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Early investigations of CBT techniques in bipolar disorder focused almost solely on the adherence to medical treatments. The main studies of this particular CBT application are by Benson (1975) and Cochran (1984). Benson (1975) reports a retrospective analysis of 31 bipolar disorder patients who were all in a manic phase at the start of treatment, receiving a combination treatment of lithium and psychotherapy. Comparisons were made between relapse in this group of people with a diagnosis of bipolar disorder and previous reports of relapse rates with lithium alone. He reports that 14% of his patients relapsed compared with the reported mean relapse rate of 34% with lithium alone. He suggests that psychotherapy is important to keep the patient motivated to continue lithium, to provide basic therapeutic support, and to monitor the patient's mood as a way of early detection of falling serum lithium levels.

Cochran's (1984) study is probably the most cited paper in the context of cognitive therapy for bipolar disorders. He evaluated the effectiveness of a preventative treatment-adherence intervention with 28 outpatients with a diagnosis of bipolar disorder who had recently started lithium treatment. The intervention consisted of six sessions of modified CBT aimed at cognitions and behaviour that seemed to be interfering with treatment adherence. Comparison was made with a control group who received standard outpatient follow-up, at the end of treatment and after 6-month follow-up. Neither the patient self-report nor the lithium levels showed an effect of the intervention; only the psychiatrists' observation showed better perceived adherence in the treatment group after therapy. At 6-month follow-up, patients in the treatment group showed significantly less hospitalisations and affective episodes. The intervention as described does not seem to take into account symptoms and other manifestations of the disorder, but pays attention only to compliance with pharmacological treatment.

A number of studies have since focused predominantly on relapse prevention and the identification of prodromal symptoms and early signs of relapse. Perry and colleagues

(1999) investigated 69 patients with a diagnosis of bipolar disorder who had had a relapse in the previous 12 months. Subjects were randomised into two conditions, 7-12 sessions with a research psychologist plus routine care or routine care alone. The CBT intervention consisted of teaching patients to recognise early symptoms of manic and depressive relapse and producing and rehearsing an action plan. By comparison, the treatment group experienced significantly longer intervals until manic relapse than the control group. Furthermore, the authors found significant improvements on measures of social functioning and employment in the treatment group compared with the control group 18 months after the baseline assessment.

Several more comprehensive studies utilising a CBT framework focused not only on treatment adherence, relapse prevention, and reduction of symptomatic distress but also on psychosocial functioning. Palmer and colleagues (1995) describe a psychoeducational and CBT programme in a group format for people with a diagnosis of bipolar disorder, currently in remission. Four participants attended 17 weekly group sessions. At the end of treatment, three of the four participants showed significant improvements in depressive and manic symptoms. Three of the four of the participants showed significant improvement in their social adjustment at the end of treatment and two at follow-up. Zaretsky and colleagues (1999) designed a cognitive behavioural intervention focusing on the treatment of acute symptoms rather than relapse prevention. In a matched case controlled design, they demonstrated the effectiveness of a 20-session CBT intervention for acute depression in the context of a bipolar disorder compared to the effectiveness in recurrent unipolar depression by comparing both groups in parallel. They found that depressive symptoms in eight bipolar and eight unipolar patients were significantly reduced after CBT intervention. Lam and colleagues

(2000) describe a cognitive therapy approach for a total of 12 bipolar patients. The treatment consisted of 12-20 sessions over 6 months. On a global symptom level (over 12 months), the treatment group had significantly fewer episodes and fewer hospitalisations than to the control group. The monthly self-report and observer ratings of manic and depressive symptoms confirmed that there was significantly lower level of manic and depressive symptoms in the treatment group over the course of the 12 months. The therapy group performed significantly better on medication compliance, social functioning, self-controlled behaviour, and coping with mania and depression prodromes. Patelis-Siotis (2001) reported outcomes of a 14-session adjunctive group CBT for patients suffering from a bipolar disorder. Forty-nine outpatients with a diagnosis of bipolar disorder currently maintained on a stable mood level on medication participated in a CBT group programme focusing on psychoeducation and cognitive behavioural intervention strategies. The results indicate no significant changes in mood-related symptoms between baseline and end of treatment. However, a significant increase in psychosocial functioning was found. Scott and colleagues (2001a) report the outcome of a randomised controlled study testing the feasibility and potential benefits of cognitive therapy for people with a diagnosis of bipolar disorder. Following assessment, patients were randomly assigned to immediate cognitive therapy or a 6-month waiting-list control condition. Both groups contained 21 subjects. Patients were followed up at 6-month intervals for a maximum of 18 months. In comparison with the waiting-list control groups, the CBT group showed significant reductions in symptoms and improvement in global functioning. They also found that significantly fewer subjects met criteria for relapse after CBT than before, and hospitalisation rates were significantly lower in the year after CBT intervention.

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