Psychotherapy in combination with drug treatment for bipolar disorder

Bipolar or borderline: a clinical overview

OBJECTIVE

To examine the empirical literature on diagnostic validators in borderline personality and bipolar illness.

METHOD

Using principles of evidence-based medicine, the highest levels of evidence were emphasized in interpretation of similarities or differences between bipolar illness and borderline personality on the five standard diagnostic validators in psychiatric nosology: symptoms, course, genetics, treatment response, and neurobiology.

RESULTS

Bipolar illness and borderline personality were found to be similar in the nosological validator of symptoms of mood lability and impulsivity, but differed notably on all other diagnostic validators, especially the course validator of past sexual abuse and the genetic validator of a bipolar family history. They also differ notably in the symptom validator of parasuicidal self-harm. Treatment response and neurobiological differences were also present and consistent.

CONCLUSION

This review of the literature indicates that these two conditions, bipolar illness and borderline personality, are different and can be distinguished. The much stronger biological and genetic evidence for bipolar illness in particular suggests that the two conditions can be reasonably seen as different kinds of clinical entities, namely a biological disease versus a psychosocially caused clinical picture. If this interpretation is correct, similarities between the two conditions, such as mood lability and impulsivity, are superficial, while differences are profound. Further, true comorbidity may be much less common than often presumed.

Cyclothymic disorder in youth: why is it overlooked, what do we know and where is the field headed?

Cyclothymic disorder is a chronic and impairing subtype of bipolar disorder, largely neglected in pediatric research. Consequently, it is rarely diagnosed clinically despite potentially being the most prevalent form of bipolar disorder. Lack of attention has added to confusion about the diagnosis and clinical presentation of cyclothymic disorder. In pediatric studies, cyclothymic disorder is commonly grouped with 'subthreshold' presentations of bipolar disorder under the undifferentiated label 'bipolar disorder not otherwise specified'. However, research indicates that cyclothymic disorder can be reliably distinguished from the other forms of bipolar disorder and from other childhood disorders. Importantly, cyclothymic disorder may be a diathesis for more acute presentations of bipolar disorder, warranting a prominent role in dimensional models of mood and psychopathology. Current evidence suggests that cyclothymic disorder has the potential to make unique contributions to our understanding of the risk factors and outcomes associated with bipolar disorder. This potential has yet to be fully realized, limiting our knowledge and ability to intervene in a meaningful way with youth who are exhibiting symptoms of a major mood disorder. Including cyclothymic disorder in future research studies of children - particularly longitudinal outcome studies - is essential for understanding the developmental trajectory of bipolar spectrum disorders and learning how to accurately diagnosis and treat the full spectrum of bipolar disorders.

Bipolar disorder

Bipolar disorder's unique combination of three characteristics - clear genetic diathesis, distinctive clinical features, early availability of an effective treatment (lithium) - explains its special place in the history of psychiatry and its contribution to the current explosive growth of neuroscience. This article looks at the state of the art in bipolar disorder from the vantage point of: (i) genetics (possible linkages on chromosomes 18 and 21q, polygenic hypothesis, research into genetic markers); (ii) diagnosis (new focus on the subjective aspects of bipolar disorder to offset the current trend of underdiagnosis due to overreliance on standardized interviews and rating scales); (iii) outcome (increase in treatment-resistant forms signaling a change in the natural history of bipolar disorder); (iv) pathophysiology (research into circadian biological rhythms and the kindling hypothesis to explain recurrence); (v) treatment (emergence of the anticonvulsants, suggested role of chronic antidepressant treatment in the development of treatment resistance); (vi) neurobiology (evaluation of regulatory function in relation to affective disturbances, role of postsynaptic second-messenger mechanisms, advances in functional neuroimaging); and (vii) psychosocial research (shedding overly dualistic theories of the past to understand the mind and brain as an entity, thus emphasizing the importance of balancing the psychopharmacological and psychotherapeutic approaches). Future progress in the understanding and treatment of bipolar disorder will rely on successful integration of the biological and psychosocial lines of investigation.

Personality Styles of Patients with Bipolar Disorder: An Exploratory Study

The relationship that exists between personality and bipolar disorder (BD) is a complex one with numerous published studies yielding conflicting results. Thus we intended to ascertain whether a relationship exists between personality and bipolar disorder in a South African sample of 23 bipolar individuals. The MCMI-III was used to confirm the diagnosis of BD and to measure personality styles. A significant relationship between bipolar disorder and the following personality styles was found: avoidant, passive-aggressive, antisocial and depressive. A significant relationship between BD and debasement was also found. No significant gender differences were found for the personality styles. These results are discussed in the light of research on BD and personality.

Bipolar disorder: What effect does treatment adherence have on risk of suicidal behavior?

