Achieving Remission and Recovery in Bipolar Disorder
Francesc Colom, PsyD, MSc, PhD
Psychoeducation and Psychological Treatments Area, Bipolar Disorders Program, IDIBAPS, CIBERSAM, Barcelona, Spain
Pharmacotherapy is the primary treatment for patients with bipolar disorder. However, despite the availability of several medications with proven efficacy for treating the disorder, preventing recurrence and returning patients to full functional recovery has proven problematic. Patients with bipolar disorder spend about half of their time symptomatic even when taking medication,1 and while almost 99% of patients reach syndromal recovery within 2 years of a first hospital admission, only about 40% achieve functional recovery by that point.2 Implementing psychoeducation and psychotherapy in addition to pharmacotherapy may improve patient outcomes by addressing several problems that impede recovery.
Barriers to Recovery
Lack of treatment adherence is a major factor in the efficacy/effectiveness gap for medications for bipolar disorder.3 Medication side effects are one reason for lack of treatment adherence, but better predictors of nonadherence are a patient’s attitude toward medication (including fear of becoming dependent and fear of side effects) and his or her denial of the severity of bipolar disorder.4 Psychiatric comorbidities, such as anxiety and substance use disorders, are common in patients with bipolar disorder and may also complicate treatment regimens and affect treatment adherence.5 Additionally, neuropsychological testing has demonstrated deficits in cognitive functioning in patients with bipolar I or II disorder when compared with control subjects,6 and cognitive impairment is associated with poor treatment adherence.7
Treatment may also be complicated by the adverse impact that bipolar disorder has on the lives of patients, including disruptions in their personal and business relationships, difficulties in carrying out job responsibilities and in enjoying leisure activities, and feelings of being ridiculed and stigmatized.8 Many patients with bipolar disorder will have suffered these social and functional impairments for many years due to the delays typically experienced in receiving a correct diagnosis.9
To effectively treat patients with bipolar disorder, clinicians must treat the complicating factors of the disorder—including adherence problems, comorbidities, and cognitive impairment—and not just the core symptom of mood dysregulation. To this end, various psychosocial interventions have been studied as adjunctive treatments to pharmacotherapy. A meta-analysis10 reported that adjunctive psychosocial therapy reduced symptom levels, improved social functioning, and significantly reduced relapse rates in patients with bipolar disorder (P = .001). The analysis found that psychosocial interventions were more useful in maintenance treatment as a prophylactic measure against relapse than as a treatment for an acute episode. Effective therapies (such as interpersonal and social rhythm therapy, family-focused psychoeducation, and group psychoeducation) focused on the illness and the consequences of the illness rather than on the patient’s personality or biographical problems.
Goals. Psychoeducation is not merely providing information to patients about their diagnosis. Patients, along with their caregivers, receive training that provides them with the tools to become proactive in the management of bipolar disorder. The primary goals of psychoeducation are relapse prevention, prevention of suicidal behavior, reduction of hospitalization rates, and improvement in functional outcomes. Secondary goals include reducing stigma and guilt, increasing self-esteem and well-being, improving stress management, and improving comorbidities.11
One evidence-based model of psychoeducation therapy is based on the Barcelona Program.12,13 This model consists of 21 weekly sessions that address illness awareness, the enhancement of medication adherence, and the early detection of the warning signs of an acute episode of either mania or depression
(AV 1). In addition, education is provided on improving the regularity of habits and avoiding substance use. The training is delivered in a group setting of 8 to 12 patients; patients should be euthymic at the time of entry to the group.12 The sessions last 90 minutes and are directed by 2 trained therapists. While patients continue to receive standard pharmacologic care, no other psychological interventions are given.
Efficacy. Psychoeducation has been shown to help patients improve their medication adherence, relapse prevention skills, and lifestyle regularity. For example, in a study14 comparing adjunctive psychoeducation with standard treatment, serum lithium levels were significantly higher and more stable at 6, 18, and 24 months for the group receiving psychoeducation versus the control group (P ≤ .05), indicating greater medication adherence (AV 2). Another study15 showed that teaching patients to identify the early warning signs of relapse significantly reduced manic relapses (P = .013) and improved social functioning (P = .003); however, depressive relapses were unaffected. Frank and colleagues16 compared interpersonal and social rhythm therapy—which, among other things, focuses on the importance of maintaining regularity in daily routines—with intensive clinical management during the acute phase. Patients receiving interpersonal and social rhythm therapy experienced longer survival times without an affective episode (P = .01).
My colleagues and I12 followed patients who had received adjunctive psychoeducation or standard pharmacologic care for 2 years after treatment cessation. The patients in the psychoeducation group experienced a significant reduction in total relapse rates (P < .001) compared with patients in the control group; the reduction extended to manic, mixed, and depressive relapses. In addition, the psychoeducation group had fewer hospitalizations per patient (P < .05) and a significantly lower mean number of days of hospitalization per patient (P < .05) than the control group. In our 5-year follow-up17 of these patients, those who had received psychoeducation were about 50% less likely to have a relapse than patients in the control group (P < .0001), and this difference was true for mania, hypomania, mixed episodes, and depression. Patients receiving psychoeducation also spent significantly fewer days acutely ill than patients in the control group (AV 3). The effect size of the intervention for relapse prevention of any type of episode was greater at the 5-year follow-up than at the 2-year follow-up, suggesting that patients who are trained via psychoeducation get better at managing their illness over time.
Cost effectiveness. A cost-effectiveness analysis18 found that subjects receiving psychoeducation had higher costs for medication and outpatient visits than did patients receiving unstructured group support. However, costs for emergency services and inpatient care were much lower for patients in the psychoeducation group, making the intervention less costly overall in the long term because it was more effective in preventing relapse.
