Psychosocial Interventions for

Bipolar Disorder
Jenifer L. Culver, PhD
Stanford University

At this point in my existence, I cannot imagine leading a

normal life without both taking lithium and having had the
benefit of psychotherapy. Lithium prevents my seductive but
disastrous highs, diminishes my depressions, clears out the
wool and webbing from my disordered thinkingkeeps me
from ruining my career and relationships, keeps me out of
hospital, alive, and makes psychotherapy possible. But,
ineffably, psychotherapy heals. It makes some sense of the
confusion, reins in the terrifying thoughts and feelings, returns
some control and hope and possibility of learning from it all
But, always, it is where I have believed or have learned to
believe that I might someday be able to contend with all of
this.
Kay Jamison

An Unquiet Mind
2

Treatment of Bipolar Disorder

Basic goals of treatment:

Alleviate acute mood symptoms

Restore psychosocial functioning
Prevent relapse of mood episodes

Psychopharmacology as foundation of
treatment
Relapse and subsyndromal symptoms
may occur even with optimal medication
treatment
3

Targets of Psychosocial
Interventions in Bipolar Disorder
Psychoeducation about bipolar disorder and
its treatment
Medication understanding and adherence
Social and work functioning
Recognition of early warning symptoms and
early intervention
Reduce impact of psychosocial factors
related to relapse
4

Evidence-Based Psychosocial
Treatments for Bipolar Disorder
Psychoeducation
Family-focused therapy
Interpersonal and social rhythm therapy
Cognitive-behavioral therapy

*Zaretsky A. Bipolar Disord. 2003;5:80-87.

Psychoeducation
Provides information about bipolar
disorder and treatment
Teaches early-warning symptom
recognition and coping skills to prevent
relapse
Individual, group, or family formats
Key element across all evidence-based
psychotherapies for bipolar disorder
6

Effects of Psychoeducation
Results from controlled studies:
Longer time to manic relapse, fewer manic relapses1
Increased knowledge of and improved attitude toward
pharmacotherapy2
Fewer hospitalizations,3,4 shorter hospitalizations4,5
Fewer relapsed patients, fewer recurrences per
patient4
Longer time to depressive, manic, hypomanic, and
mixed recurrence4
1Perry

A, et al. BMJ. 1999;318:149-152; 2Peet M, Harvey NS. Br J Psychiatry. 1991;158:197200; 3Cochran SD. J Consult Clin Psychol. 1984;52:873-878; 4Colom F, et al. Arch Gen
Psychiatry. 2003;60:402-407; 5Colom F, et al. Bipolar Disord. 2004;6:294-298.

% of Patients Remaining Well

Psychoeducation Is an Effective
Adjunctive Maintenance Therapy
100

Psychoeducation Superior to Control for:

Time to recurrence (graph)
Number of relapsed patients
Number of recurrences/patient

80

60

21-week
Psychoeducation
Group

40

N=120
P<.003

20

21-week
Nonstructured
Group

0
0

12

18

24

Time to Recurrence (months)

Colom F, et al. Arch Gen Psychiatry. 2003;60:402-407.

Family Treatments
High expressed emotion is associated with
increased risk of relapse and poor outcomes
in bipolar disorder1
Miklowitz and colleagues adapted familyfocused therapy, which has been successful
in schizophrenia, for use in bipolar disorder

1Miklowitz

DJ, et al. Psychopharmacol Bull. 1986;22:628-632; 2Clarkin JF, et al. J Affect Disord.
1990;18:17-28; 3Clarkin JF, et al. Psychiatr Serv. 1998;49:531-533; 4van Gent EM & Zwart FM.
J Affect Disord. 1991;21:15-18;

Family-Focused Treatment
Assessment of family or couple
Psychoeducation about bipolar disorder
(symptoms, early recognition, etiology,
treatment, self-management)
Communication skills training (behavioral
rehearsal of effective speaking and listening
strategies)
Problem-solving skills training
Miklowitz DJ, Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. New York:
Guilford Press; 1997.

