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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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

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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

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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

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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

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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

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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)

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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?

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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

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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

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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

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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

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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

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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!

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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)

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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

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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

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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

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LIFE Goals Self Help Workbook

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Best Bipolar Website

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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 =)

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Major Bipolar-CBT Books

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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

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The Cognitive Model
Thoughts
Behaviours
Feelings
Core
Belief
Situation

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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.

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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.

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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

28. 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

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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

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Major CBT Books for Bipolar Disorder

31. World Wide Web

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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 =)

33. 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.

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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.

40. 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

41. 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

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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 =

43. IPSRT Slides from:
Holly A. Swartz, M.D.
Associate Professor of Psychiatry
University of Pittsburgh School of Medicine

44. What does theWhat does the
bodybody’s clock’s clock
have to do withhave to do with
moods andmoods and
moodmood
disorders?disorders?

45. Circadian Rhythms and Mood
Disorders
Body clocks are sensitive to
shifts
Makes it harder to stay
on schedule

46. 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

47. 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

48. 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.

49. 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

50. 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

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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

52. 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)

53. 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

54. 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

55. 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

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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

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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

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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

59. 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

60. 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

61. 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

62. 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”

63. So Which Psychotherapy?
Meds
Talk

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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?

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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

66. 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.