Medication remains the cornerstone of treatment for bipolar disorder, so prescription of at least a mood stabilizer would be routine. Furthermore, while there may be cost factors in seeing a physician and filling a prescription, for all practical purposes such interventions are feasible in virtually all health-care environments in the developed world. Specific medication recommendations are outlined elsewhere in this volume, and would be combined with basic 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). However, abundant data demonstrate poor medication adherence in bipolar disorder (Cohen et al., 2000); thus, the next level of intervention would be compliance-enhancing strategies. Such strategies would generally fall into the category of psychoeducation, which multiple studies have demonstrated to improve medication compliance and overall treatment adherence (Sperry, 1995). Key studies have also shown that psychoeducation improves clinical outcomes; a median of nine sessions designed to educate the patient on the signs and symptoms of early relapse and the development of an early-warning strategy dramatically reduced time to relapse into mania and improved quality of life in a randomized controlled trial (Perry et al., 1999). A manual on group psychotherapy for bipolar disorder, which includes detailed instructions for a six-session "phase I of the Life Goals Program", could be a template for either individual or group psychoeducation (Bauer & McBride, 1996). This psychoeducational intervention has been validated in a pilot study (Bauer et al., 1998); we are now comparing this to a 20-session CBT intervention in a randomized controlled trial of 210 bipolar patients across multiple sites in Canada, which will also provide further delineation of the benefits of psychoeducation.
Beyond psychoeducation, specific psychotherapeutic interventions are now emerging. At the time of our earlier reviews (Huxley et al., 2000; Parikh et al., 1997b), we found 32 peer-reviewed reports involving just 1052 bipolar patients (average number per study was just 33), with only 13 studies having some form of control group. Since 1999, various reports of psychosocial interventions have been published, including many randomized, controlled trials, some of which involved close to 100 subjects each.
Findings from these latest studies have been summarized elsewhere in this volume, but bear brief summary to allow consideration of treatment choice. A randomized, controlled comparison of intensive clinical management (CM) versus interpersonal and social rhythm therapy (IPSRT) involving 82 subjects revealed few differences in impact, with significant increases in relapses when subjects were crossed over from one modality to the other as part of the research design (Frank et al., 1997; 1999). The authors suggested that disruption to the psychosocial treatment routine itself was a sufficient stressor to provoke relapse— an important demonstration of the value of "continuity of care" (Hammen et al., 1992; Hammen & Gitlin, 1997). Several studies—some pilot, others full trials (Hirschfeld et al., 1998; Lam et al., 2000; 2003; Scott et al., 2001)—have demonstrated marked efficacy of CBT versus "treatment as usual" in overall illness course, incorporating both prevention of relapse and reduction in overall affective and functional morbidity. However, each of these interventions was lengthy (16-20 sessions), and all were delivered as individual psychotherapy. Access to CBT therapists, particularly those who are comfortable with and knowledgeable about bipolar disorder, is universally difficult, and offering 20 sessions of individual CBT to every new bipolar patient is impractical and costly. Moreover, a significant portion of CBT interventions for bipolar disorder incorporates basic psychoeducation, including illness recognition and development of relapse-prevention strategies. Such difficulties have led us to conduct a series of studies on psychoeducation alone (five sessions) versus treatment as usual (Parikh et al., 2001), individual psychoeducation (seven sessions) versus individual CBT (20 sessions) (Zaretsky et al., 2001), and a recent comparison of six sessions of group psychoeducation versus 20 sessions of individual CBT (Parikh et al., unpublished). Preliminary findings from a recently completed 'randomized, controlled trial (Zaretsky et al., 2001) involving seven individual sessions of psychoeducation compared to the same seven sessions plus 13 sessions of CBT, all drawn from another manual (Basco & Rush, 1996), suggest that a brief psychoeducational intervention was indeed very similar in impact to the longer psychoeducation (PE) plus CBT. One key difference in our study was that CBT was clearly more successful than PE in reducing dysfunctional attitudes in those who entered CBT (during the maintenance phase of bipolar disorder) with very high dysfunctional attitudes scores. If we keep in mind earlier findings about persistent negative cognitions in many patients with bipolar depression (Zaretsky et al., 1999), as well as abnormal cognitive styles (Reilly-Harrington et al., 1999), and the additional costs of CBT, a picture may be emerging that suggests brief group psychoeducation for all nonpsy-chotic bipolar patients as an initial step, with CBT being relegated to a secondary role for individuals with persistent problems and, in particular, persistent dysfunctional attitudes.
A similar analysis may be done regarding the role of family and marital interventions for bipolar disorder. As we previously reviewed (Huxley et al., 2000), 13 earlier studies of marital or family therapy, though severely limited methodologically, did suggest benefit from these interventions. Of the six controlled studies, the two with the fewest subjects and shortest interventions (Van Gent & Zwart, 1991, who used a five-session intervention for partners of bipolar patients and Honig et al., 1997, who used a six-session intervention with couples) showed the fewest benefits. Among the two controlled studies showing the most clinical benefit, Clarkin et al. (1998) used a 25-session marital intervention for couples; Miklowitz and Goldstein (1990) used a 21-session family therapy treatment to achieve results (in a pilot study). A larger (involving 101 bipolar patients with their families) randomized, controlled study by Miklowitz et al. (2000) used the 21-session family intervention compared to two family sessions and follow-up crisis management, and did show improvements in terms of fewer depressive relapses for the family-intervention group, but primarily in those families prospectively identified as having the highest negative expressed emotion. Furthermore, outcome was not related to therapist fidelity to the model (Weisman et al., 2002). Such findings are sobering; high-intensity treatments of typically more than 20 sessions, involving considerable patient effort to involve family, offer some benefit. The direct and indirect costs of such an intervention surely must be high. The ability of the health-care system to support such an intervention or the likelihood of many patients and families being able to attend such an intervention must surely be low. Balancing resources with need, and wisdom with evidence, perhaps such intensive family interventions are best reserved for those with early evidence of high need, such as high negative expressed emotion and obvious conflict—a recommendation that would mirror common clinical practice.
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