Academic journal article Journal of Cognitive Psychotherapy

Combining Medication Treatment and Cognitive-Behavior Therapy for Bipolar Disorder

Academic journal article Journal of Cognitive Psychotherapy

Combining Medication Treatment and Cognitive-Behavior Therapy for Bipolar Disorder

Article excerpt

Bipolar disorder (BPD) is a severe, recurrent psychiatric illness characterized by a chronic course of vacillating episodes of major depression and mania that impair functioning across many psychosocial domains ( DSM-IV; DSM-IV-TR ). Within each type of episode, changes occur in mood, cognitive processing, and regulation of vegetative functioning. Typical mood shifts include sadness (in depression) or euphoria (in mania). Either state can produce irritability, anxiety, and anger. In addition, both the process and the content of cognitive functioning are altered. Typical changes in process include decreased speed of thought in depression and increased speed of thought in mania. Content changes include negativity in depression and in mixed states, and grandiosity or paranoia in manic states. According to the cognitive-behavioral model of BPD (Basco & Rush, 2005), these changes in mood and cognition are accompanied by behavioral changes, typically increases in activity in mania and decreases in activity in depression. These behavioral changes, in turn, generally have a negative impact on the individual's psychosocial functioning, such as slowed work productivity, neglect of household or family responsibilities, and reduced involvement in social activities, bring negative consequences to patients as well as those in their primary support groups. In mania, risk taking, disorganized behavior, sleep loss, and reduced medication adherence quickly exacerbate symptoms, reduce quality of functioning, and create significant psychosocial problems. BPD is sensitive to stress (Goodwin & Jamison, 1990). As symptoms alter functioning, new stressors are created as a consequence. Added stress exacerbates symptoms, and functioning may decline further.

Keywords: cognitive therapy; bipolar; medication; noncompliance

Patients suffering from BPD have often been ill for quite some time prior to accurate diagnosis and treatment. Given that many have already married and begun families at the time of symptom onset, it is no surprise that when adequate care is finally offered, the clinician may need to spend as much time on marital and parenting issues as on medically treating the underlying disorder. Indeed, it is probably uncommon for purely medical management to suffice in any patient with newly diagnosed BPD.

Early on in the treatment of a patient with BPD, medication management may have to take first priority, because the patient may simply be too ill to benefit from or tolerate psychotherapy. Patients with severe mania, those who cycle very rapidly, those with psychosis, and those with profound depression may require the improvement that comes from beginning a medication regimen and the stabilization and decrease in symptom intensity that usually follows. Once this is achieved, formal psychotherapy can begin. During this early phase, when the severity of symptoms may interfere with psychotherapy, much useful psychotherapeutic work can be done with patients' families. Education about the disorder as well as support by the management team can help prepare the family for further psychotherapeutic work after the patient is stabilized.

There is no absolute rule for when to begin psychotherapy. In general, manic or mixed patients need to be relatively free of intense psychotic symptoms and stable enough to tolerate 15-20 minutes of interaction without becoming agitated or irritable. Early in treatment with a very ill patient, the sessions may be quite brief. Some outpatients can benefit from several brief office visits during a week rather than one hour-long session. Some patients suffering from depression may benefit little from psychotherapy until psychosis and intense psychomotor retardation have improved. An example is Jim, who was referred for treatment in an effort to avoid rehospitalization. Jim had been hospitalized several weeks before and had been released once his suicidal ideation subsided. However, his depression continued to be so severe that it was difficult for him to make conversation or maintain eye contact. …

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