10

FFT + Medication Delays Relapse More Than

Crisis Management (CM) + Medication
Cumulative Survival Rate

1.0

(N=101)
p = .003

0.8
0.6
0.4
FFT + medication

0.2

CM + medication
0.0
0

10

20

30

40 50 60 70 80
Weeks of Follow-up

Mean survival = FFT, 73.5 weeks; CM, 53.2 weeks.

Miklowitz DJ, et al. Arch Gen Psychiatry. 2003;60:904-912.

90 100 110

11

Interpersonal and Social Rhythm

Therapy (IPSRT)
Integrates:
Psychoeducation
Social rhythm therapy to regulate social

rhythms (eg, sleep, social) by monitoring and

modifying routines
Interpersonal psychotherapy to improve

quality of interpersonal relationships and

satisfaction with social roles
12

IPSRT Increases Stability of Social

Rhythms Over Time
Social Rhythm Metric Score

IPSRT
(n=18)

P=.006
4

ICM
(n=20)

2
0

10

20

ICM = intensive clinical management.

30

40

50

60

70

80

Weeks of Treatment

Frank E, et al. Biol Psychiatry. 1997;41:1165-1173.

13

Cognitive Behavioral Therapy

Psychoeducation
Enhancing Medication Compliance
Monitoring of mood and early warning signs
Monitor behavior to prevent mood escalation
(e.g., routine and sleep)
Challenge thoughts and beliefs contributing to
mood disturbance
Dealing with long-term vulnerability issues

Lam DH, et al. Arch Gen Psychiatry. 2003;60:145-152.

14

CBT Effective for Bipolar Depression

and Relapse Prevention
In early controlled studies, CBT plus meds
(vs meds alone) yielded:
Fewer
1,2
Relapses
2,3
Hospitalizations
2
Subsyndromal fluctuations
Improved
1,2
Medication adherence
1
Global functioning
2
Social functioning
2
Coping with depression and mania prodromes
1Scott

J, et al. Psychol Med. 2001;31:459-467; 2Lam DH, et al. Cognit Ther Res. 2000;24:
503-520; 3Cochran SD. J Consult Clin Psychol. 1984;52:873-878.

15

Adjunctive CBT
Enhanced Outcomes Over 12 Months
CBT + medication
management

% of Patients With Events

60

Medication
management

50
40
30
20
10
0

Depression

Mania

(P<.001)

(P<.002)

Lam DH, et al. Arch Gen Psychiatry. 2003;60:145-152.

Mixed

Admission
(P<.003)
16

Adjunctive CBT Decreases

Days in Bipolar Episodes
End of therapy

45

Mean Days in Episode

40
35
30

CBT + medication
management
Medication management

25

P<.01
20
15

CBT group had

fewer days in bipolar
episodes (p<.01)
even after covarying
for number of
previous episodes.

10
5
0

Intention to Treat
Lam DH, et al. Arch Gen Psychiatry. 2003;60:145-152.

17

Future Directions:
Dialectical Behavior Therapy?
Skills Modules
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness

Format of group
Lecture
Didactic discussion
Homework
Mood monitoring
18

Stanford DBT Skills Group

Retrospective chart review (n=16) of patients
receiving DBT skills group at Stanford:
Decreased
Days with sadness

Days with anhedonia

Severity of anhedonia
Distractibility

Increased:
GAF scores
Culver et al. (2005)

19

Which Therapy?
Almost all studies showed some benefit of
psychosocial interventions
No definitive evidence comparing key therapies
Therapies overlap in targets for change
Treatment choice influenced by:
Patient choice
Availability of therapist
Individual characteristics
20

Where to Start?
Psychoeducation
Consider asking your

therapist and/or
psychiatrist for more
education about the
disorder
Read structured
psychoeducational
materials

21

Where to Start?
Monitoring of mood symptoms
NIMH Lifechart available online at:

www.bipolarnews.org
(click on Lifecharting)

Plan for early intervention

Work with your therapist and/or psychiatrist to

develop a plan to help you recognize early

warning symptoms and take action

22

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Conclusions
Even with optimal pharmacotherapy, individuals
with bipolar disorder may have subsyndromal
symptoms and/or problems with psychosocial
functioning
Adjunctive psychosocial treatments can improve
clinical outcomes and psychosocial functioning
Structured, evidence-based therapy can be
helpful even when mood is stable

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