Bipolar disorder is associated with high risk for suicidal behavior. Lack of adherence to treatment is one factor that may be partly responsible for this common complication. We searched MEDLINE with the combination of the key words "compliance" or "adherence" with "suicide" and "bipolar", limited to English language papers published between 1990 and July 2008.We evaluate the existent literature studying the influence of treatment adherence on suicidality among these patients. Our findings show a limited number of studies addressing this issue, mostly conducted with patients enrolled in lithium clinics. Results suggest an association between non-adherence and an increased risk of suicidal behavior among bipolar patients. Whether non-adherence leads to increase risk of suicidality due to specific properties of interventions such as lithium treatment or simply is secondary to mood stabilization is still an open question.

Psychotherapeutic intervention and suicide risk reduction in bipolar disorder: a review of the evidence

BACKGROUND

25-50% of bipolar patients attempt suicide at least once in their lifetime and completed suicide in this population is about 1% annually, about 60 times the rate of the general population. Psychotherapy may be an effective adjunctive option in preventing suicide in bipolar patients. It has been suggested that interpersonal, cognitive and behavioural techniques may be effective in controlling mood shifts, increasing compliance with pharmacotherapy, and maintaining morale in the face of therapeutic adversity and incomplete response. The aim of our study was to systematically review the literature concerning the efficacy of psychosocial interventions in reducing the risk for attempting or committing suicide.

METHODS

We searched MEDLINE with the combination of the key words 'psychotherapy' or 'psychoeducation' or 'cognitive therapy' or 'behavio(u)ral therapy', 'cognitive-behavio(u)ral' or 'family therapy' or 'social rhythm' or 'rhythm' with 'suicide' and 'bipolar', limited to English language papers published between 1990 and January 2008. Papers were selected based on the criterium that they provided definite data on the role of psychotherapy in suicide prevention, and specifically in bipolar disorder.

RESULTS

Our search returned 481 references, of which 17 were selected based on the above criteria. The selected papers were classified according to the area of suicide prevention they were dealing with as 1. Psychosocial and demographic factors, 2. Psychological profile and 3. Efficacy of psychotherapies.

DISCUSSION

Our paper summarizes specific features and correlates of suicide in bipolar patients and possible targets of psychosocial intervention in the prevention of suicide in bipolar patients. Although studies researching the effect of psychosocial interventions on suicidal behaviour are virtually non-existent, hard data concerning the effectiveness of psychosocial interventions in bipolar disorder are emerging, but still suffer from methodological drawbacks.

Pediatric Bipolar Disorder

In the past decade, interest in and research on pediatric bipolar disorder (BD) has increased substantially. Prevalence rates of the disorder have doubled in outpatient settings, while twice as many research articles on pediatric BD were published in the past five years as in the prior decade. This review focuses on recent developments in the study of pediatric BD. We examine current research on the diagnostic boundaries of BD in youths, in particular the issues of episodicity and irritability, and provide assessment guidelines. We review data elucidating the pathophysiology of pediatric BD, with a focus on how these results may inform diagnosis. Finally, we discuss treatment approaches for pediatric BD, particularly psychotherapeutic interventions. Throughout the review, we pay particular attention to youths with severe chronic irritability, hyperarousal, and hyperreactivity, who reflect the population in whom the diagnosis of BD is most debated.

Psychotherapy in controlled psychopharmacology trials. Does it matter if we ignore it?

The controlled trial is now the standard for assessing efficacy of new treatments in Psychiatry, as it is in the rest of medicine. Psychiatric outcomes with treatment are influenced by concurrent psychosocial factors. Psychotherapy, alone or in combination with pharmacotherapy is an effective treatment. Thus, if concomitant receipt of psychotherapy is not controlled for in a psychopharmacology trial, outcome may be biased. In this study, all peer reviewed journal articles describing the results of randomized, controlled psychopharmacology trials in two separate years were carefully reviewed to assess the possible influence of control versus lack of explicit control for effect of concomitant psychotherapy on clinical outcome. One hundred sixteen articles, published in the years 1996 and 2000, were reviewed. Those with categorically positive or non-positive global outcome were assessed for description of concomitant receipt of psychotherapy by subjects randomized to different pharmacotherapy treatments. Description of comparability in potentially confounding demographic and clinical variables was present in all studies. Only 22% of 89 studies meeting inclusion criteria explicitly controlled for concomitant psychotherapy. Seventy five percent of 20 studies that did, and only 46% of 69 studies that did not, found different outcomes in groups randomized to different pharmacotherapy interventions (p=.024). This result was not accounted for by other aspects of study design such as placebo-vs.-active control comparison, trial size, length, geographic location, number of sites or authors, source of funding, or diagnostic composition)-suggesting that uncontrolled receipt of psychotherapy may reduce likelihood of finding a difference between a new treatment and a control pharmacotherapy intervention. If confirmed by further investigation, the results may warrant adoption of relevant recommendations for controlled trial design in psychopharmacology research. The method used in this report may be useful in other areas of controlled trial research to assess influence of confounding variables.

