Elsevier

Journal of Affective Disorders

Volume 156, 1 March 2014, Pages 46-55
Journal of Affective Disorders

Review
Psychosocial interventions in bipolar disorder: What, for whom, and when

https://doi.org/10.1016/j.jad.2013.12.017Get rights and content

Abstract

Background

Bipolar disorder (BD) is a chronic condition with a high relapse rate, morbidity and psychosocial impairment that often persist despite pharmacotherapy, highlighting the need for adjunctive psychosocial treatments. It is still unclear which populations are most likely to benefit from which approach and the best timing to implement them.

Methods

A review was conducted with the aim to determine what the efficacious psychological treatments are, for whom and when. Randomized-controlled trials and key studies in adults with BD published until June 2013 were included

Results

The adjunctive psychological treatments most commonly tested in BD were cognitive-behavioral therapy, psychoeducation, interpersonal and social rhythm therapy, and family intervention. The efficacy of specific adjunctive psychosocial interventions has been proven not only in short- but also long-term follow-up for some treatments. Outcomes vary between studies, with most trials focused on clinical variables like recurrence prevention or symptom reduction and less attention, although gradually expanding, paid to other aspects such as psychosocial functioning. The samples were usually in remission or with mild symptoms when recruited but there were a few studies with acute patients, which resulted in discrepant findings. The efficacy of psychological interventions seems to differ depending on the characteristics of the subjects and the course of the illness. Different approaches, such as functional remediation and mindfulness-based cognitive therapy, have begun to be tested in BD.

Limitations

Heterogeneity of comparison groups.

Conclusions

Adjunctive psychological treatments can improve BD outcomes. Although several moderators and mediators have been identified, more research is needed to design shorter but effective interventions tailored to the characteristics of the target population. Ideally, the treatment should be introduced as soon as possible, although it does not mean that more complex patients would not benefit from psychotherapy.

Introduction

Considering burden of disease as a measure of the loss of years of healthy life, bipolar disorder (BD) together with other mental illnesses represent a major and growing cause of chronicity and disability (Murray et al., 2012), drawing attention to the need for identification and implementation of effective and affordable strategies (Catala-Lopez et al., 2013). Despite the fact that there are many available pharmacological agents to treat BD (Fountoulakis et al., 2012, Grunze et al., 2013; Nivoli et al., 2013), pharmacotherapy does not always assure the absence of relapses and morbidity (Vieta et al., 2013). Recently, a 5-year study showed that subsyndromal symptoms and psychosocial stress at baseline predicted earlier episode relapse (De Dios et al., 2012). In addition to this, psychosocial functioning is frequently impaired in bipolar patients, even in remission (Rosa et al., 2010). Variability in functional outcome can be captured by at least two dimensions representing clinical severity and cognitive dysfunction (Reinares et al., 2013). Longitudinal studies show that the probability of functional recovery after an episode is lower and more difficult to achieve than syndromal recovery (Tohen et al., 2000, Rosa et al., 2011). The prognosis of the illness can be even worse in cases which have a poor adherence, as is frequently the case with BD (Berk et al., 2010, Murru et al., 2013). All this data highlights the need of an integrative approach and an ambitious treatment that goes beyond syndromic recovery.

Specific adjunctive psychotherapies have been shown to improve illness outcome (Geddes and Miklowitz, 2013). However, not all the trials have produced positive results (Scott et al., 2006, Miller et al., 2004, Meyer and Hautzinger, 2012, de Barros et al., 2013, Gomes et al., 2011). Furthermore, it is still unclear which populations are most likely to benefit from which approach and the best timing to implement psychosocial treatments. In the last few years effort has been made to design or adapt some psychological approaches such as cognitive remediation to the field of BD in order to cover aspects for which current approaches have shown limited success.

The aim of this review was to update the knowledge on psychological treatments in BD in order to answer the questions about which treatments are most efficacious, for whom and when.

Section snippets

Methods

A review of psychosocial interventions in BD was conducted. The search included randomized-controlled trials (RCT) on psychological treatments in adults with BD published in English up to June 2013. Exceptionally, key studies, even if not actual RCTs, were included if they had contributed to opening new lines of research in BD. A Medline computerized search was carried out using the term bipolar disorder combined with psychosocial treatments, psychological treatments, psychotherapy,

Results

The search identified the adjunctive psychological treatments most commonly tested in BD, namely cognitive-behavioral therapy, psychoeducation, interpersonal and social rhythm therapy, and family intervention. In addition to this, other modalities of treatment such as functional remediation, and mindfulness-based cognitive therapy have started to be assessed in this field. Table 1 summarizes the main components of these psychological approaches.

Discussion

Based on the examination of the studies on adjunctive psychological treatments in BD, some provisional answers to the questions that guided this review (what, for whom and when) can be given.

Role of funding source

No funding source.

Conflict of interest

Dr. María Reinares has served as speaker for the company Adamed.

José Sánchez-Moreno declares he has no conflict of interest.

Dr. Konstantinos N. Fountoulakis has received support concerning travel and accommodation expenses from various pharmaceutical companies in order to participate in medical congresses. He has also received honoraria for lectures from Astra-Zeneca, Janssen-Cilag, Eli-Lilly and a research grant from the Pfizer Foundation.

Acknowledgments

This work was supported by the Ministry of Economy and Competitiveness, Centro de Investigación en Red de Salud Mental, CIBERSAM “Cofinanciado por FEDER. Unión Europea”. “Una manera de hacer Europa” and the Generalitat de Catalunya to the Bipolar Disorders Group (2009 SGR 1022).

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