Dr. Nasreen Khatri, a clinical psychologist and researcher at the Rotman Research Institute, a brain Institute fully affiliated with the University of Toronto and core CREST.BD member, describes current research and the clinical impact of cognitive behaviour therapy (CBT) in bipolar disorder. CBT is an evidence-based, collaborative, structured self-management talk therapy that helps individuals to monitor and manage symptoms of bipolar disorder by improving problem-solving skills. Learn about the evidence and considerations for CBT treatment for bipolar disorder in adults and how CBT can be used in combination with medication to optimize wellness and quality of life for people who have bipolar disorder. Dr. Nasreen Khatri is a registered clinical psychologist who specializes in the assessment, treatment and research of mood and anxiety disorders. From 2004 to 2012, she led the Mood and Related Disorders Clinic and Cognitive Behaviour Therapy (CBT) service at Baycrest. In 2012, Dr. Khatri joined the Rotman Research Institute, a brain institute fully affiliated with the University of Toronto, where she studies how mood disorders impact the aging brain. Dr. Khatri’s research has been funded by the Canadian Institutes of Health Research (CIHR), the Alzheimer’s Society of Canada (ASC), and in 2013 she was awarded the Women of Baycrest Innovators in Research Award. In addition to her research and private practice, she has completed over 150 presentations, most recently for Bell Let's Talk Day. She has been cited in the media, including The Globe and Mail, The Wall Street Journal (US) and The Daily Mail (UK). She currently blogs for The Huffington Post on the topic of Mind your Mood: Depression and the Aging Brain. She serves on the Board of Trustees of The Psychology Foundation

1. Getting Even:
Cognitive Behaviour Therapy (CBT)
and
Bipolar Disorder
November 26, 2014
University of British Coumbia
CREST.BD Webinar Series
Presented by:
Nasreen Khatri, PhD, CPsych
Rotman Research Institute, Baycrest
Toronto, Ontario

2. Learning Objectives
1. Overview of bipolar disorder (BD) (esp
depression) in adults
2. Describe the emotional and cognitive impact of
depression in BD
3. Summarize clinical impact of Cognitive
Behaviour Therapy (CBT) in BD

3. Background and Review
• BD is a mental disorder characterized by
severe mood swings
• Lifetime Prevalence in Canada: 1%
• Lifetime Prevalence of depression: 8%
• Days spent depressed outnumber days spent
manic 3 to 1 (Kupka et al, 2007)

4. Untreated Depression
•Leads too …
• Physical Health problems (diabetes, heart disease, stroke, arthritis)
• Makes current health problems worse
• May double the risk of developing dementia later in life
(Saczynski, et al., Neurology, 2010)

5. BD and Depression

6. Chronicity
Depression is more like diabetes than a broken ankle

7. Consequences of Depression
• Depression ranked as the 2nd most burdensome
disease in the world in terms of Total Disability
based on lifetime prevalence, early age of onset, high
chronicity and role impairment
- World Health Organization

8. Cognitive Symptoms of Depression
• Problems thinking, concentrating or making decisions
• Recurrent thoughts of death (negative bias and guilt)
• (In)attention, executive function

9. Cognition in mood disorders
• Neuropsychological cognitive measures
predict poorer functional outcomes, for
example, in terms of return to employment
or quality of life
– Jaeger et al. Psychiatry Res 2006;145:39-48.
– Martinez-Aran et al. Bipolar Disord
2007;9:103-113.

10. Cognitive domains
affected by depression
• Executive Control
• Affective Processing
• Feedback Sensitivity
• Memory
– Clark et al. Annu Rev Neurosci
2009;32:57-74.

11. Executive Control
• Executive function: higher-level processes involved
in the flexible organization of behavior, including
working memory, forward planning, and the
inhibition of dominant responses.

12. Cognitive Model of Depression
• A stress-diathesis model which posits that negative
thoughts about oneself, others and the future, (cognitive
triad),
• Precipitated by a perceived stressor in the
environment,
• Activates underlying schemas (i.e., core
beliefs, self-knowledge networks) that lead to the
development, maintenance and relapse of depression

13. Stoic Philosophy
Events are Impersonal and Indifferent
“What is a “good” event? What is a “bad” event? There is no
such thing! What is a good person? The one who achieves
tranquility by having formed the habit of asking on every
occasion,”
“What is the right thing to do now?”
- Epictetus
(1st Century Roman)

14. Cognitive Behavior Therapy (CBT)
• Short-term, time-limited, structured therapy
• 15-20 weekly 1-hr sessions
• Focuses on relationship between mood, thoughts and behavior
• Identifies and reframes distorted and negative views of self and
the world

15. CBT
• One of the most validated and empirically supported
treatments for depression
• Assumes that psychological disorders involve dysfunctional
ways of thinking
• The way an individual feels and behaves is influenced by the
way they think and how they structure their experience
• Modifying dysfunctional thinking Þ Improvement in
symptoms

16. CBT: The Key Ingredients
• The Cognitive Model (thought influences emotion)
• Good therapeutic alliance
• Structure
• Time-Limited
• Goal Oriented and Problem Focused
• Collaborative
• Educational

17. Key Ingredients
• Present and Future Focus
• Specific Techniques to change thinking,
mood and behavior (e.g., thought records)
• Experiential Learning
• Guided Discovery
• Case Conceptualization
• Skill Acquisition/Homework

18. Behavioral Techniques
• Activity Monitoring & Scheduling
• Graded Task Assignments
• Exposure to steps on hierarchy
• Relaxation (e.g., controlled breathing, PMR)
• Social Skills Training (e.g., assertiveness)
• Exercise
• Behavioral Experiments to test out thoughts and beliefs

19. Goals of CBT for
Bipolar Disorder
• Psychoeducation
• Medication
• Understanding
• & Adherence
• Mood
• Charting

20. CBT and BD
• Mood rating and monitoring
• Activity monitoring
• Preventing episodes by knowing and predicting triggers
• Relapse signature
•Healthy lifestyle to manage energy levels (exercise,
relaxation training

21. Mayberg HS. J Clin Invest. 2009; 119(4): 717–725.

22. CBT for BD
• CBT is successful adjunct treatment for BD
(Lam et al, 2003)

23. Conclusions
• BD presents a complex clinical picture with consequences for
the individual, family and society – medication may not be enough
• CBT is an empirically supported treatment for depression in
and as an adjunct therapy for bipolar disorder
•CBT empowers indvdiasl with BD to be an active partner in
their wellness journey
• Future treatments should focus on relapse prevention, booster
sessions, brain imaging and the neural signature of recovery (CIHR
grant)