Timing of psychoeducation. When their caregivers receive psychoeducation, patients with bipolar disorder show a significantly longer time to recurrence of affective episodes (P = .012).19 However, caregiver psychoeducation appears effective only when patients are in the early stages of bipolar disorder. The same holds true for patients receiving psychoeducation directly: the number of previous episodes appears to affect the time spent ill. In a post hoc analysis20 of the 5-year follow-up study17 described above, only patients with 6 or fewer episodes at study entry achieved a reduction of time spent in every type of episode. Those with 7 to 8 episodes at entry showed a reduction in time spent in all episodes except mania; patients with 9 to 14 episodes spent fewer days in hypomania and depression (but not mixed states or mania); and patients having more than 14 episodes at study entry showed no reduction in time spent ill.
Patients with more previous episodes may not respond to psychological treatments as well as those in the early stages of the illness for a number of reasons. First, cognitive functioning, in terms of attention, learning, executive functioning, and memory, may be impaired in long-time patients. Additionally, changing lifestyle patterns becomes more difficult over time, and, for patients with more than 11 episodes, kindling and sensitization may be an issue.21 Tailored treatment interventions that can help patients who are in advanced stages of bipolar illness include cognitive rehabilitation focusing on problem-solving and nonverbal working memory, social care, family support for the patient, and outside support for the patient’s family. The added treatment challenges that arise as the illness progresses underscore the importance of early integrated treatment for patients with bipolar disorder.
For Clinical Use
- Use pharmacotherapy as the primary treatment for patients with bipolar disorder
- Be aware that problems such as medication nonadherence and cognitive impairment are major factors in the lack of recovery among patients with bipolar disorder
- Use psychoeducation early in treatment to help patients achieve functional recovery by addressing problems such as nonadherence and by providing tools to help patients and their families be proactive in managing the disorder
Lithium (Lithobid and others)
Take the online posttest.
- Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6):530–537.
- Tohen M, Hennen J, Zarate CM JR, et al. Two-year syndromal and functional recovery in 219 cases of first-episode major affective disorder with psychotic features. Am J Psychiatry. 2000;157(2):220–228.
- Guscott R, Taylor L. Lithium prophylaxis in recurrent affective illness: efficacy, effectiveness and efficiency. Br J Psychiatry. 1994;164(6):741–746.
- Scott J, Pope M. Nonadherence with mood stabilizers: prevalence and predictors. J Clin Psychiatry. 2002;63(5):384–390.
- McElroy SL, Altshuler LL, Suppes T, et al. Axis I psychiatric comorbidity and its relationship to historical illness variables in 288 patients with bipolar disorder. Am J Psychiatry. 2001;158(3):420–426.
- Dittmann S, Hennig-Fast K, Gerber S. Cognitive functioning in euthymic bipolar I and bipolar II patients. Bipolar Disord. 2008;10(8):877–887.
- Martinez-Aran A, Scott J, Colom F, et al. Treatment nonadherence and neurocognitive impairment in bipolar disorder. J Clin Psychiatry. 2009;70(7):1017–1023.
- Morselli PL, Elgie R. GAMIAN-Europe/BEAM survey I: global analysis of a patient questionnaire circulated to 3450 members of 12 European advocacy groups operating in the field of mood disorders. Bipolar Disord. 2003;5(4):265–278.
- Ghaemi SN, Sachs GS, Chiou AM, et al. Is bipolar disorder still underdiagnosed? are antidepressants overutilized? J Affect Disord. 1999;52(1–3):135–144.
- Scott J, Colom F. Psychosocial treatments for bipolar disorders. Psychiatr Clin North Am. 2005;28(2):371–384.
- Colom F, Vieta E, Martinez A, et al. What is the role of psychotherapy in the treatment of bipolar disorder? Psychother Psychosom. 1998;67(1):3–9.
- Colom F, Vieta E, Martinez-Arán A, et al. A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar disorder whose disease is in remission. Arch Gen Psychiatry. 2003;60(4):402–407.
- Colom F, Vieta E, Scott J. Psychoeducation Manual for Bipolar Disorder. New York, NY: Cambridge University Press; 2006.
- Colom F, Vieta E, Sánchez-Moreno J, et al. Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium levels. Bipolar Disord. 2005;7(suppl 5):32–36.
- Perry A, Tarrier N, Morriss R, et al. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. BMJ. 1999;318(7177):149–153.
- Frank E, Kupfer DJ, Thase ME, et al. Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry. 2005;62(9):996–1004.
- Colom F, Vieta E, Sánchez-Moreno J, et al. Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial [published correction appears in Br J Psychiatry. 2009;12(4):110]. Br J Psychiatry. 2009;194(3):260–265.
- Scott J, Colom F, Popova E, et al. Long-term mental health resource utilization and cost of care following group psychoeducation or unstructured group support for bipolar disorders: a cost-benefit analysis. J Clin Psychiatry. 2009;70(3):378–386.
- Reinares M, Colom F, Rosa AR, et al. The impact of staging bipolar disorder on treatment outcome of family psychoeducation. J Affect Disord. 2010;123(1–3):81–86.
- Colom F, Reinares M, Pacchiarotti I, et al. Has number of previous episodes any effect on response to group psychoeducation in bipolar patients? a 5-year follow-up post hoc analysis. Acta Neuropsychiatrica. 2010;22(2):50–53.
- Kapczinski F, Dias VV, Kauer-Sant'Anna M, et al. Clinical implications of a staging model for bipolar disorders. Expert Rev Neurother. 2009;9(7):957–966.