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Psychotherapy for bipolar disorder: What works, and when?
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Psychotherapy for bipolar disorder: What works, and when?

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Bipolar disorder often produces many symptoms and consequences, and so often needs many types of treatment, both medication and psychotherapy. The major forms of psychotherapy studied in bipolar ...

Bipolar disorder often produces many symptoms and consequences, and so often needs many types of treatment, both medication and psychotherapy. The major forms of psychotherapy studied in bipolar disorder are Psychoeducation (teaching key illness management techniques), Cognitive-Behavioural Therapy (CBT), Interpersonal and Social Rhythm Therapy, and Family-Focussed Therapy.
Each of these approaches has some value, but:
How do they differ?
How does a person choose a therapy?
What is the role of more general psychotherapy?
During this presentation, Dr. Sagar Parikh provides a clear summary about each of the major psychotherapy treatments, how they compare in terms of research studies, and how they compare in terms of style and practicality. Some tips on how to choose a therapist are also highlighted.

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  • Cognitive restructuring in bipolar depression looks like cognitive restructuring for unipolar depression. Indeed, there is evidence that standard unipolar depression strategies offer benefit to bipolar patients (Zaretsky et al, 1999, Canadian J Psychiatry, 44, 491-494). <br /> In cognitive-restructuring, thoughts are treated as “guesses” about the world and patients are taught to examine the evidence for or against a thought. Periods of negative moods are used to cue formal cognitive restructuring. In addition, attention is devoted to the development of more useful thinking (self-coaching) strategies. For patients with bipolar disorder, extra attention is devoted to the identification of hypomanic thinking patterns as a cue for restructuring and additional therapeutic attention. <br /> Cognitive-behavioral therapy is a therapy of doing, and care is taken to ensure that patients have adequate skills for the demands of life. In many ways, bipolar patients must become experts at managing interpersonal stress as part of their overall therapeutic efforts. <br />
  • The key long term goal in Bipolar disorder is to reduce the impact of the disease on the patient and their relatives and friends. To this end the treatment goals are an increase in the length of periods of stability coupled with management of symptoms of either pole as they present. <br />

Psychotherapy for bipolar disorder: What works, and when? Psychotherapy for bipolar disorder: What works, and when? Presentation Transcript

  • www.canmat.orgwww.canmat.org PSYCHOTHERAPY FOR BIPOLAR DISORDER: WHAT WORKS, AND WHEN Sagar V. Parikh, M.D. FRCPCSagar V. Parikh, M.D. FRCPC Professor, Department of PsychiatryProfessor, Department of Psychiatry University of TorontoUniversity of Toronto ISAD Secretary and Education ChairISAD Secretary and Education Chair Co-Head, Section of Affective Disorders, WPACo-Head, Section of Affective Disorders, WPA sagar.parikh@uhn.casagar.parikh@uhn.ca
  • www.canmat.orgwww.canmat.org Outline  Identify the role for psychosocial interventions, including types and evidence for each type  Clarify central role for psychoeducation  Practical self-help strategies  Tips on Selecting a Therapy / Therapist
  • www.canmat.orgwww.canmat.org About Bipolar Disorder  BD is a serious lifetime condition – Elevated mood state (mania) + depression  Prevalence of 1-3% worldwide  High disability and mortality  1st line of treatment: Complex pharmacotherapy
  • www.canmat.orgwww.canmat.org The Limits of Pharmacotherapy  Even with good compliance, relapse is common, so we need more treatments!  How Psychosocial Treatments can help: – Modify stressors that could trigger episodes – Reduce acute symptoms – Deal with the psychological consequences of illness—to self, family, and friend  Psychosocial interventions may have direct biological treatment effects
  • www.canmat.orgwww.canmat.org How Psychosocial Interventions Could Alter Biolog yy  Improve medication use – affects biology directly  Normalize sleep / wake cycles, which in turn improves hormones tied to sleep  Dampen high expressed emotion and reduce impact of stressful life events, which in turn reduce surges of stress chemicals / hormones and the overall stress system  Increase exercise, which affects body in many ways
  • www.canmat.orgwww.canmat.org Treating Mood Disorders: A Population Health Approach  Main way to plan treatment for any chronic disease  Find out the prevalence, treatment, and realistic outcomes of the disorder from a community perspective, not just clinic view  To achieve success, keep in mind all views: patient, provider, clinic design (system)
  • www.canmat.orgwww.canmat.org Barriers to Optimal TreatmentBarriers to Optimal Treatment Patient View What do I want? System View What is evidence based and worth paying for? Provider View What can I provide?
