Smart goals for bipolar disorder

Medication isn’t the only effective treatment for bipolar disorder. Individuals with this disease may also benefit from psychosocial treatment, experts say.

“The first line of intervention for bipolar disorder is medication,” says Simon Rego, PsyD, chief psychologist at Montefiore Medical Center and associate professor of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine in New York City. “But some patients with bipolar disorder may have trouble complying with medication and/or dealing with the consequences of the disorder.” This is where psychosocial treatments can make a difference, he adds.

Psychosocial treatment doesn’t preclude the need for medication. Long-lasting injectable antipsychotic medications now are available that have some potential advantages for those who take them: early identification of non-adherence to medication, no need to remember to take medication every day, and reduced relapse frequency and rehospitalization rates. The indication for these medications (such as aripiprazole, olanzapine, paliperidone and risperidone) is for schizophrenia, however. Speak to your healthcare provider to learn more.

Psychosocial treatment can not only improve a patient’s adherence to medication but can increase their understanding of the illness, says David Roane, MD, chairman of the Department of Psychiatry at Lenox Hill Hospital in New York City. “A person with bipolar may lose their job or their relationships with other people,” Dr. Roane says. “Psychosocial treatments can help them readjust.”

Here is a rundown of some psychosocial treatments that can be beneficial.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT), which involves trying to change your patterns of thinking, is effective for bipolar disorder, according to the American Psychological Association. Strategies that are used in CBT include role-playing to get ready for interactions that could be problematic, facing fears directly rather than practicing avoidance, and learning techniques to calm and relax the mind and body.

Research suggests that adding cognitive-behavioral therapy to a treatment plan can improve the outcome of bipolar disorder, according to the American Psychological Association. 1

A good treatment outcome is one in which the mood episodes are stabilized and the patient is equipped with the cognitive and behavioral skills necessary to become more aware of triggers and how to manage them more effectively, Dr. Rego says. “In the case of Bipolar 1 Disorder, we may also measure a good outcome by a decrease in hospitalizations as well as a reengagement in work, better interpersonal relationships, and an overall improvement in the quality of life,” he explains.

“I believe that CBT is helpful,” says Scott Krakower, DO, assistant unit chief, psychiatry, Zucker Hillside Hospital in Glen Oaks, New York, “It’s effective with both adolescents and adults. There is a mindfulness component to this form of therapy that is also useful to patients.”

CBT can help a person with bipolar to recognize the warning signs of a mood change and can help them learn to change unhealthy patterns of behavior, Dr. Krakower explains.

Article continues below

Concerned about Bipolar Disorder?

Take our 2-minute Bipolar quiz to see if you may benefit from further diagnosis and treatment.

Take Bipolar Quiz

Interpersonal and Social Rhythm Therapy (IPSRT)

IPSRT, an adjunctive therapy for individuals with mood disorders, outlines techniques to improve medication adherence, manage stressful life events, and reduce disruptions in social rhythms. With this form of therapy, patients learn skills that can help them protect themselves against the development of future episodes. Managing the patient’s symptoms and improving his interpersonal relations is the primary focus of IPSRT.

The efficacy of IPSRT for the treatment of bipolar mood episodes has been supported by two large clinical studies, Dr. Rego says. “It can be useful to avoid disruptions in social rhythm,” he says. “The term, a disruption in social rhythm, sounds fancy, but it really just means any change to our regular daily routines, such as the time we wake up, the times we eat our meals, and the time we go to bed,” Dr. Rego explains.

“It helps individuals with bipolar disorder to understand what worsens and what triggers their illness,” says Stephen Ferrando, MD, director of psychiatry at Westchester Medical Center Health Network (WMCHealth) located in Valhalla, New York.

Individuals with bipolar disorder may not sleep well, and lack of sleep may trigger mania, he says. “Interpersonal and social rhythm therapy is a type of behavioral therapy used to treat the disruption in social circadian rhythms,” Dr. Ferrando explains. “It teaches people the skills that can protect them from other triggers. For instances, IPSRT teaches sleep management skills.”

IPSRT can help a person learn coping skills, Dr. Ferrando says. “The individual learns to manage conflict and thus avoid a manic episode that can do a lot of damage,” he explains.

Family-Focused Therapy

This can also be beneficial for those with bipolar disorder, according to the American Psychological Association.3 Family members are taught to recognize the warning signs of either a manic or a depressive episode, Dr. Roane says, and both family members and patients are taught better communication skills. “A family member can help to identify when a person with bipolar disorder is about to go into a new episode before it happens,” he says, “The family members can tell when a patient is not taking medication, so it’s critical for the family to be involved.”

Unfortunately, many patients with bipolar disorder tend to not involve their family in their treatment plan, Dr. Roane says. His advice? Bring the family into therapy when the person is doing well. “This works better than when a relapse is happening,” he says.

A core component of family-focused therapy is psychoeducation, Dr. Roane explains. “This means educating people about the illness, the treatments available, and the risk of non-adherence to medication,” he explains.

Family-focused therapy is important because it can often help a patient get back on track with their family. “A lot of times, a patient will recover from a manic episode and tend to minimize or not remember how bad they were,” Dr. Ferrando says, “The family may have been traumatized by what happened. This form of therapy can help a family through this by emphasizing appropriate behavior on the part of the patient.”

Overall, most individuals with bipolar disorder will need treatment with antipsychotic or mood-stabilizing medications. But psychosocial treatments may be added in order to improve the individual’s functioning, according to the American Psychological Association.

Article Sources Last Updated: Jun 4, 2019

PMC

One of the challenges facing clinical psychiatry is how to treat bipolar depression effectively.1 Surprisingly, its neurobiology and rational decisions about its treatment remain somewhat of a mystery. Recent findings have even called into question the role of traditional antidepressants in bipolar depression when other classes of drugs may be more effective first-line treatments for this illness.2 Setting aside the thorny question of whether antidepressants induce manic switches or rapid cycling, it seems worthwhile to consider recent clinical studies and try to make sense of their implications for the neurobiology of bipolar depression.

