This chapter began by citing the example of a young man with bipolar disorder, and posed a question about the best treatment approach. Surely, the start of the answer is rooted in evidence, and some of the evidence has been reviewed briefly earlier. But clinical reality is influenced by a number of variables that extend beyond research evidence or "best practices". Patient attitudes, stigma on the part of both the patient and the provider, costs, availability of suitable providers, convenience, transportation access, the enthusiasm of providers, the nature of the treatment alliance, and the specific treatment preferences of a local environment are among the determinants of treatment initiation and continuation (Parikh, 1998). Large epidemiological surveys, such as the US National Comorbidity Survey (Kessler et al., 1994) and the Mental Health Supplement to the Ontario Health Survey (Parikh et al., 1996; 1997a; 1999), document that most individuals who fulfill diagnostic criteria for various mood disorders are not receiving treatment; among those in treatment, the median annual treatment frequency is less than 10 visits to any type of provider. Faced with this evidence and cognizant of the cost of high-intensity services, we must make recommendations for treatment that reflect what is readily achievable as well as what might constitute "best practice".
Integration of all of these perspectives would suggest that treatment be conceptualized in a pyramid form, much like Maslow's hierarchy of needs (Maslow, 1987), as noted in Figure 13.1. At the base of the pyramid in this figure is the need for pharmacotherapy and clinical management (supportive therapy including specifying treatment and monitoring outcome, offering practical advice for immediate problems such as work or school stressors, and instilling hope for relief of symptoms), essential for all patients. The second layer,
involving appropriate health-system design (tailored health services), would benefit most patients, and would involve specific suggestions on the use of the chronic disease model for bipolar disorder, with the creation of a health-care team for bipolar disorder. The treatment team would probably include nurse care coordinators/practitioners as key components, together with the ready availability of educational and other supports for both patients and health-care providers. The third layer, necessary for almost all patients, would be individual psychoeducation; based on the evidence and cost, brief group psychoeducation would be the ideal model. Various studies are employing Bauer and McBride's manual (1996) for group psychotherapy, from which a six-session psychoeducational component (phase I of the Life Goals Program) may be extracted. The highly readable and scripted format of the manual, its use in many studies, and even its translation into French and adoption in various clinical sites in Quebec and Europe suggest that this manual may be a prime model for cost-effective group psychoeducation.
The fourth layer of the pyramid, now necessary for fewer patients, would be specific individual psychotherapy—most likely, CBT or IPSRT. However, in reality, the benefits of both of these treatments include the fact that a key component of CBT includes illness education, relapse-prevention drills, and attention to sleep and other behavioral routines—in other words, topics already covered through the basic psychoeducation. Similarly, IPSRT includes many psychoeducational components as well. The unique features of CBT revolve around challenges to distorted cognitions and more detailed modulation of behavioral routines than would be done in basic psychoeducation. Similarly, the unique features of IPSRT
would include the extremely meticulous attention to social and biological rhythms, and, to some extent, interpersonal conflict/deficit resolution (Malkoff-Schwartz et al., 1998). In view of this, CBT could perhaps be reserved for those with poor illness management despite receipt of psychoeducation, and particularly those with very high dysfunctional attitudes at outset (easily quantified by the Dysfunctional Attitudes Scale [Weissman, 1979]). Recommendations of IPSRT would also be limited to those individuals both with poor illness management despite psychoeducation and with prominent interpersonal issues. In addition, pending additional research, both CBT and IPT may be appropriate to target specific types of episodes, such as bipolar depression (Swartz & Frank, 2001; Zaretsky et al., 1999).
Above the CBT and IPT layers of the pyramid, family and marital interventions would include basic psychoeducation as the fifth layer, possibly integrated with the original psychoeducation of the patient (Reinares et al., 2002). A separate sixth layer would be the more extensive and costly "gold standard" treatments, as described by Miklowitz and Goldstein (1990; 1997) or Clarkin et al. (1998), restricted to those with severe family and/or marital discord (Miklowitz et al., 1998). At the seventh level of the pyramid would be a rehabilitation layer; for purposes of this model, simple management of basic return to work and school would be incorporated into the first layers of pharmacotherapy and clinical management as well as in individual psychoeducation. In layer seven, "rehabilitation" refers to much more complex and detailed efforts to restore functioning, suitable for a small group of patients. Finally, the last layer of the pyramid would utilize psychotherapy models, such as psychodynamic therapy, to deal with more complex issues, personality problems, etc.
To return to the example, cited at the beginning of the chapter, of the young man with bipolar depression and a background of medication noncompliance and skepticism about the medical model, we can now develop some recommendations.
(1) Start a mood stabilizer, consider an antidepressant, offer practical advice (such as consider time off work or school, spend time with friends, etc.) and instill hope.
(2) In addition to the treating physician, consider enlisting a nurse who will more closely monitor the patient and may be able to form a more detailed treatment alliance that permits other interventions as below.
(3) Add basic psychoeducation (six sessions from Bauer and McBride's (1996) manual).
(4) Consider phase-specific psychotherapy: CBT for bipolar depression, particularly if a simple administration of the Dysfunctional Attitudes Scale shows an extremely high score.
(5) Consider adding IPSRT if the above measures are insufficient, particularly after medication and CBT interventions.
(6) Evaluate for family discord; provide one to two sessions of family psychoeducation.
(7) Consider an occupational therapy consultation if difficulty in returning to work or school is anticipated.
(8) Initiate family interventions as acute episode stabilizes, if indicated.
(9) Consider detailed psychotherapy if indicated after episode stabilizes; issues such as shame, stigma, and diminished self-esteem and future potential are common.
This sequence of steps assumes that treatment expertise is available in each modality; in reality, many jurisdictions will not be able to provide all treatments. But based on the treatment pyramid model, and in view of the fact that the most basic layers of the pyramid are those with both evidence and feasibility with respect to cost and practicality, it is advisable for any clinic undertaking to treat bipolar disorder to attempt to organize resources to provide as many of the basic layers of treatment as possible. To invest clinic resources heavily in IPSRT or family interventions, for example, without adequate efforts at more basic interventions would result in a mismatch between treatment needs and treatment available. The challenges of bipolar disorder are many; so, too, are the methods of treatment. Construction of a treatment model incorporating chronic disease-management principles allows for rational clinic planning, and for wise delivery of care to patients.
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