  • www.canmat.orgwww.canmat.org Overview of Psychosocial Interventions  Effectiveness of Psychotherapy Treatments in Bipolar Disorder: State of the Evidence – Huxley NA, Parikh SV and Baldessarini RJ – Harvard Review of Psychiatry, 2000  Conclusion: few studies, poor methods
  • www.canmat.orgwww.canmat.org Major Psychosocial Studies in Past Decade  Psychoeducation – many RCTs (+) with diverse approaches  Cognitive Behavioural Therapy – Several small RCTs (+), one large (+), one large (-)  Interpersonal and Social Rhythm Therapy – Single small RCT weakly (+), second (+)  Family Focused Therapy – One small (+), several larger ones (+ or =) RCT = Randomized Controlled Trial, the gold standard in research studies
  • www.canmat.orgwww.canmat.org Caveat to Psychosocial Studies  Almost all studies were given in MAINTENANCE phase, ie after people were generally recovered. The goal was prevention of relapse; secondly, improved functioning  One large study addressed bipolar depression  No psychotherapy for mania; brief, direct, polite communication
  • www.canmat.orgwww.canmat.org PSYCHOEDUCATION 1. Any educational experience which meets a patient’s specific learning needs 2. Involves clinician/patient interaction 3. Influences behaviour towards improved functioning and well-being Sperry, 1995
  • www.canmat.orgwww.canmat.org PSYCHOEDUCATION Topics Bipolar Literature Review Topics • Early recognition of signs and symptoms • Overview of course and impact of illness • Daily life management skills • How to deal with families and relationships • How to deal with employers/school • Effect of attitude on compliance Pollack, 1993; Lish et al, 1994; Kusumakar et al,1995; Parikh, et al, 1996
  • www.canmat.orgwww.canmat.org Group Psychoeducation Colom et al, Archives 2003  A RCT of 120 patients, 2 year F/U  All euthymic  21 sessions, 90 min.  Outcomes– fewer relapses (67% vs 92%) and hospitalizations  Useful adjunct—but high relapse rates!