Treating bipolar depression with antidepressants remains a popular option in clinical practice and published guidelines. Most clinicians choose the drug or class of drugs, usually selective serotonin reuptake inhibitors and bupropion, that is most effective and best tolerated.1 However, the recently published results from the STEP-BD project found no benefit to adding an antidepressant (paroxetine or bupropion; n = 179) compared with placebo (n = 187) to a mood stabilizer in a large naturalistic sample of patients with bipolar I and II disorders.2 This intriguing finding certainly questions whether antidepressants, a common intervention for bipolar depression, are effective in the treatment of this remarkably disabling and difficult-to-manage condition.

Practice guidelines and clinical consensus support the use of mood stabilizers such as lithium or anticonvulsants either as monotherapy or add-on therapy for bipolar depression.1 In general, this treatment is not considered to be highly effective for bipolar depression because symptoms often improve slowly or incompletely. When lithium is included as a comparator in maintenance trials for new potential mood stabilizers, results show it is effective in the prevention of manic relapses, but limited in the prevention of relapses into depression.3

I have had a long interest in bipolar depression. In a proof of principle study, my research colleagues and I questioned whether adding a second mood stabilizer could treat depressive symptoms as effectively as adding an antidepressant, and we were surprised to see that both treatments had such a similar effect.4 A recent meta-analysis of the treatment of bipolar disorder showed that valproate had a surprising ability to prevent depressive relapses, and at least a few studies have suggested the drug may be an effective treatment for acute depressive symptoms in bipolar disorder.1,5 In light of the recent data suggesting that antidepressants may have little effect when added to a mood stabilizer, this treatment option might warrant reconsideration and further study. To make the situation even less clear, at least one anticonvulsant, lamotrigine, lacks antimanic properties, and although it is an adequate antidepressant agent in bipolar depression, it is not as effective in the treatment of major depressive disorder.6 Carbamazepine has fallen out of favour with many clinicians owing to adverse effects and complicated drug interactions; however, in my experience, it can be a very useful agent for the treatment of bipolar depression.1 Taken together, traditional mood stabilizers, including anticonvulsants, are potentially effective treatments for bipolar depression.

The increasing acceptance of atypical antipsychotics as mood stabilizers was first based on their proven ability to treat acute mania and, more recently, on their effectiveness in the treatment of bipolar disorder and their acute antidepressant effects. Olanzapine has been shown to have acute antidepressant effects in bipolar disorder either alone or in combination with fluoxetine.7 Although quetiapine has been established for some time as an agent with antidepressant effects in bipolar disorder, some recent data have shown even more impressive effects. Two studies involving close to 1500 depressed patients with bipolar I and II disorders compared quetiapine with placebo and either lithium or paroxetine.8,9 In both studies, quetiapine was reported to be more effective in reducing depressive symptoms compared with placebo or the other agent after an 8-week trial. Interestingly, neither lithium nor paroxetine was more effective than placebo. Although few would have argued with the results for lithium before the publication of the STEP-BD results,2 the lack of apparent effect of paroxetine found in that study was an unexpected outcome. Nonetheless, atypical antidepressants are emerging as effective treatments for bipolar depression.

Historically, we have extrapolated from the mechanism of action of psychotropic drugs to construct or validate neurobiologic models of psychiatric disorders. Do these results suggest that monoaminergic mechanisms are less important in our understanding of bipolar depression than of unipolar depression? Do the surprisingly encouraging results for anticonvulsants suggest that we should look more closely at either GABAergic (quite popular at one time) or glutamatergic hypotheses for bipolar depression? Since lamotrigine has not been shown to be effective in unipolar depression, this may indeed support such a change in our thinking. Finally, although the effects of atypical antipsychotics offer new options for a phase of bipolar disorder that is difficult to treat, they limit our understanding of the neurobiology of the disorder even further. Theories on the antidepressant effects of antipsychotic medications have ranged from modulating dopamine and serotonin to sharing metabolite properties with other antidepressants to demonstrating intracellular mechanisms for antidepressants and lithium. In sum, it is hard to find a parsimonious and elegant explanation for the emerging effectiveness of these drugs in bipolar depression.

It is encouraging to see so many new findings in a previously moribund area of psychiatric research. Although these encouraging clinical data may raise more questions than they answer, they may point to the need to discard older models of the neurobiology of psychiatric disorders, to be open to new data and to explore new treatments.

(updated 3/2019)

Bipolar psychotherapy is not Freud, not couches, not talk/talk/talk. There are specific skills to learn. Learning them may help you as much as pills. Sorreee, so far no one’s shown that you can do without pills entirely using these skills. However, you may be able to get by with fewer medications or lower doses (talking with you provider of course).

Until the early 2000’s, treatment for bipolarity was all about pills. Then five therapies were shown to improve outcomes compared to pills alone. You’ll find details below on these old therapies below. The common ingredients are important parts of bipolar treatment. Unfortunately, many parts of bipolar psychotherapy are hard to do on your own.

Common ingredients in bipolar psychotherapy

  1. Education: learn a lot about what you’re managing. It’s just like diabetes: the more you know, the better a job you can do. I hope my website helps with this important first step.
  2. Manage your sleep. Sorry, your body is not the same as your friend’s who can stay up all night no problem. You need a regular pattern of sleep: a regular bedtime, regular rise time. Skip this step and you’ll be asking medications to work uphill.
  3. Watch out for drugs. No THC marijuana. Maybe high-CBD marijuana, but y0u’ll have to be careful about type and grade. Alcohol okay in small amounts that doesn’t mess with your sleep (if in doubt, take it out until you’re sure).
  4. Monitor mood and energy. If you can spot changes early you can turn them around before they turn into big and/or long episodes. How? Tighten up your sleep control (lot’s to learn there) and learn a whole bag-of-tricks for slowing yourself down when accelerating; or keeping going when getting depressed. Until you’re good at this, some external monitors may help you (friends, mood charting, your therapist).
  5. Turn down the noise. Relationship stresses, job stresses, old conversations in your head, repeatedly tripping over your own feet when trying to move your life forward: all these will get in the way of good mood stability. A half-decent basic therapist can help you with all the common life stresses.

Some of these you can do on your own, but some can be hard without a good guide. Unfortunately, finding someone who knows bipolar psychotherapy can be difficult: there aren’t many such therapists.

However, most good therapists actually know most of these tools, even if they don’t recognize themselves as doing bipolar psychotherapy. If you find someone whom you trust, she/he may be able to help you through many of the recommended steps. You might have to point the way based on your reading.

