Cognitive Behavioral Treatment of Bipolar Disorder

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Diagnostic Considerations
Manic Episode
1 week high, euphoric, or irritable mood plus 3 (4) of the following:
exaggerated feelings of importance
little need for sleep
racing thoughts
pressured speech
distractibility
increased goal directed behavior (agitation)
reckless behavior
Hypomanic Episode
4 days of high, euphoric, or irritable mood plus 3 (4) symptoms (no impairment, psychotic features, need for hosp.)

Diagnostic Considerations
Bipolar I
At least one manic or mixed episode
May or may not have depressive episode, but most do (71% of sample)
3.5 more likely to have depressive symptoms than manic/hypomanic (Judd et al., 2002)
Bipolar II
At lease one hypomanic episode and one or more depressive episodes
38 times more likely to have depressive symptoms than hypomania (Judd et al., 2003)
Bipolar I vs II status is only inconsistently predictive of shorter term outcomes (cf., Judd et al., 2003; Miklowitz et al., 2007; Otto et al., 2006).

Characteristics of Patients With Bipolar Disorder
Prevalence
1-2% of the population
Age of Onset
Late teens to early 20s (earlier age of onset is associated with a worse course; Perlis et al. 2006).
Sex Ratio
Equal, but more rapid cycling among women
Comorbidity
Anxiety, Substance Use, ADHD
Course
75% relapse 4-5 years, half in 1 year (the proportion of days ill predicts episode frequency the next year; Perlis et al., 2004)

Comorbidity in Bipolar Disorder
(assessed in 1000 patients enrolled in STEP-BD)
Kogan et al., 2004

Diagnostic Issues – Major Depression
Depression:
Youth hospitalized for severe depression (young and severe) – 41% experienced manic/hypomanic episode over next 15 years (Goldberg et al., 2001)
Depression + Substance Use Disorder
Depression + Borderline Disorder
Depression + psychosis (schizoaffective disorder)

Presentation with Psychosis
Is it mania?
Schizophrenia?
Substance Induced?
Schizoaffective?
History and family help

An Abundance of Distress and Disability
Family, job, personal
Post-episode studies
6 months after: 30% unable to work; only 21% worked at their expected level (Dion et al., 1988)
1.7 years after hospitalization: 42% had steady work performance (Harrow et al., 1990)
Relatively high rates of suicide in bipolar disorder (predicted prospectively by days depressed and previous attempts; Marangell et al., 2006)

Psychosocial Treatment

Topics
What is the evidence for the efficacy of psychotherapy for bipolar disorder?
What are the targets of treatment?
What are the elements of treatment?

Psychosocial Treatment for Bipolar Disorder
Initial Encouragement:
Psychosocial Predictors of Bipolar Course
Incomplete Efficacy of Mood Stabilizers
Practice Characteristics
Majority of bipolar patients are engaged in some sort of psychosocial care
Direct Evidence
Promising outcomes from well-controlled trials

Role of Psychosocial Factors
in Bipolar Disorder
Psychosocial stressors impact the course of bipolar disorder:
Family stress (expressed emotion)1
Negative life events 2
Cognitive style 3
Sleep disruptions 4
Anxiety comorbidity 5
1 Miklowitz et al. (1988)
2 Johnson & Miller, (1997); Ellicott et al. (1990)
3 Reilly-Harrington et al., 1999
4 Malkoff-Schwartz et al. (1998)
5 Simon et al. (2004); Otto et al. (2006)

Pharmacotherapy for Bipolar Disorder
Advances in the field, but among patients taking medications:
Half relapse first year
Three-quarters relapse over several years
Continued role impairment between episodes
Poor medication adherence
(Gitlin et al., 1995; Keck et al., 1998; O’Connell et al., 1991; Tohen et al., 1990)

Focused Psychosocial Treatments for Bipolar Disorder
The product of diverse theoretical orientations, but with a high degree of similarity in strategies.
In particular, randomized trials have shown support for
Cognitive Behavioral Therapy (CBT)
Interpersonal and Social Rhythm Therapy (IPSRT)
Family-Focused Treatment (FFT)

Common Treatment Elements
Among CBT, IPSRT, FFT
Psychoeducation providing a model of the disorder and risk and protective factors (e.g., the role of sleep and lifestyle regularity).
Communication and problem-solving training aimed at reducing familial, relationship, or external stress.
Review of strategies for the early detection and intervention with mood episodes (including increased support, pharmacotherapy, more-frequent monitoring).

1. Cochran (1983)
2. Perry et al. (1999)
3. Lam et al. (2000), Lam et al. (2003); Scott et al. (2001)
4. Frank et al. (1997); Frank et al. (1999)
5. Miklowitz et al. (2003); Rea et al. (2003); Simoneau et al. (1999); also Clarkin et al. (1998)
6. Colom et al. (2003)
7. Scott et al. (2006)
8. Miklowitz et al. 2007
Some of the Influential, Psychosocial Clinical Trials
Medication adherence1
Detection of prodromal episodes, early intervention2
Individual CBT for Relapse Prevention3
Individual IPSRT for Relapse Prevention4
Family Interventions for Relapse Prevention5
Group Psychoeducation for Relapse Prevention6
Individual CBT for Episode Treatment 7
Intensive CBT, IPSRT, or FFT for Bipolar Depression 8

Cochran S. J Consult Clin Psychol. 1984;52:873-878.
Cognitive-Behavioral Therapy (CBT)
for Medication Adherence (Cochran, 1984)
Relapse Prevention
6 sessions of adjunctive CBT vs standard clinical care4
At end point and at 6-month follow-up, CBT patients had
Greater medication adherence
Lower hospitalization rates

Lam et al. - An Early CBT Success
103 bipolar patients randomized to CBT or TAU
12-18 sessions individual CBT
Information
Monitoring of mood & cognitions (early intervention)
Management of sleep and routine
Attention to “making up for lost time”
8 dropout in each condition
Lam et al., 2003, Arch Gen Psychiatry, 60:145-152

Medication Adherence
Lam et al., 2003, Arch Gen Psychiatry, 60:145-152
Percent of Patients

Clinical Outcome (days ill over 1 year)
Lam et al., 2003, Arch Gen Psychiatry, 60:145-152
Mean Days in Status

Survival Analysis
(N = 103)
Lam et al., 2003, Arch Gen Psychiatry, 60:145-152

Family-Focused Treatment
Elements
Psychoeducation about bipolar disorder
Communication-enhancement training
Problem-solving training1
Outcome
Adjunctive FFT appears to effect1
Depressive symptoms
Manic symptoms
Rehospitalization times
Miklowitz DJ, et al. Arch Gen Psychiatry. 1988;45:225-231.

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Week of Follow-Up
Cumulative Survival Rate
1-Year Survival Rates Among Bipolar Patients in Family-Focused Treatment versus Case Management
Wilcoxon Test, χ2 (1) = 4.4, p = .035
Miklowitz DJ, et al. Arch Gen Psychiatry. 1988;45:225-231.

Six Objectives of FFT
Help the patient and her or his relatives to:
Understand the nature of bipolar disroder and cyclic mood disturbances.
Accept the concept of vulnerability to future episodes
Accept a crucial role for mood-stabilizing medication for symptom control
Distinguishing between personality and bipolar disorder
Recognize and develop coping skills for managing the stressful life events that trigger recurrences of bipolar disorder
Reestablishing role and interpersonal functioning after a mood episode

Interpersonal and Social Rhythm Therapy
Educate patient about bipolar disorder
Identify current interpersonal problem areas
(e.g., grief, disputes, role transitions, interpersonal
deficits)
Initiate social rhythm metric
Frank et al. Biological Psychiatry 1997 1165-1173

Colom F, et al. Arch Gen Psychiatry. 2003;60:402-407.
Group Psychoeducation vs. Standard Care
21 Weeks of Randomized Treatment, 2-year follow-up
120 outpatients in remission for 6 months
Standard Care
Treatment algorithms
Monthly sessions
Serum levels of medications assessed
Group Treatment 21 90-minute sessions
Outcome
Recurrences at endpoint: 38% in group vs. 60% in SC
Recurrences at 2 years: 67% in group vs. 92% in SC

Colom F, et al. Arch Gen Psychiatry. 2003;60:402-407.
Psychoeducation?
Psychoeducation
What is bipolar illness
Symptoms
Treatments
Serum levels
Early detection of episodes
Risk reduction - substance use
Lifestyle regularity
Stress management
Problem solving

CBT, IPSRT, FFT vs. Collab Care
for Bipolar Depression
Miklowitz et al., 2007, Archives Gen Psychiatry