  • www.canmat.orgwww.canmat.org What is the LIFE Goals Program?  A psychoeducational and problem solving approach to the psychosocial treatment of bipolar disorder using cognitive, behavioural, and low intensity interpersonal strategies (PHASE I—six sessions)  Group members learn how to develop accurate perceptions of themselves, their illness & their environment, set realistic goals & cope with problems more effectively (MOSTLY PHASE II—variable sessions)
  • www.canmat.orgwww.canmat.org Core Agenda of LIFE Goals  Imparting education  Focusing on early warnings signs and triggers of episodes  Developing detailed and person-specific action plans for illness management
  • www.canmat.orgwww.canmat.org LIFE Goal Methods  It is an educational intervention, not classic psychotherapy  The model is an interactive workshop! Handouts and Homework!  The therapist speaks at least 50% of the time  Patients reveal a little or a lot; varies by person and by session
  • www.canmat.orgwww.canmat.org The Life Goals Program Structured group psychotherapy for bipolar disorder: The Life Goals Program By Bauer, M., McBride, L. Springer Publishing Company, 2nd ed 2003 (First edition also in French) And Overcoming Bipolar Disorder (workbook) By Bauer, Kilbourne, Greenwald, Ludman, McBride New Harbinger Publications,2008
  • www.canmat.orgwww.canmat.org LIFE Goals Self Help Workbook
  • www.canmat.orgwww.canmat.org
  • www.canmat.orgwww.canmat.org Best Bipolar Website
  • www.canmat.orgwww.canmat.org Major Psychosocial Studies in Past Decade  Psychoeducation – many RCTs (+) with diverse approaches  Cognitive Behavioural Therapy (CBT) – Several small RCTs(+), one large (+), one large(-)  Interpersonal and Social Rhythm Therapy – Single small RCT weakly (+), second (+)  Family Management – One small (+), several larger ones (+ or =)
  • www.canmat.orgwww.canmat.org Major Bipolar-CBT Books
  • www.canmat.orgwww.canmat.org CBT for BD and MDD are Similar  CBT for Major Depression (MDD) has many tools and approaches, which apply well for BD  Key Features of CBT – Structured (macro and micro) – Flexible – Collaborative – Focuses on skill acquisition Scott, Br J of Psychiatry 1995; 167: 581-588
  • www.canmat.orgwww.canmat.org The Cognitive Model Thoughts Behaviours Feelings Core Belief Situation
  • www.canmat.orgwww.canmat.org CBT Manuals for Bipolar Disorder  Basco & Rush: Cognitive Behavioral Therapy for Bipolar Disorder. New York, Guilford Press, 1996.(now 2nd ed)  Lam, Jones, Hayward & Bright: Cognitive Therapy for Bipolar Disorder: A Therapist’s Guide to Concepts, Methods, and Practice, Chichester UK, Wiley, 1999.  Newman, Leahy, Beck, Reilly-Harrington, Gyulai: Bipolar Disorder: A Cognitive Approach, Washington DC, American Psychological Association, 2002.
  • www.canmat.orgwww.canmat.org CBT Treatment Program  20 sessions of individual CBT, 50 minutes long  Includes some basic psychoeducation  Major emphasis on activity scheduling / behavioral activation  Major emphasis on dysfunctional cognitions, both depressive and manic  Based on manual by Lam et al.
  • www.canmat.orgwww.canmat.org Cognitive Restructuring and Skills 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
  • RCT of CBT in BDRCT of CBT in BD Lam et al, Archives 2003Lam et al, Archives 2003  N=103 , selected as high relapsers(10+)  Intervention—CBT or treatment as usual  CBT: 12-18 weekly 1 hr. sessions followed by 2 booster sessions in next 6 months  Outcomes in Relapses (CBT vs control):  28% vs 50% at 6 months  44% vs 75% at 12 months  No differences after year one
  • www.canmat.orgwww.canmat.org CBT for Bipolar Disorder Conclusions  CBT has applicability to BD as well as many other disorders  Uses CBT tools that help with anxiety, sleep and other problems too
  • www.canmat.orgwww.canmat.org Major CBT Books for Bipolar Disorder
  • World Wide Web
  • www.canmat.orgwww.canmat.org Major Psychosocial Studies in Past Decade  Psychoeducation – many RCTs (+) with diverse approaches  Cognitive Behavioural Therapy – Several small RCTs (+), one large (+), one large (-)  Interpersonal and Social Rhythm Therapy – Single small RCT weakly (+), second (+)  Family Focused Therapy (FFT) – One small (+), several larger ones (+ or =)
  • Family-Focused Treatment (FFT) of Bipolar Disorder • NEXT set of slides with this background all courtesy of Dr. David Miklowitz Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach, 2nd Ed. NY: Guilford Press, 2010.