One of the newest therapies focuses almost entirely on controlling sleep, and it got really good results in its first research trial. So, your first steps to adding a bipolar-specific psychotherapy are:

A. Keep learning. There’s a ton of stuff on this site; and, the most recent book version with Dr. Aiken is better organized.

B. Start tuning up your sleep: regular bedtime, regular rise-time. I know that can be extremely difficult. A therapist can help you (see next item!).

C. Start shopping for a therapist who can help you get your sleep and daily rhythms really steady.
See my page on the new therapy that focuses on sleep. And see my page on Finding a Therapist.

A workbook for Bipolar 2

Because this website is mostly about Bipolar II and other non-manic versions of bipolar disorder, I’ll link here one workbook that’s specific for these versions and has many of these common ingredients of therapy. As with any workbook, you’ll only get as much out of it as you put into it. Most people do best with these things if they use them with a therapist (which works even if the therapist is not well-versed in these techniques; just go through the workbook together. The key is to do the exercises in the book, not just read the book). Okay, have a look at The Bipolar II Workbook. But return to my website here for continued updated bipolar education (free; and I have no $ connection to this workbook either).

Update 3/2019: The rest of this page is old material, circa 2010, on the original five bipolar psychotherapy studies. I’m leaving all this here for therapists, if they need to see what they’ve missed.

Five specific bipolar psychotherapies

In April 2007 a major research program published their results testing three out of these five versus a 3-session education program. When any of these three were added to mood stabilizer treatment for patients with bipolar disorder experiencing significant depression, patients recovered more quickly and more were likely to stay well.Miklowitz

The three psychotherapies, all of which are described below, were:

  • Bipolar-specific Cognitive Behavioral Therapy
  • Interpersonal Therapy with Social Rhythm Therapy
  • Family-Focused Therapy (for patients with family who could join in treatment)

There two more kinds of therapy which have been studied in bipolar disorder. All of the five therapies share many ingredients in common, summarized below. This is a long essay. You might want to skip right to the summary. Or you may skip to a particular technique from the links for the five programs to be discussed:

Therapy Reporting Authors Usual # sessions BP I / BP II
Prodrome Detection Perry and colleagues 9 not specified
Psychoeducation Colom, Vieta, and colleagues 21 BPI and BP II
Cognitive Therapy (Basco, Rush) Lam and colleagues 14 BP I
Interpersonal / Social Rhythm Frank and colleagues not specified
Family-Focused Therapy Miklowitz and colleagues 21 BPI and BP II

None of these bears much resemblance to traditional “psychoanalytic” psychotherapy (the modern version of Freudian technique), which has not been studied in bipolar disorder. They are specific approaches developed to address known needs of bipolar patients and families.

As you’ll see, all the therapies emphasize similar ingredients:

  1. Identifying signs of relapse and making plans for early detection and response;
  2. Using education to increase agreement between doctor, patient and family about what it being treated and why;
  3. Emphasis on the need to stay on medications even when well;
  4. Stress management, problem-solving, and focus on improving relationships; and
  5. Regular daily rhythms for sleep, exercise, eating, activities

We will look at each in turn, starting with the simplest.

Prodrome Detection

In this study, a psychologist “with little previous clinical experience” met with patients up to 12 times (average 9) while the rest of the clinical team proceeded as usual. She discussed with the patient her/his personal experience of bipolar disorder and the signs preceding manic and depressive episodes in the past. They planned and rehearsed a plan for action should those symptoms appear again. The plan was written on a laminated card, carried by the patient. The therapist helped the patient keep a weekly diary, increasing to daily notes if symptoms were appearing. She informed the rest of the treatment team (a psychiatrist and mental health worker and primary care physician) of the plan. That was it, nothing any fancier than that, although it looks like she is a very smart person from the style of the write-up, of which she is the primary author.

Here are the striking results for prevention of manic episodes (prevention of depression was much less dramatic). The lines show the total number of patients having some sort of manic recurrence (so, as time goes on, the number grows and grows). If we watched long enough, and everyone had a relapse of some sort, the line would eventually flatten way up to the right at 1.0, meaning 100% of the patients had finally relapsed. As you can see, in the control group that didn’t get to meet with the psychologist, 50% of the group (the 0.5 line from left to right) had relapsed in some way in about a year).

By comparison, in the group who met with the psychologist, in one year only about 20% relapsed. We have to wonder if just anybody could get these results, besides Ms. Perry, but still, it’s pretty impressive. I’m planning on adding some of her tricks, like the card thing, to my approach, based on this result — for patients who have clearly identifiable “episodes” and pre-episode warning signs.

PsychoEducation

This research team (including Dr. Vieta, who provided much of the material for this entire essay) added 21 sessions of education about bipolar disorder, in groups of 8-12 patients each, to routine treatment in their clinic. A control group received 21 sessions of “nonstructured” meetings with the same two therapists, but in these groups, they tried not to teach about bipolar disorder (think about it: this was a very rigorous test of the theory that education itself is the active ingredient in the different outcomes shown below).

Look at the difference between these groups (this is the same kind of graph as shown above, except in reverse — it shows the total proportion of patients remaining well, so a curve that falls down more slowly means that more patients are staying well):

What did these education groups study? Here is their 21-week topic list:

  1. Introduction
  2. What is bipolar illness?
  3. Causal and triggering factors
  4. Symptoms (I): Mania and Hypomania
  5. Symptoms (II): Depression and mixed episodes
  6. Course and outcome
  7. Treatment (I): mood stabilizers
  8. Treatment (II): antimanic agents
  9. Treatment (III): antidepressants
  10. Serum levels: lithium, carbamazepine, valproate
  11. Pregnancy and genetic counseling
  12. Psychopharmacology vs alternative therapies
  13. Risks associated with treatment withdrawal
  14. Alcohol and street drugs: risks in bipolar illness
  15. Early detection of manic and hypomanic episodes
  16. Early detection of depressive and mixed episodes
  17. What to do when a new phase is detected?
  18. Regularity
  19. Stress management techniques
  20. Problem-solving techniques
  21. Final session

Over the next 2 years the education group had about one third as many hospitalizations as the control group. As of December 2006, their treatment manual for this program is available in English thanks to diligent work on the translation by Dr. Colom. If you’re a therapist and ready to use it, you can buy it on Amazon.