O papel da equipe multidisciplinar no manejo do paciente bipolar

O transtorno de humor bipolar (THB) é uma patologia incurável, recorrente e crônica, sendo que inúmeros fatores de vida relacionados ao estresse demonstram influenciar o curso da doença. Devido a estes fatores, a doença está associada com grave disfunção familiar, social e ocupacional, especialmente quando o tratamento farmacológico não é realizado de forma continuada. O papel prioritário da equipe multidisciplinar no tratamento do pacientes com transtorno de humor bipolar é melhorar a aderência medicamentosa, diminuindo os riscos de recaída. Neste artigo, são apresentadas possíveis causas biopsicossociais envolvidas no surgimento e curso da doença, incluindo-se eventos de vida, meio familiar e refratariedade farmacológica. São descritas as funções da equipe multidisciplinar no tratamento da bipolaridade, avaliando-se, neste contexto, a eficácia terapêutica das diversas abordagens psicossociais em uso e as perspectivas neste campo de "intervenção preventiva".

Family-focused treatment versus individual treatment for bipolar disorder: results of a randomized clinical trial

Recently hospitalized bipolar, manic patients (N = 53) were randomly assigned to a 9-month, manual-based, family-focused psychoeducational therapy (n = 28) or to an individually focused patient treatment (n = 25). All patients received concurrent treatment with mood-stabilizing medications. Structured follow-up assessments were conducted at 3-month intervals for a 1-year period ofactive treatment and a 1-year period of posttreatment follow-up. Compared with patients in individual therapy, those in family-focused treatment were less likely to be rehospitalized during the 2-year study period. Patients in family treatment also experienced fewer mood disorder relapses over the 2 years, although they did not differ from patients in individual treatment in their likelihood of a first relapse. Results suggest that family psychoeducational treatment is a useful adjunct to pharmacotherapy in decreasing the risk of relapse and hospitalization frequently associated with bipolar disorder.

Bipolar disorder

Bipolar, or manic-depressive, disorder is a frequent, severe, mostly recurrent mood disorder associated with great morbidity. The lifetime prevalence of bipolar disorder is 1.3 to 1.6%. The mortality rate of the disease is two to three times higher than that of the general population. About 10-20% of individuals with bipolar disorder take their own life, and nearly one third of patients admit to at least one suicide attempt. The clinical manifestations of the disease are exceptionally diverse. They range from mild hypomania or mild depression to severe forms of mania or depression accompanied by profound psychosis. Bipolar disorder is equally prevalent across sexes, with the exception of rapid cycling, a severe and difficult to treat variant of the disorder, which arises mostly in women. Because of the high risk of recurrence and suicide, long-term prophylactic pharmacological treatment is indicated. Lithium salts are the first choice long-term preventive treatment for bipolar disorder. They also possess well documented antisuicidal effects. Second choice prophylactic treatments are carbamazepine and valproate, although evidence of their effectiveness is weaker.

Impact of early onset bipolar disorder on family functioning: adolescents' perceptions of family dynamics, communication, and problems

OBJECTIVE

This research investigated the impact of adolescent onset bipolar illness on perceived family functioning in stabilized bipolar I (B) and unipolar (U) probands, and normal controls (C).

METHOD

Sample N=119: 44 bipolar 1(17 M, 27 F), 30 unipolar (9 M, 21 F), and 45 controls (19 M, 26 F). Mean ages: 19.9, 18.5 and 18.2 years, respectively.

INSTRUMENTS

Family Adaptability and Cohesion Scale (FACES II), Parent-Adolescent Communication Scales (PACS), Social Adjustment Inventory for Children and Adolescents (SAICA).

RESULTS

There were no significant group or sex differences between controls and mood disordered youth--assessed intermorbidly--in ratings of relationship with either parent. Bipolars acknowledged significantly more minor conflicts with parents than either unipolars or controls. Ratings by mood disordered subjects were significantly less positive in terms of shared activities and communication with siblings. Mood disordered youth and controls were not differentiated on the basis of family adaptability, and all family cohesion scores were within population norms. No significant group differences were observed in communication with parents.

LIMITATIONS

This self-report study was conducted intermorbidly, does not include objective measures of family functioning, nor does it assess the effect of psychiatric illness in other family members on family functioning.

CONCLUSIONS

Assessed intermorbidly, bipolar adolescents' perceptions of family dynamics do not seem to diverge significantly from controls. Further research is needed to investigate the impact of adolescent bipolar illness on family life during acute phases of the illness, as well as the effect on family functioning of psychiatric disorders in other family members.

