People with bipolar disorder are much less likely to receive psychotherapy (26-50% of patients in one study got therapy) as opposed to psychiatric medications (46-90% were treated with medications) according to a study sponsored by the Depressive and Bipolar Support Association. This is not surprising since many mental health professionals were taught when we were in training that bipolar depression did not respond to therapy, and, in fact, often got worse.
That this is not true has been shown in many well designed clinical trials which are summarized in a 2020 article in JAMA Psychiatry. However, the components of therapy which work best for bipolar disorder (BD) are not the same as the components of therapy that help people with unipolar depression.
David Miklowitz et al identified 39 randomized clinical trials among individuals with BD (36 of adults and 3 of adolescents) in which a manualized psychosocial intervention plus pharmacotherapy was compared with a control intervention plus pharmacotherapy, they then used the technique of Network Meta-Analysis to evaluate the components of effective psychotherapy. .
The authors examined illness recurrence as the primary long-term outcome. They conclude that manualized treatments were associated with reduced episode recurrence compared to “treatment as usual.” And family or group delivery of psychoeducation and skills appeared superior to individual delivery of these interventions.
With regard to secondary outcomes (affective symptoms over 1 year), data supported cognitive behavioral therapy (CBT), family therapies, and interpersonal therapies over treatment as usual for reducing depression.
Network Meta-Analysis allows a comparison between treatments that were never directly compared if both were compared with a third treatment. And it also allowed an analysis of the specific components of therapy associated with effective outcomes.
In terms of reducing recurrences (the primary outcome measure), psychoeducation with guided practice of illness management skills in a family or group format was associated with reducing recurrences vs the same strategies in an individual format (OR, 0.12; 95% CI, 0.02-0.94).
In terms of reducing depressive symptoms, cognitive behavioral therapy (SMD, −0.32; 95% CI, −0.64 to −0.01) and, with less certainty, family or conjoint therapy (SMD, −0.46; 95% CI, −1.01 to 0.08) and interpersonal therapy (SMD, –0.46; 95% CI, −1.07 to 0.15) were more effective than treatment as usual.
Higher study retention was associated with family or conjoint therapy (OR, 0.46; 95% CI, 0.26-0.82) and brief (less than 6 sessions) psychoeducation (OR, 0.44; 95% CI, 0.23-0.85) compared with standard psychoeducation.
As a clinic we will be reviewing this data carefully and incorporating its findings into the way we provide care for people with bipolar.
Goldstein TR, Hafeman DM. Beyond Efficacy and Toward Dissemination and Personalization of Psychotherapy for Bipolar Disorder. JAMA Psychiatry. Published online October 14, 2020. doi:10.1001/jamapsychiatry.2020.2980
Depression and Bipolar Support Alliance. DBSA Survey Center: preferences for the treatment of bipolar disorder survey. Published 2017. Accessed August 14, 2020. https://www.dbsalliance.org/wp-content/uploads/2019/02/DBSA_Survey_Center_BPD_Treatment_Preferences_FINAL.pdf
Miklowitz DJ, Efthimiou O, Furukawa TA, et al. Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. JAMA Psychiatry. Published October 14, 2020. doi:10.1001/jamapsychiatry.2020.2993