Cognitive Therapy

This technique was introduced in 1996 by Drs. Basco and Rush (Ph.D. and M.D. respectively) in their book Cognitive Therapy for Bipolar Disorder. For psychologists seeking training in this method — or patients and families seeking the most thorough treatment possible and willing to teach their therapists while both patient and therapist learn by working through the a training manual — another more recent book describes the technique used by the authors of the largest research study of this method: Cognitive Therapy for Bipolar Disorder: A Therapist’s Guide to Concepts, Methods and Practice, by Dominic Lam and colleagues.

They too have shown a strikingly lower relapse rate in patients who had 14 sessions of this therapy added to their regular treatment. Note that this is not quite as rigorous a test as the PsychoEducation method above, since the control group here is getting no additional treatment, whereas Colom and colleagues conducted an identical group for the controls, without the education. Thus there is a chance that the improvement we’re seeing here is simply due to 14 sessions with skilled, caring therapists, and not necessarily due to the treatment described in their book. However, in any case, the results are still impressive:

Again the results are shown as a total number of patients remaining well, so the slower decrease in the treatment group (green) means more patients are staying well longer with the additional treatment.

Here are some of the main focus points in this therapy (from an excellent summary by Otto and colleagues):

Focus Technique Details
Medication adherence Motivational interviewing
Habit-training
Engage patient as co-therapist
e.g. Rollnick and Miller 1995e.g. behavioral steps: colored dots, pill-minderse.g self-monitoring, report forms
Early Detection / Intervention Treatment contracts (see list below )Two Person Feedback Rule”48-Hour Rule”
Stress Stress / Lifestyle Management Understand importance of sleep; protect sleep/wake cycleProblem-solving, communication skills, routine cognitive tools(Exercise)
Co-morbidity CBT emphasis Treating social phobia, panic disorder, substance use, eating
Depression Standard CBT Identifying dysfunctional beliefs, etc.

The Harvard program makes extensive use of written plans, with a separate “treatment contract” for each of the following:

  1. Building a Support team
  2. Depressive Symptoms
  3. Personal Triggers of Depression
  4. Coping with Depression
  5. Personal Triggers of Mood Elevation
  6. Mood Elevation Symptoms
  7. Coping with Mood Elevation
  8. Agreement

There is even a free, online CBT for depression that is worth looking at if you can’t find a good, live CBT therapist, or can’t afford one. This is a great program but you’ll have to be very disciplined about working all the way through it to get the benefit. If you do, research shows you’ll likely get as much benefit as if you’d seen a live therapist (wow. true). Wagner

The data supporting this method are not as strong for the other methods described in this essay. We will skip quickly on to another method which incorporates this approach. Professionals may recognize the following graph from the 1999 publication by Frank et al, which primarily shows that if you start with one method, be it IPSRT or regular clinical management with interpersonal therapy (ICM), you’re better off if you stick with it:

Family-Focused Therapy (FFT)

As far back as 1990, Dr. Miklowitz and his research team at the University of Colorado were at work adapting a Behavioral Family Management technique, previously studied in patients with schizophrenia and their families, to bipolar disorder.Miklowitz

How does Family-Focused Therapy work? As described in his book by that title (1997), FFT includes:

  • the same kind of “psychoeducation” found in method #2 above;
  • a “relapse drill” similar to method # 1 above; and
  • ways to make the diagnosis easier to accept, a big part of the cognitive method #3 above.

However, this therapy also includes the family in a major way, which is not a feature of any of the above approaches. In addition to involving family members in all the steps just listed, it also focuses on communication within the family, teaches communication skills, and prepares the entire family for relapse episodes so that all members (not just the patient) have a plan for what to do when symptoms start to reappear.

In the research studies below, this method consisted of 21 therapy sessions over 9 months. Using this technique, his team reduced relapse rates in patients who’d been hospitalized for mania.Rea 2003 Another study using this method was published in 2000Miklowitz(c) with the following results:

As before, this shows the total number of patients staying well. Over a year, many relapse, but the treatment group (red line) does so more slowly. Unlike previous methods, this one shows the same pattern but for depressive relapse, which has been more difficult to address in most of the studies shown here (the PsychoEducation method is an exception, also showing as much or more benefit in preventing depressive relapse).

Like almost all the others, this therapy also focuses on the importance of “adherence” — staying on medications — and showed a specific benefit there (it’s a little unnerving to note that the control patients, shown below in yellow, were not taking medications as directed half the time, and that even when improved by treatment, shown in red, that was still a problem 25% of the time):

I hope, my readers, if you’re still with me here, that you’re already seeing the main point: all these treatment have common ingredients. As a final demonstration of that point, here are results Dr.Miklowitz and his team obtained when they combined FFT with IPSRT. IFIT is the combined therapy, in red; the comparison group received treatment as usual plus 2 family education sessions and crisis management (CM):

Summary

  1. All five treatments shown here have solid evidence demonstrating their effectiveness (for the moment, no other psychotherapies have this and to my knowledge, no others are being researched in this way).
  2. Most have a strong education component.
  3. Most emphasize looking for, and planning for, signs of relapse.
  4. Most include some way of looking at “illness acceptance“, including what’s getting in the way of that.
  5. Several include some emphasis on regular rhythms of sleep and activity.
  6. One emphasizes involving the family very directly. Some are more intensive (time, energy, and presumably money) than others.

More Workbooks by Psychotherapy Type

Below is a diatribe about research money (we don’t get bucks like cancer and heart disease centers: frustration) and a list of books for each of these kinds of therapy.

To answer this properly, with the same kind of emphasis on evidence, will take additional research. Since these studies cost a lot and take years of work, I doubt we’ll see “head-to-head” comparisons (we don’t have that for many medications, either). For now it looks simpler to conclude that they all have some merit and that elements of each, at minimum the simpler ones, should be part of a treatment package that most patients with bipolar disorder receive.

Unfortunately, at least in my area, money problems are driving treatment programs in the opposite direction (e.g public mental health programs). So once again I think it may be up to people like you, who have managed to read all the way to this point, to get these treatments for yourself or your family member.

You can buy the books and teach yourself from them (here they are again with a link to Amazon.com so you can see more about each — but watch out for getting sucked into buying something you didn’t need while you’re there!)