Treatment-resistant bipolar disorder

Over the last few years, the number of potential pharmacotherapies for bipolar disorder has greatly expanded. Yet the database for virtually all these newer treatments consists of case reports and case series. Among these newer treatments, recently released anticonvulsants are most promising. Lamotrigine has already shown efficacy for treating bipolar depression, while gabapentin's efficacy has yet to be documented in a controlled study. Alone among its medication class, topiramate, another anticonvulsant, is associated with weight loss. Novel antipsychotics are effective in treating acute mania. With the exception of clozapine, their efficacy as true mood stabilizers is still unknown. Utilizing combinations of mood stabilizers is common and appropriate but demands knowledge of potential pharmacokinetic interactions. Other approaches for treatment resistant bipolar disorder include high-dose thyroid hormones, calcium channel blockers, electroconvulsive therapy, and omega-3 fatty acids. Finally, the efficacy of adjunctive psychosocial strategies is a topic of active investigation.

Social support and self-esteem predict changes in bipolar depression but not mania

INTRODUCTION

Our own and other research has suggested that social support predicts course of bipolar disorder, with particularly strong effects on depressive symptoms. Within this paper, we examine which components of social support appear most powerful.

METHODS

Thirty-one individuals with Bipolar I disorder were followed longitudinally for 9 months. Participants completed a standardized symptom severity interview monthly, and at a 2-month follow-up, they completed the Interpersonal Support Evaluation List. At a 6-month follow-up, they completed the Rosenberg Self-Esteem Inventory.

RESULTS

Self-esteem support appeared to the most important predictor of change in depression across a 6-month follow-up, and multiple regression analyses suggested that social support effects were mediated through self-esteem. LIMITATIONS AND IMPLICATIONS: Although the small sample size suggests a need for replication, current results highlight the importance of psychosocial variables in the course of bipolar depression. Self-esteem may be a particularly important target for clinical interventions.

Psychosocial interventions for bipolar disorder

The limitations of pharmacotherapy and the emergence of data supporting a role for psychosocial factors in the course of bipolar disorder have led to increased interest in the use of psychosocial interventions to improve outcomes. Although this area of study has suffered from a lack of systematic data, preliminary evidence suggests that the combined use of psychosocial interventions and medication is superior to pharmacologic treatment alone. Further research is necessary to identify and the psychosocial risk factors associated with bipolar disorder to design effective interventions to diminish their effects and improve outcome. The introduction of formal, manual-based psychotherapeutic interventions that include specific educational components has been particularly promising.

Adjunctive cognitive-behavioral therapy for rapid-cycling bipolar disorder: an empirical case study

A basic biopsychosocial model of episode onset in rapid-cycling bipolar disorder is presented with a special emphasis on cognitive and other psychosocial contributors. A three-pronged, face-valid, cognitive-behavioral treatment protocol meant to supplement medications is deduced from the available research literature. The concrete treatment components focus on prevention of mood cycles, early detection of cycle onset, and mood restabilization during cycles. The treatment protocol was pilot tested on a rapid-cycling bipolar patient who first received pharmacotherapy only followed by pharmacotherapy plus adjunctive cognitive-behavioral therapy (CBT). Detailed treatment measures were collected before, during, and after treatment. A comparison of Beck Depression Inventory and Young Mania Scale scores in pharmacotherapy versus pharmacotherapy plus CBT conditions suggest the addition of CBT produces significant clinical gains. Scores on the Beck Anxiety Inventory and Hopelessness Scale provide further support for the CBT treatment model. These preliminary results suggest cognitive-behavioral or similarly structured psychosocial treatment models could greatly enhance the medical treatment of rapid-cycling bipolar patients and warrants further controlled investigation.

A relapse prevention group for patients with bipolar and substance use disorders

Although bipolar disorder is the Axis I disorder associated with the highest risk of having a coexisting substance use disorder, no specific treatment approaches for this dually diagnosed patient population have thus far been developed. This paper describes a 20-session relapse prevention group therapy that the authors have developed for the treatment of patients with coexisting bipolar disorder and substance use disorder. The treatment uses an integrated approach by discussing topics that are relevant to both disorders and by highlighting common aspects of recovery from and relapse to each disorder.

Assessment and treatment of bipolar disorder in the elderly

The aetiology of late-onset bipolar disorder is heterogeneous because the disease is more likely to have a secondary (i.e. a medical disorder or medication-induced) cause in older than in younger patients. Elderly patients with bipolar disorder typically require lithium dosages that are 25 to 50% lower than those used in younger individuals. Information on the use of valproic acid (sodium valproate) in elderly patients with bipolar disorder is limited but encouraging. In contrast, there is virtually no information regarding the use of carbamazepine or other drugs in this patient group. Electroconvulsive therapy is well tolerated by older people and can be useful for these patients.