treatment as an adjunct to pharmacotherapy during stabilization and maintenance treatment; (2) review the empirical literature on adjunctive family, individual, and group therapy in relapse prevention and symptom management, and (3) explain the purposes, hypotheses, and design of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) a large-scale, multicenter effectiveness trial comparing four different forms of psychosocial intervention for acutely depressed bipolar patients (Sachs et al., 2003).

Limitations of Pharmacotherapy in the Outpatient Maintenance of BPD

Despite the clear benefits offered by mood stabilizers and other adjunctive pharmacotherapy for BPD (Goodwin & Ghaemi, 1998; McElroy & Keck, 2000; Thase & Sachs, 2000), a wealth of evidence suggests that these treatments are not enough by themselves to end the cycling and disability associated with the disorder. Ongoing recurrences and subsyndromal exacerbations appear to be the norm even with medication use (Gelenberg et al., 1989; Gitlin, Swendsen, Heller, & Hammen, 1995; Suppes, Dennehy, & Gibbons, 2000). Tohen, Waternaux, and Tsuang (1990), for example, found that relapses occurred in 72% of a Veterans Administration sample of BPD patients followed over 4 years, with the majority (51%) occurring during the first year. Likewise, Gitlin et al. (1995) found that 37% of outpatients in a university-based affective disorders clinic relapsed over 1 year, 60% over 2 years, and 73% over 5 years. Furthermore, a disturbingly low proportion of patients remains stable and symptom-free even when they do not relapse. After a first hospitalization for a bipolar, manic or mixed episode, only 26% of patients achieve a full symptomatic recovery over 12 months, and only 24% achieve full recovery of social-occupational functioning (Keck et al., 1998).

Problems with medication adherence complicate the outpatient management of BPD (Goodwin & Jamison, 1990). Patients complain bitterly about side effects of mood stabilizers such as weight gain, nausea, or cognitive dysfunction. Others report enjoying their manic periods and that medications take away feelings of exhilaration and creativity, yet do little to alleviate their ongoing depression. Accordingly, it is not surprising that poor medication adherence has been found in one-half to two-thirds of patients within the first year of treatment, with some data suggesting a modal length of compliance with mood stabilizers of 2 months (Johnson & McFarland, 1996; Keck et al. …

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