#1. Prodrome Detection — no manual for this to my knowledge (the paper is linked in full text though)

#2. PsychoEducation — the manual is now available in English: The Psychoeducation Manual for Bipolar Disorder. This is a remarkable text. It details each of the 20 sessions from a group leader’s point of view, including tips on opening the session, specific tools used in each session, things to watch out for in that particular session — and all with a very amusing sense of humor.

#3. Cognitive Therapy for Bipolar Disorder

The Bipolar Workbook: Tools for Controlling Your Mood Swings by Monica Basco

Dr. Basco is one of the originators of bipolar-specific CBT, as evidenced by her comprehensive book on the subject:

Cognitive Therapy for Bipolar Disorder by Basco and Rush

#4. IPSRT — this treatment approach is described by Ellen Frank, one of the developers of this method, in her book entitled Treating Bipolar Disorder. There is no other treatment manual available to my knowledge. Here is a review of the book.

#5. FFT — Bipolar Disorder: Family-Focused Treatment Approach (for therapists) and The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (for patients and families)

Perhaps you can recruit some local therapist — one that your insurance might pay for; and one that may be easier to find than a psychiatrist who knows and is willing/able to use all this stuff — to work through the book with you. (This may be a pie-in-the-sky idea, I should warn you. I learned some methods this way, but I’m not sure it’s typical of what other therapists do).

Sticking With Your Bipolar Treatment Plan

Since first being diagnosed with bipolar disorder at age 17, Kristin Finn has gone off her mood-stabilizing medications only twice — during each of her two pregnancies.

Both times, Finn worked carefully with her health care team to develop a plan for managing bipolar disorder without the assistance of medications. The plan included journaling, exercise, stress management, and avoidance and awareness of the things she knew might trigger her depression or mania.

Finn chronicled her journey in the book Bipolar and Pregnant, written because it was so difficult for her to find the information she needed to manage her condition during pregnancy anywhere else. And as a speaker for the Depression and Bipolar Support Alliance, she continues to share her experiences as a woman living with bipolar disorder.

Bipolar Treatment Plan: Why Compliance Matters

According to Ken Duckworth, M.D., medical director of the National Alliance on Mental Illness (NAMI), Finn’s compliance with her treatment plan year after year is not the norm. A majority of people with the disorder — as many as 64 percent, according to some estimates — don’t stay with their treatment plan throughout their lives, for various reasons.

“For one, nobody wants to take medications for a long period of time,” Dr. Duckworth says. “And people with bipolar disorder can go years between episodes, making taking the medication seem unnecessary.” Other reasons that people report for discontinuing their bipolar treatment plan include missing the “highs” associated with mania, denial that they have the condition, a poor doctor-patient relationship, co-existing personality disorder, drug or alcohol abuse, and medication side effects.

Unfortunately, Duckworth says that he’s seen patients discontinue their treatments without a plan or support and then suffer great personal setbacks when their untreated bipolar disorder reemerges — including job loss, trouble with the law, broken relationships, financial catastrophes, and suicide attempts.

Bipolar Treatment Plan: Plan Carefully for Changes

Duckworth recommends that anyone considering a change to his or her approach to managing bipolar disorder follow Finn’s lead; that is, make any modifications with the knowledge and assistance of their healthcare team, and be sure to have a well-thought-out plan of action.

“Be in a dialogue with your doctor,” he says. “Weigh the pros and cons that all the effects will likely have on your life, and have a plan for managing that.”

According to Finn, there were two keys to her success. The first was writing her plan down on paper before discontinuing her medication. When she struggled with symptoms of her untreated bipolar disorder, like the inability to stop talking incessantly, she could refer back to her written plan and refresh her memory about what steps she had decided to take when they occurred. “I could look back on that, and reel myself in,” she says.

The second key component of Finn’s plan was asking certain people in her life to be on the lookout for signs of a relapse. In fact, Finn actually signed agreements with her support team to resume taking her medication again if they thought she needed it.

“When you’re depressed or hypomanic, you can’t see yourself clearly,” she notes. “You can’t see how you are behaving clearly.”

In short, the best way to managing bipolar disorder over a lifetime is to have a well- thought-out plan for managing bipolar disorder, to communicate it to those around you, to work with your support and health care teams to put it into play, and to be ready to make changes as needed. Duckworth says, “Whether or not taking a mood-stabilizing medication is better or worse than the effects of not taking one is a decision each person with bipolar disorder must decide for themselves. Doctors can’t make people take their meds, we can only try to help them understand the consequences of not taking them.”

Treatment

Comprehensive Treatment for Bipolar Disorder

A comprehensive treatment plan for bipolar disorder aims to relieve symptoms, restore your ability to function, fix problems the illness has caused at home and at work, and reduce the likelihood of recurrence. A complete treatment plan involves:

Medication – Medication is the cornerstone on bipolar disorder treatment. Taking a mood stabilizing medication can help minimize the highs and lows of bipolar disorder and keep symptoms under control.

Psychotherapy – Therapy is essential for dealing with bipolar disorder and the problems it has caused in your life. Working with a therapist, you can learn how to cope with difficult or uncomfortable feelings, repair your relationships, manage stress and regulate your mood.

Education – Managing symptoms and preventing complications begins with a thorough knowledge of your illness. Education is a key component of treatment. The more you and your loved ones know about bipolar disorder, the better able you will be to avoid problems and deal with setbacks.

Lifestyle Management – By carefully regulating your lifestyle, you can keep symptoms and mood episodes to a minimum. This involves maintaining a regular sleep schedule, avoiding alcohol and drugs, following a consistent exercise program, minimizing stress, and keeping your sunlight exposure stable year round.

Support – Living with bipolar disorder can be challenging, and having a solid support system in place can make all the difference in your outlook and motivation. Participating in a bipolar disorder support group gives you the opportunity to share your experiences and learn from others who know what you’re going through. The support of friends and family is also invaluable.

Medication Treatment for Bipolar Disorder

Most people with bipolar disorder need medication in order to keep their symptoms under control. When medication is continued on a long-term basis, it can reduce the frequency and severity of bipolar mood episodes and sometimes prevent them entirely. If you have been diagnosed with bipolar disorder, you and your doctor will work together to find the right drug or combination of drugs for your needs. Because everyone responds to medication differently, you may have to try several different medications before you find one that relieves your symptoms.