  • Family-Focused Treatment (FFT) of Bipolar Disorder • Up to 21 sessions over 9 months • Begins with assessment of patient and family • Engagement phase • Psychoeducation about bipolar disorder (symptoms, early recognition, etiology, treatment, self-management) • Communication enhancement training (behavioral rehearsal of effective speaking and listening strategies) • Problem-solving skills training Miklowitz DJ. Bipolar Disorder: A Family-Focused Treatment Approach, 2nd Ed. NY: Guilford Press, 2010.
  • The Colorado Treatment Outcome Study: Bipolar Adults (n = 101) Patient Begins in an Acute Mood EpisodePatient Begins in an Acute Mood Episode Diagnostic and Family AssessmentDiagnostic and Family Assessment Random AssignmentRandom Assignment Trimonthly follow-upsTrimonthly follow-ups 1-year follow-up and family reassessment1-year follow-up and family reassessment 2-year follow-up2-year follow-up Crisis Management (CM)  pharmacotherapy visits and medication  2-3 sessions of family education  crisis management as needed Crisis Management (CM)  pharmacotherapy visits and medication  2-3 sessions of family education  crisis management as needed FFT plus pharmacotherapy visits and medication FFT plus pharmacotherapy visits and medication
  • FFT + Medication Delays Relapse More than Crisis Management + Medication Miklowitz DJ, et al. Arch Gen Psychiatry. 2003; 60: 904-912 0.0 0.2 0.4 0.6 0.8 1.0 0 10 20 30 40 50 60 70 80 90 100 110 CM + Meds FFT + Meds Weeks of follow-up Cumulativesurvivalrate FFT vs. CM, p = 0.003 M=73.5 weeks M= 53 weeks
  • Family Focussed TherapyFamily Focussed Therapy Micklowitz et al, Arch Gen Psych 2003Micklowitz et al, Arch Gen Psych 2003  Intervention worked—for those dedicated families -- expensive in time and money for system and family
  • Pediatric Bipolar Disorder  2% lifetime prevalence1  At risk for the 4 S’s2 : – School/job problems – Substance abuse – Suicide (10%-15%) – Social dysfunction  High rate of familial transmission3  Early onset = poor prognosis4 Stress-generating and stress sensitive 1 Merikangas et al., 2007; 2 Goldberg et al., 2004; 3 Goodwin and Jamison, 1997; 4 Leverich GS et al. (2007), J Pediatr 150(5):485-490
  • Colorado/Pittsburgh Collaborative Study: Adolescents With Bipolar Disorder in FFT (N=58) Miklowitz DJ, et al. Arch Gen Psychiatry 65(9):1053-1061, 2008. 1.5 2 2.5 3 0 24 48 72 96 EC FFT F [1, 5014] = 9.15, p = 0.0025 A-LIFEPsychiatricStatusRating Time after Randomization, wks.
  • FFT and Pharmacotherapy for Bipolar Adolescents: A 3-site Comparative Effectiveness Trial • 145 adolescents with bipolar I or II • DSM-IV mood episode in past 3 months • Active symptoms in prior month • Carefully controlled pharmacotherapy • FFT-A versus 3-session EC
  • 2-Year Recovery and Recurrence Rates: No Differences Between FFT and EC for Adolescents (N = 145) with Bipolar I or II Disorder PercentofPatients Miklowitz, Schneck et al., 2014, Am J Psychiatry
  • www.canmat.orgwww.canmat.org Major Psychosocial Studies in Past Decade  Psychoeducation – many RCTs (+) with diverse approaches  Cognitive Behavioural Therapy – Several small RCTs (+), one large (+), one large (-)  Interpersonal and Social Rhythm Therapy (IPSRT) – Single small RCT weakly (+), second (+)  Family Management – One small (+), several larger ones (+ or =
  • IPSRT Slides from: Holly A. Swartz, M.D. Associate Professor of Psychiatry University of Pittsburgh School of Medicine
  • What does theWhat does the bodybody’s clock’s clock have to do withhave to do with moods andmoods and moodmood disorders?disorders?