No Significant Differences Among the Intensives: CBT, IPSRT, FFT

Given this Evidence...
...What are Some Targets for Psychotherapy?
Medication adherence
Early detection and intervention
Stress and lifestyle management
Treatment of bipolar depression
Treatment of comorbid conditions

Medication Non-Adherence
in Mood Disorder
98 patients taking mood stabilizers (80% bipolar)
50% non-adherence rate last year
30% non-adherence last month (<70% adherent)
Predictors of non-adherence:
denial of severity of illness
previous non-adherence
greater illness duration
(Scott & Pope, 2002, J Clin Psychiatry, 63:384-390)

Relapse Prevention
Patient as cotherapist
Treatment contract
Training in early detection
Use of treatment team

Individualized Treatment Contract
Why contract?
Formulate a plan for the future
How I know I am depressed
Plan during depression
I am manic when…
Plan during mania (include who initiates the plan)
Other modules
Substance abuse, Bulimia, Gambling, Budget, etc

Mood Charting
Enables early and accurate identification of
changes in mood
Allows for early intervention prior to severe episodes
Tracks medication doses and adherence to
psychological treatment
Tracks hours slept and sleep/wake times
Notes daily psychosocial stressors that may
serve as triggers for relapse

Strategies for Hypomania
Explore medical solutions
(e.g., dosage or medication changes)
Counteract impulsivity
Give car keys or credit card to someone to hold
“Make rules” about staying out late or giving
out phone number
Avoid alcohol and substance use
Minimize stimulation
Avoid confrontational situations
Newman et al. Bipolar disorder: A Cognitive Therapy Approach. 2001

Cognitive-Behavioral Therapy
for Bipolar Depression/Relapse Prevention
Structure of Sessions
Review of symptoms, progress, and problems
Construction of the agenda
Discussion, problem solving, rehearsal
Consolidation of new information/strategies
Assignment of home practice
Troubleshooting of homework (including signposts of adaptive change)

Cognitive Restructuring and Skill Acquisition
Restructuring
Education (role and
nature of thoughts)
Self-monitoring
of thoughts
Identification of errors
Substitution of
useful thoughts
Core beliefs and strategies
Skill acquisition
Assertiveness
Communication skills
Problem solving

Cognitive Restructuring
Examine the evidence for the thought
Generate alternative explanations
De-catastrophize
Debunk “shoulds”
Find the logical error
Test out its helpfulness

Questions Used to Formulate Rational Response
What is the evidence that the automatic thought is true? Not true?
Is there an alternative explanation?
What is the worst that could happen? Would I live through it?
What’s the best that could happen?
What’s the most realistic outcome?

Questions Used to Formulate Rational Response (Cont’d)
What is the effect of my believing the automatic thought?
What is the cognitive error?
If a friend was in this situation and had this thought, what would I tell him/her?

Respecting Hot Emotions
Interventions are in relation to, not in spite of, the patient’s current mood.
Train emotional regulation skills
Gain access to mood-state dependent cognitions

Activity Assignments:
Bipolar Disorder
Management of sleep
Management of over/under activity
Management of destructive activities (substance use)
Resetting goals given limitations due to the disorder

Activity Assignments - 1
Independent Intervention or used in conjunction with cognitive restructuring
Help ensure that therapy is not over-focused on thinking rather than doing
Often requires a problem-solving analysis to understand patterns of over- and under-activity relative to the patient’s values

Activity Assignments - 2
Monitor current Activities
For change:
Start small (where the patient is)
Be specific
Rehearse elements in session
Define outcome objectively
Troubleshoot problems and signposts
Review cognitions (expectations, concerns)

Activity Assignments - 3
Review performance relative to objective criteria (and the degree of mood disturbance)
Assess the patient’s cognitive and emotional response to the assignment
Discuss further applications

Well-Being Therapy Phase
In this phase, therapeutic effort and monitoring is devoted to increasing periods of well being rather than reducing pathology.
It provides a way to consolidate gains around positive outcomes
An excellent strategy for fading out treatment

End of Treatment
Patient has skills to act as his or her own therapist
Patient focuses on well-being
Therapist contact fades

Cognitive-Behavioral Therapy
for Comorbid Disorders
Anxiety disorders
Substance use disorders
Eating disorders