Check in frequently with your doctor. It’s important to have regular blood tests to make sure that your medication levels are in the therapeutic range. Getting the dose right is a delicate balancing act. Close monitoring by your doctor will help keep you safe and symptom-free.

Continue taking your medication, even if your mood is stable. Do not stop taking your medication as soon as you start to feel better. Most people need to take medication long-term in order to avoid relapse.

Do not expect medication to fix all your problems. Bipolar disorder medication can help reduce the symptoms of mania and depression, but in order to feel your best, it is important to lead a lifestyle that supports wellness. This includes surrounding yourself with supportive people, getting therapy, and getting plenty of rest.

Be extremely cautious with antidepressants. Research shows that antidepressants are not particularly effective in the treatment of bipolar depression. Furthermore, they can trigger mania or cause rapid cycling between depression and mania in people with bipolar disorder.

Therapy for bipolar disorder: An Important Part of Treatment

Research indicates that people who take medications for bipolar disorder are more likely to get better faster and stay well if they also receive therapy. Therapy can teach you how to deal with problems your symptoms are causing, including relationships, work and self-esteem issues. Therapy will also address any other problems you may be struggling with, such as substance abuse or anxiety.

Three types of therapy are especially helpful in the treatment of bipolar disorder:

  • Cognitive-Behavioral Therapy
  • Family-Focused Therapy
  • Dialectical-Behavioral Therapy

Cognitive-Behavioral Therapy
In cognitive-behavioral therapy, you examine how your thoughts affect your emotions. You also learn how to change negative thinking patterns and behaviors into more positive ways of responding. For bipolar disorder, the focus is on managing symptoms, avoiding triggers for relapse, and problem-solving.

Family-Focused Therapy
Living with a person who has bipolar disorder can be difficult, causing strain in family and marital relationships. Family-focused therapy addresses these issues and works to restore a healthy and supportive home environment. Educating family members about the disease and how to cope with its symptoms is a major component of treatment. Working through problems in the home and improving communication is also a focus of treatment.

Dialectical-Behavioral Therapy
Dialectical-Behavioral Therapy is a comprehensive cognitive-behavioral treatment that was originally developed to treat chronically suicidal individuals suffering from borderline personality disorder (BPD). However, it has been found especially effective for those with suicidal and other multiply occurring severely dysfunctional behaviors. Research has shown it to be effective in reducing suicidal behavior, psychiatric hospitalization, treatment dropout, substance abuse, anger and interpersonal difficulties.

Source: Help Guide and Depression and Bipolar Support Alliance

Setting & Achieving Goals

At times, living with depression or bipolar disorder may make it seem difficult to set and achieve goals. It might feel almost impossible to think about the things that you hope for or care about. But goal setting is an important part of wellness, no matter where you are on your path to recovery. Work on what you can when you can.

To help determine what goals you’d like to set, ask yourself the following questions.

  • What motivates me?
  • What interests me?
  • What would I do more of if I could?
  • What do I want?
  • What do I care about, or what did I care about before my diagnosis?
  • Where do I want my life to go?
  • What brings me joy?
  • What are my dreams and hopes?

It helps to start small and work up to larger goals. You might want to begin by setting one small goal for yourself at the beginning of each day. As you become more confident, look at the different areas of your life and think about your short and long term goals.

Short Term Goals Examples

  • Be out of bed by __:00 am.
  • Finish one household chore.
  • Call or go online to find a DBSA support group to find out when and where it meets.

Possible Long-Term Goals

  • Get training or experience for a job.
  • Change a situation, e.g., find a new place to live.
  • Strengthen a relationship with a friend or family member.

Remember to break your goals down into small steps at first. A goal such as “move to a new city” can be difficult to visualize and plan all at once. Ask yourself what you need to do first. What can you do now that will help you eventually reach this goal?

Creating the Life You Want Recovery Goal Setting – A three-part series

Bipolar disorder is characterized by a manic episode followed by either a depressive or hypomanic episodes. People caught in a depressive episode experience at least two weeks of feeling sad, empty, or hopeless. They lose interest in activities they once enjoyed and may lose weight, have difficulty sleeping, or may spend more than half the day in bed. They may feel both exhausted and agitated, worthless, excessively guilty, and lose their ability to concentrate or make simple decisions. And most dangerously, they may lose their will to live, and even seek ways to end their life. People in the midst of a manic episode experience at least a week of persistently elevated or irritable mood. They may be expansive — seeing themselves as possessing special powers or abilities. They may shout at or start arguments with people they don’t know. They may lose their need for sleep — feeling fully rested after only 3 hours. They may be so talkative that people have trouble interrupting them. They may experience their thoughts as racing, so much so that they are incapable of keeping their mind focused on one thing. They may be so active that friends and family are worried about them. And they may be so impulsive and reckless that they put their physical and financial health at risk. Depressive and manic episodes can vary in frequency, intensity, and duration. Bipolar I disorder is characterized by intense manic episodes. At their worst, people may require hospitalization. Bipolar II disorder is characterized by more brief (4 days), less intense episodes of mania, which is called hypomania.

6 Cognitive Behavioral Therapy Techniques for Bipolar Disorder

If you’re living with bipolar disorder, you’re probably well-accustomed to the unpredictable mood swings that are a hallmark of the condition. Not only can these highs and lows create tension in your relationships and career, but left untreated, the condition can lead to suicide.

The good news is that bipolar disorder can be controlled. While medication plays an important role in recovery, adding cognitive behavioral therapy (CBT) to your treatment plan can help stabilize your mood and keep your life on track.

CBT for Bipolar Disorder: How It Works

What causes the highs and lows of bipolar disorder? According to a study published in January 2015 in the journal Psychology and Psychotherapy: Theory, Research and Practice, bipolar mood swings are influenced by your thoughts. The researchers found that having extremely negative thoughts may bring on what’s called “descent behaviors” (such as withdrawing from friends) associated with depression, while overly positive thoughts can lead to “ascent behaviors” (such as risk taking) associated with mania.

Practicing CBT may be a way to level out these extremes. “Cognitive behavioral therapy capitalizes on the fact that our thoughts, actions, and emotions are all interconnected and can influence one another,” says Simon Rego, PsyD, director of the CBT Training Program at Montefiore Medical Center/Albert Einstein College of Medicine in New York.