  • Circadian Rhythms and Mood Disorders Body clocks are sensitive to shifts Makes it harder to stay on schedule
  • Manic and Depressive Episodes = Pathological Entrainment of Biological Rhythms Change in Social Prompts (Social Zeitgebers = Unobservable Variables) Ehlers, Frank & Kupfer. Arch Gen Psychiatry 1988;45:948-952. Life Events Schema for Social Zeitgeber Theory of Moods and Mood Episodes Change in Somatic Symptoms Change in Stability of Biological Rhythms Change in Stability of Social Rhythms
  • Change in Stability of Social Rhythms • Death of a beloved spouse leads to psychological loss AND a loss of regular daily routines (e.g. wake time, meal times, other daily routines, bedtime) • Death of a not-so-beloved dog still involves a loss of regular daily routines
  • Essential Elements of Interpersonal and Social Rhythm Therapy (IPSRT) • Social rhythm therapy¹ Regularize daily routines Emphasizes the link between regular routines and moods Uses Social Rhythm Metric to monitor routines • Interpersonal psychotherapy² Emphasizes link between mood and life events Focus on interpersonal problem area (grief, role transition, role disputes, interpersonal deficits) 1. Frank E, et al. Biol Psychiatry 2000;48:593-604; Frank E, et al, Arch Gen Psychiatry 62:996- 1004, 2005. 2. Klerman GL, et al. Interpersonal Psychotherapy of Depression, Basic Books, New York, 1984.
  • IPSRT in MaintenanceIPSRT in Maintenance Frank et al, Arch Gen Psych 2005Frank et al, Arch Gen Psych 2005 • N=175 randomized over 10 years • Four arms—acute and maintenance – IPT / IPT – ICM / ICM (intensive clinical management) – IPT / ICM – ICM / IPT • Two year follow-up – Acute—no differences – Maintenance—getting IP/SRT first reduced relapse subsequently
  • MANUAL FOR INTERPERSONAL AND SOCIAL RHYTHM THERAPY Frank, E. TREATING BIPOLAR DISORDER: A CLINICIAN’S GUIDE TO INTERPERSONAL AND SOCIAL RHYTHM THERAPY. The Guilford Press, New York, NY, 2005. guilford.com amazon.com barnesandnoble.com
  • www.canmat.orgwww.canmat.org Comparing the Major Psychosocial Treatments  Psychoeducation – Several studies compared to CBT primarily  Cognitive Behavioural Therapy – Two comparisons to Psychoeducation  Interpersonal and Social Rhythm Therapy – One comparative study for bipolar depression  Family Focused Therapy – One comparative study for bipolar depression, one to Psychoeducation
  • The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD): A Study of Therapy Effectiveness “Collaborative Care” (3 sessions of individual education, coping strategies and prevention planning) “Collaborative Care” (3 sessions of individual education, coping strategies and prevention planning) Intensive therapy (< 30 sessions in 9 mos.) •Cognitive Behavioral Therapy (CBT) •Interpersonal and Social Rhythm Therapy (IPSRT) •Family Focused Therapy (FFT) Intensive therapy (< 30 sessions in 9 mos.) •Cognitive Behavioral Therapy (CBT) •Interpersonal and Social Rhythm Therapy (IPSRT) •Family Focused Therapy (FFT) 293 bipolar depressed adults treated by 30 therapists in 15 sites Pharmacotherapy initiated How long until recovery? (Actual mean = 13 sessions)
  • The STEP-BD Multisite Program (15 sites, N=293) (Miklowitz et al., 2007; Arch Gen Psychiatry) χ2(3) = 8.02, p = .046 Hazard Ratios (vs CC) CBT: 1.34, p = .12 FFT: 1.87, p = .013 IPSRT: 1.48, p =.048
  • Psychoeducation vs CBT:Psychoeducation vs CBT: A National RCT (Study 3)A National RCT (Study 3)  Funded by Stanley Foundation and CIHR 6 Group PE Sessions OR 20 Individual CBT Sessions
  • Study 3 DesignStudy 3 Design • To examine the relative merits and costs of adding CBT or PE to medication in Bipolar Disorder • Compares six sessions of group PE vs 20 sessions of individual CBT, using BEST manuals • Outcomes: average mood weekly (overall mood burden) plus time to recurrence of either depression or mania Parikh et al, J Clin Psychiatry 2012
  • www.canmat.orgwww.canmat.org Results: Weekly Symptoms Depression Week 0 10 20 30 40 50 60 70 Mean(+/-SE) 1.4 1.6 1.8 2.0 2.2 2.4 2.6 2.8 PE CBT Mania Week 0 10 20 30 40 50 60 70 Mean+/-SE 1.0 1.1 1.2 1.3 1.4 1.5 1.6 PE CBT Depression Mania LIFE mean scores by treatment group – 8 week intervals • Significant decline in LIFE scores in both groups • No significant difference by treatment group Parikh et al J CLIN PSYCH 2012
  • www.canmat.orgwww.canmat.org Results: Time to Recurrence Major Depressive Episode N = 95 recurrences (Hypo)manic Episode N = 59 recurrences • No difference in recurrence rate by treatment group Survival curves for recurrence with depressive or manic episode Parikh et al J CLIN PSYCH 2012
  • www.canmat.orgwww.canmat.org Results: Cost Psychoeducation 2 staff hours/90 min. session x 6 sessions @ 4 participants / group = $180 per participant CBT 1 staff hour/session x 20 individual sessions = $1200 per participant
  • Advantages of Brief Psychoeducation: LIFE Goals • Briefer psychoeducational treatments have substantial effect; consider treatment hierarchy (stepped care) • Research evidence: 3 major studies have used LIFE Goals program (more than any other mode) • LIFE Goals draws from familiar PE methods and is easy to teach or learn • LIFE Goals is relatively inexpensive, and easy for patients to attend
  • VIII. Psychodynamic/ Insight Therapy VII. Occupational Therapy/ Rehabilitation VI. Detailed Family/Marital Therapy V. Brief Family/Marital Psychoeducation IV. CBT or IPT if indicated After PE or For Depression III. Patient Psychoeducation (6 sessions) II. Tailored Health Services (Health Care Team) I. Pharmacotherapy and Clinical Management Bipolar Disorder Treatment Model (Parikh, 2002) Treatment Hierarchy LIFE Goals
  • Common Elements of Therapies • All major bipolar psychosocial therapies emphasize education on illness and its treatment • All have version of “relapse drill” • ….thus all have psychoeducation piece, but add something else
  • Mindfulness  Based upon Buddhist meditation techniques  Can be taught to groups of people  Creates an emotional “distance” from thoughts (“metacognitive awareness”)  “Thoughts aren’t facts”
  • So Which Psychotherapy? Meds Talk
  • www.canmat.orgwww.canmat.org Barriers to Optimal TreatmentBarriers to Optimal Treatment Patient View What do I want? System View What is evidence based and worth paying for? Provider View What can I provide?
  • www.canmat.orgwww.canmat.org Choosing a Therapy / Therapist • Decide on personal priorities / needs first • Sequence treatments – coping skills (PE), specific tools for depression, family or marital, rehabilitation, dealing with personal issues • Explore what is available in your area • Ask therapist about specific Bipolar Experience • Give it a try but set goals at start • Always with mood stabilizing medication
  • Long-Term Treatment GoalsLong-Term Treatment Goals for Bipolar Disorderfor Bipolar Disorder  Increase length of periods of stability  Treat both manic and depressive episodes when they occur1  Reduce severity of mood symptoms when they occur  Improve overall patient functioning2 Sachs GS. J Clin Psychopharmacol 2003;23(suppl 1):S2-S8. Tohen M, et al. Am J Psychiatry 2003; 160:2099-2107.