CBT teaches you how to catch, challenge, and change flawed thoughts as well as identify and correct troublesome behavior patterns. For example, imagine your boss emails you saying she wants to talk to you about your latest project. A negative emotional response, such as jumping to the conclusion that she hates your work and that you’re going to get fired, can take you down the path to depression. CBT teaches you to respond to situations with calmer thoughts, such as that your boss may simply want to ask you some questions about your work, which keeps your mood stable. “People often feel better emotionally and attain a better quality of life after undergoing CBT,” Dr. Rego says.

A study published in January 2015 in The British Journal of Psychiatry supports adding CBT to bipolar disorder treatment. In the study, researchers compared two groups of people recently diagnosed with bipolar disorder. One group received standard treatment, which included medication and support from community groups, a psychiatrist, or a regular doctor. The other group received standard treatment and CBT. The researchers found that the latter group achieved a better, longer-lasting recovery than the group that didn’t receive CBT.

6 CBT Techniques for Bipolar Disorder

CBT teaches several important skills that target the core ways bipolar disorder affects you, Rego says. These include:

1. Accepting your diagnosis. The first step is to understand and acknowledge that you have a disorder that’s responsible for your symptoms. This is often difficult for people with bipolar disorder to accept, so teaching the signs, symptoms, causes, and course of the disorder is essential. It helps people embrace the idea of getting help while also knowing they’re not alone, Rego says.

2. Monitoring your mood. This is often done using a worksheet or journal, which is kept up on a daily basis between sessions and then reviewed with your therapist. People are asked to rate their mood daily on a 0-to-10 scale, in which 0 represents “depressed,” 5 stands for “feeling OK,” and 10 is equivalent to “highly irritable or elevated mood.” The purpose is to become more aware of mood triggers and changes.

3. Undergoing cognitive restructuring. This process focuses on correcting flawed thought patterns by learning how to become more aware of the role thoughts play in your mood, how to identify problematic thoughts, and how to change or correct them. The therapist teaches the patient how to scrutinize the thoughts by looking for distortions, such as all-or-nothing thinking, and generating more balanced thinking.

4. Problem-solving frequently. This step involves learning how to identify a problem, generate potential solutions, select a solution, try it, and evaluate the outcome. Typically first taught in therapy, problem-solving is then practiced between sessions. Problems can be in any domain of life, from relationship distress to unemployment to credit card debt. All of these stressors, if not resolved, can put you at greater risk for a lapse.

5. Enhancing your social skills. Some people with bipolar disorder lack certain social skills, which causes them to feel that they aren’t in control of a certain aspect of their lives. Learning skills such as assertiveness can help you manage interpersonal relationships better.

6. Stabilizing your routine. Engaging in activities on a regular and predictable basis establishes a rhythm to your day, which helps stabilize your mood. Examples include exercising in the early afternoon, setting a consistent sleep and mealtime schedule, making social plans, and doing chores around the house.

How to Maximize Bipolar Treatment

For optimal results with your bipolar treatment plan, Rego suggests these steps:

  • Listen to your doctor. Come to terms with the fact that you have bipolar disorder. Following your doctor’s advice and taking medications as prescribed is critical to stabilizing your mood.
  • Do your CBT homework. CBT requires you to do work on your own in between therapy sessions. “The best predictor of success in CBT is to do all the homework,” Rego says. Skills are built through regular practice.
  • Continue learning about bipolar disorder. Read self-help books, join a support group, and ask your doctor or therapist questions to better understand the condition. The best way to help control bipolar disorder is to be an active participant in your treatment.

Bipolar Disorder Treatment – Psychotherapy and Cognitive Behavioral Therapy

Bipolar Treatment – Psychotherapy

Psychotherapy is a non-medical “talking” therapy that can be very effective and helpful for some bipolar patients, but generally only as an adjunctive bipolar treatment to be provided along side medication treatment. This is in contrast to unipolar forms of depression, which can in many cases be quite adequately and safely treated with certain forms of psychotherapy alone. All depressive illnesses have complex and mixed causes and maintaining factors, both physical and psychological in nature. However, the physical components of the average bipolar illness are, for the most part, stronger and more resistant to psychological intervention than are the physical components of the average unipolar depressive illness.

People who have not experienced quality psychotherapy tend to think of it as a sort of “pep talk” providing motivation without substance, or perhaps a mystical or metaphysical sort of process. These are mistaken impressions, however. Receiving effective bipolar treatment psychotherapy is about being instructed or coached in methods of effective coping with bipolar symptoms in a non-judgmental environment. Just as athletes benefit from coaching, so too do patients.

Psychotherapy offers several kinds of benefits to patients. There are several supportive aspects to therapy. Patients typically come to regard therapy as a safe place to talk about how their bipolar illness is impacting them and their families. Patients may also benefit from the objective third party monitoring and prompting that a therapist can provide concerning patients’ conditions, mood states, and capacity for self-harm. Therapists also work with patients to help them strengthen coping and social skills that are impacted by their bipolar disease, so as to help them better navigate their social and occupational worlds, and to better resist the temptations of the extreme mood states that they must contend with. Finally, therapists may also help motivate patients to maintain their bipolar medication routines, and to know when such routines require adjustment. Medically trained therapists (e.g., Psychiatrists, and some Psychologists in several states) can monitor and prescribe bipolar medications as well as provide psychotherapy. However, more typically medication monitoring and psychotherapy responsibilities are split between two different professionals.

There is no one variety of psychotherapy. Instead, multiple approaches with varying utilities have been developed. Three varieties of psychotherapy in particular have been found useful for treating bipolar disorder treatment.

Bipolar Treatment – Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT), the dominant psychotherapy bipolar treatment available today, is based on the premise that many (but certainly not all) mood problems are based less on physical brain problems, and more on habitually dysfunctional ways that people learn to appraise and interpret stressful events occurring in their lives. The stressfulness of life events becomes magnified, and certain bipolar symptoms occur or become exaggerated as a byproduct of faulty judgments.

The process of cognitive behavioral therapy involves therapists teaching patients methods they can use to become aware of and then examine their distorted thinking and perceptual processes and then perform reality testing upon their distorted judgments so as to make them more accurate. Thoughts influence patients’ perceptions of the world, and in turn those perceptions become patients’ reality. Distorted thoughts lead to unstable or faulty perceptions. For example, people experiencing a manic episode might falsely conclude that they have endless energy, and as a result may overexert themselves while exercising. They may take multiple aerobics classes or run for hours. Although their perception is that they are tireless, their body will soon give them a true reality check. The eventual fatigue and emotional crash can add to the physical and psychological distress they experience. Improving patients’ capacity for effective reality testing helps them to become more aware of situations when they are acting in unusual or potentially self-damaging ways, and helps them to stop potentially harmful behaviors before they become truly harmful.

CBT Patients learn that they can reduce the negative impact of bipolar manic depression by learning to identify and correct habitual and automatic thought and judgment distortions that would lead them to exaggerated and harmful conclusions. Patients are taught to write down their perceptions along side the events that trigger those perceptions, and then to examine what they have recorded for evidence of bias or inaccuracy. Throughout this process of learning, exploring and testing perceptions, patients gain bipolar disorder coping strategies while improving skills of awareness, introspection and evaluation. Patients’ improved coping and reality testing skills, properly applied, help them to decrease the extremeness of their mood swings (where possible), reduce the impact of their bipolar illness on their social and occupational relationships, improve their motivation to remain on bipolar medication, and generally function to help reduce their chance of catastrophic relapse.

Patients must possess a certain level of insight into their bipolar symptoms before CBT can be useful. For this reason, CBT is most appropriate for medicated and reasonably stable patients, and more specifically those medicated patients who are fairly verbal and able to reflect about their bipolar disorder. Patients who are in the midst of any sort of extreme bipolar manic depressive episode will not benefit from CBT.

The importance of therapy for bipolar disorder

Research indicates that people who take medications for bipolar disorder are more likely to get better faster and stay well if they also receive therapy. Therapy can teach you how to deal with problems your symptoms are causing, including relationship, work, and self-esteem issues. Therapy will also address any other problems you’re struggling with, such as substance abuse or anxiety.

Three types of therapy are especially helpful in the treatment of bipolar disorder:

  1. Cognitive-behavioral therapy
  2. Interpersonal and social rhythm therapy
  3. Family-focused therapy

Cognitive-behavioral therapy

In cognitive-behavioral therapy (CBT), you examine how your thoughts affect your emotions. You also learn how to change negative thinking patterns and behaviors into more positive ways of responding. For bipolar disorder, the focus is on managing symptoms, avoiding triggers for relapse, and problem-solving.

Interpersonal and social rhythm therapy

Interpersonal therapy focuses on current relationship issues and helps you improve the way you relate to the important people in your life. By addressing and solving interpersonal problems, this type of therapy reduces stress in your life. Since stress is a trigger for bipolar disorder, this relationship-oriented approach can help reduce mood cycling.

Social rhythm therapy is often combined with interpersonal therapy is often combined with social rhythm therapy for the treatment of bipolar disorder. People with bipolar disorder are believed to have overly sensitive biological clocks, the internal timekeepers that regulate circadian rhythms. This clock is easily thrown off by disruptions in your daily pattern of activity, also known as your “social rhythms.” Social rhythm therapy focuses on stabilizing social rhythms such as sleeping, eating, and exercising. When these rhythms are stable, the biological rhythms that regulate mood remain stable too.

Family-focused therapy

Living with a person who has bipolar disorder can be difficult, causing strain in family and marital relationships. Family-focused therapy addresses these issues and works to restore a healthy and supportive home environment. Educating family members about the disease and how to cope with its symptoms is a major component of treatment. Working through problems in the home and improving communication is also a focus of treatment.

Complementary treatments for bipolar disorder

Most alternative treatments for bipolar disorder are really complementary treatments, meaning they should be used in conjunction with medication, therapy, and lifestyle changes. Here are a few of the options that show promise:

Light and dark therapy – Like social rhythm therapy, light and dark therapy focuses on the sensitive biological clock in people with bipolar disorder. This easily disrupted clock throws off sleep-wake cycles, a disturbance that can trigger symptoms of mania and depression. Light and dark therapy regulates these biological rhythms—and thus reduces mood cycling— by carefully managing your exposure to light. The major component of this therapy involves creating an environment of regular darkness by restricting artificial light for ten hours every night.

Mindfulness meditation – Research has shown that mindfulness-based cognitive therapy and meditation help fight and prevent depression, anger, agitation, and anxiety. The mindfulness approach uses meditation, yoga, and breathing exercises to focus awareness on the present moment and break negative thinking patterns.

Acupuncture – Some researchers believe that acupuncture may help people with bipolar disorder by modulating their stress response. Studies on acupuncture for depression have shown a reduction in symptoms, and there is increasing evidence that acupuncture may relieve symptoms of mania also.

Status: Modest Research Support for depression* and Modest Research Support for mania

It is important to note that there are many manuals of cognitive therapy for bipolar disorder, including group and individual approaches. Of these, the findings based on the manual by D. Lam and others have been particularly positive, as have those from the one-year report of the Systematic Treatment Enhancement Program for bipolar disorder (STEP; Miklowitz et al., 2007). Findings from other manuals have not achieved strong research support to date (Patelis-Siotis et al., 2001; Scott et al., 2006). All cognitive therapy manuals include a psychoeducational component regarding the biological basis of the illness, the need for medications, and the early warning signs of symptoms. They also include a focus on identifying maladaptively negative thoughts about the self, and teaching clients skills to challenge these overly negative thoughts. Many also include ideas about how to target the overly positive thoughts that might be present during mania. The Lam manual is distinguished by an integration of cognitive interventions with more extensive focus on promoting regular sleep and regulating extreme goal striving. The Lam manual is designed for 12 to 18 individual weekly sessions, followed by 2 booster sessions over the next 6 months, and only the randomized controlled trials that used this particular manual have shown effects in diminishing manic symptoms over time.

Key References (in reverse chronological order)

Clinical Resources

Training Opportunities

For more information about workshops, contact Dominic Lam, University of Hull, Holly House, Welton Old Road, Welton, Brough, North Humber HU15 1HU, Tel: 01482 669310

Teaching Resources

CBT for Bipolar Disorder Slide Set

*Although findings of two trials indicated that CT lead to reduced depression, CT has been labeled as probably efficacious due to null results in at least one major study.

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *