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452 The APA Publishing Textbook of Mood Disorders, Second Edition
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what the patient’s subjective experience reflects, he or she must also be thinking
about which components of the depressive illness are more biological and require
medication and which aspects are amenable to psychotherapy.
Psychotherapy today does not necessarily imply that the therapist and the patient
are in the same room. Online apps, video conferencing platforms, texting, email, and
phone therapy have dramatically changed the therapeutic playing field. Definitive re
search is not yet available, but practice is far ahead of empirically derived data on efficacy. Therapists are routinely receiving text messages from their patients, and these
interactions frequently lead to more extended conversations via text. Phone therapy
and videoconferencing therapy are also practiced in many situations where patient
and therapist cannot be together for reasons of travel, relocation, or out-of-town business—or, as in the case of the COVID-19 pandemic, public health reasons. Most psychotherapists today view online communication with patients as virtually unavoidable
(Gabbard 2019). Some of it, like appointment changes, may not be unprofessional or
unethical, but breaches of confidentiality are always a risk with communications that
are not in-person. Clinicians must be hypervigilant about how any remote communication is conducted.
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CHAPTER 26
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Psychotherapeutic
Approaches
to Bipolar Disorder
David J. Miklowitz, Ph.D.
Lisa A. O’Donnell, Ph.D.
Bipolar disorder is characterized by a relapse/remission course, with varying
degrees of symptomatic and functional disability between episodes. Lithium, other
mood stabilizers, and second-generation antipsychotics are usually recommended as
first-line treatments for acute episodes of mania or depression. However, medication
alone is often an insufficient strategy for managing the illness over the long term.
Rates of recurrence are high even for individuals receiving medication (i.e., a recurrence rate of 41% at 1 year), with those younger than 18 years at greatest risk for recurrence (Gignac et al. 2015).
Increasingly, treatment guidelines for bipolar disorder are recommending a combination of medications and psychosocial treatments (Goodwin et al. 2016; Yatham et
al. 2018). Adjunctive psychotherapies aim to reduce the impact of psychosocial stressors through increasing access to social supports; enhancing functioning in the areas
of academic, school, and work performance; and enhancing quality of life despite
limitations imposed by the illness. Consistent with many models of chronic disease
management, treating bipolar disorder requires a biopsychosocial approach incorpo
rating pharmacotherapy in the context of psychoeducation, illness management
strategies, and skills training. This chapter reviews the current state of research evidence on the use of different forms of individual, group, and family therapy approaches in the treatment of bipolar disorder. Space constraints preclude a review of
all existing open and randomized controlled trial (RCT) studies of each modality, but
common themes observed across trials will be highlighted, along with recommendations for future research.
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Individual Psychosocial Approaches
Interpersonal and Social Rhythm Therapy
Interpersonal psychotherapy (IPT) is based on the view that depression exists within
the context of interpersonal stressors. These stressors typically occur in the areas of
grief and loss, role transitions, interpersonal disputes, and social skills deficits. The so
cial rhythm disruption theory proposes that among individuals with vulnerabilities to
circadian disruption, life stressors that disrupt the regularity of daily and nightly rou
tines can trigger mood episodes (Ehlers et al. 1988). Interpersonal and social rhythm
therapy, or IPSRT, is a form of IPT specifically designed for individuals with bipolar
disorder to assist them in regulating their sleep/wake cycles and other daily rhythms,
managing interpersonal stressors, and preventing future depressive and manic episodes.
IPSRT is given in variable lengths and frequencies depending on the acute or longterm objectives of the program. The initial phases typically include assessment of the
quality and number of the patient’s relationships, identification of one or more inter
personal problem areas, psychoeducation about the link between daily routines and
mood, and the recording of daily activities and sleep/wake cycles. The intermediate
phase focuses on managing mood symptoms, regulating social and sleep/wake
rhythms, and resolving key interpersonal problems. The preventive phase focuses on
reinforcing regular social rhythms and working toward reducing the impact of inter
personal stressors in the future.
A 2-year clinical trial examined 175 acutely depressed, manic, or mixed-episode
adults with bipolar I disorder who received pharmacotherapy and were randomly as
signed to receive either IPSRT or intensive clinical management (ICM; psychoeducation, illness management strategies, general support) during an acute treatment phase
(Frank et al. 2005). Then, after symptoms stabilized, patients were again randomized
into a two-year maintenance phase of either IPSRT or ICM. Results found no differences
between these four groups for time to remission. However, those in the acute IPSRT
treatment arm had a longer time to recurrence, more time well, and better occupational
functioning during the maintenance phase than those in the acute ICM condition.
Moreover, the association between treatment with IPSRT and later recurrence was me
diated by improvements in social rhythm stability during acute treatment.
In the only trial of psychotherapy given without concurrent medication, Swartz et
al. (2018) allocated 92 acutely depressed adults with bipolar II disorder into one of
two groups: IPSRT plus placebo or IPSRT plus quetiapine. In 12 weeks of treatment,
the IPSRT plus quetiapine group improved faster in depression and hypomania
scores compared with the IPSRT plus placebo group. Those receiving quetiapine were
exposed to more severe side effects (including significantly greater weight gain) than
those receiving IPSRT plus placebo. At a 5-year follow-up, both groups had similar
symptom status.
In a study in New Zealand, 100 patients between the ages of 15 and 36 years (mean
26.6 years) with bipolar I disorder, bipolar II disorder, or bipolar disorder not otherwise specified (NOS) were randomly allocated to receive medication plus IPSRT or
medication plus specialist supportive care (psychoeducation and supportive engage-
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ment) (Inder et al. 2015). Both treatments were administered in an average of 26–27
sessions over 18 months. The IPSRT included adaptations for adolescents with bipo
lar I or bipolar II disorder (Hlastala et al. 2010), such as age-relevant differences in
sleep/wake cycles and areas of interpersonal conflict. The two treatment groups ex
perienced similar reductions in depressive and manic symptoms and improvements
in social functioning, with no group differences over 3 years in symptom severity or
time to recurrence (Inder et al. 2017).
IPSRT was one of three psychotherapies found to hasten recovery in comparison
with brief treatment in the Systematic Treatment Enhancement Program for Bipolar
Disorder (STEP-BD) study (see discussion later in this chapter). Thus, the balance of
evidence for IPSRT is positive, although the New Zealand study suggests that it may
not outperform standard supportive care for younger patients. There are few data on
moderators of response to IPSRT, such as whether patients who begin treatment with
high social rhythm variability are more likely to benefit than those with minimal
rhythm disruption.
Cognitive-Behavioral Therapy
Most psychotherapies referred to as “cognitive” assume that the meaning people attach to situations is the primary causal influence on their emotions and behaviors.
Treatment of a recurrent mood disorder, then, involves identifying and challenging
negativistic or distorted thinking and encouraging patients to consider alternative,
healthier meanings to provocative situations. In extensions of cognitive-behavioral
therapy (CBT) to bipolar disorder, the overly optimistic or grandiose thinking associ
ated with hypomanic or manic episodes is addressed through cognitive restructuring, such as by encouraging patients to consider the risks as well as potential benefits
of impulsive choices (Lam et al. 2003). Additionally, CBT attempts to reduce the with
drawal and avoidance associated with depression by increasing the patient’s engagement with his or her environment (behavioral activation). More recent adaptations of
CBT have also included exercise and healthy lifestyle management as ways of com
bating depressive mood states (Sylvia et al. 2019).
The average length of CBT for bipolar disorder is 20 individual sessions, including
booster sessions, over a period of 6–9 months. Treatment typically starts with psychoeducation on topics such as medication adherence, stress management, and daily
mood monitoring. Addressing automatic negative thoughts and core dysfunctional
beliefs often makes up the body of treatment. For relapse prevention, CBT teaches patients to detect early warning signs of recurrence and implement prevention-oriented
coping strategies.
Despite the large body of research supporting CBT as an effective treatment for
major depressive disorder, evidence for its effectiveness in bipolar disorder is incon
clusive. In the United Kingdom, Lam et al. (2003) randomly allocated 103 euthymic
adults with bipolar I disorder to receive either cognitive therapy (CT) with medications and regular psychiatric follow-up or medications and psychiatric follow-up
(usual care) only. Over 12 months, those receiving CT had fewer and shorter depressive episodes, fewer hospitalizations, and better social functioning than those in
usual care. These results were maintained at the 30-month follow-up, although the effect on relapse reduction was significant only in the first 12 months (Lam et al. 2005).
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Scott et al. (2006) conducted an RCT across five U.K. community mental health
agencies, comparing pharmacotherapy alone with pharmacotherapy plus 22 sessions
of individual CT over 18 months. The study (N=253) included acutely ill and remitted
patients. There were no group differences in recurrence rates except for patients who
had fewer than 12 lifetime episodes; these were less likely to experience a recurrence
in CT plus pharmacotherapy than in pharmacotherapy alone. In turn, patients with
more than 12 prior episodes were less likely to experience a recurrence in pharmaco
therapy alone than in CT plus pharmacotherapy. This finding was interpreted as CT
being more advantageous for individuals with a less recurrent form of bipolar disor
der, or those earlier in the illness course.
Although CBT includes psychoeducation about bipolar disorder, there are group
treatments that focus exclusively on psychoeducation (see section below) and do not
contain all of the individual elements of CBT, such as cognitive restructuring. A large
Canadian RCT with 204 adults with bipolar I or bipolar II disorder compared 20 ses
sions of individual CBT plus medications with 6 sessions of a brief group psychoeducation treatment plus medications. After 18 months, the brief group treatment was
found to be just as effective as CBT in terms of symptom reduction and likelihood of
relapse, and it could be delivered at a much lower cost (Parikh et al. 2012).
CBT contains many of the “nonspecific” features of supportive psychotherapy,
such as empathy, support, and provision of illness-related information. Thus, the
question arises as to whether the unique components of CBT account for its effects
above and beyond its nonspecific components. In 76 euthymic adults with bipolar
disorder, an RCT comparing 20 sessions of CBT with 20 sessions of supportive ther
apy found equivalent relapse rates over a 2-year follow-up (Meyer and Hautzinger
2012). Similar findings emerged from a pilot RCT of 32 depressed adults with bipolar
I disorder that compared 18 sessions of CBT with 18 sessions of supportive therapy.
Both groups showed similar improvements in depression and overall functioning,
but neither group showed changes in manic symptoms (Deckersbach et al. 2018).
A U.K. study compared pharmacotherapy plus an 18-session recovery-focused
CBT approach against pharmacotherapy alone in 67 euthymic adults with bipolar
disorder (Jones et al. 2015). Compared with traditional CBT, recovery-focused CBT
places a greater emphasis on working collaboratively with patients to address personal goals related to the disorder and its associated features. Over a 15-month followup, recovery-focused CBT was found to be associated with greater improvements in
personal recovery and increased time to mood relapse compared with pharmacother
apy alone.
Overall, CBT appears to be an effective adjunct to pharmacotherapy for adults
with bipolar disorder, although it is unclear whether it is any more effective than supportive therapy. Results from the Canadian trial indicate that group psychoeducation
is a more cost-effective option. The effects of CBT appear to be more consistent for de
pressive symptoms than for manic symptoms.
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Group Psychoeducation
Administering psychoeducation in a group format has many advantages, including
reduced costs in settings where multiple patients need to learn the same set of coping
skills. Patients report that groups are where they feel most understood and less stig-
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matized. In one of the first RCTs to examine group psychoeducation for individuals
with bipolar disorder, Bauer et al. (2006) tested a “Life Goals Program” as part of a
larger systematic care intervention. Patients in the trial (N=306) were randomly allo
cated to receive either “collaborative chronic care treatment” or treatment as usual
(TAU). The collaborative chronic care treatment consisted of pharmacotherapy, a
nurse care coordinator to help ensure medication adherence, and the Life Goals Pro
gram delivered in five weekly and then twice-monthly groups for up to 3 years. In
addition to teaching relapse prevention strategies, the groups focused on the attain
ment of personalized life goals. Patients in the TAU condition received medication
sessions and occasional psychotherapy, as per Veterans Affairs’ usual care protocols.
Over 3 years, patients receiving the collaborative chronic care intervention had 6.2
fewer weeks in mood episodes, as well as greater improvements in social and occupational functioning and quality of life, than patients receiving TAU. Contrary to the
results for CBT, the effects were primarily on length of manic episodes; there were no
differences between the conditions in the length of depressive episodes.
These results were largely replicated in a separate trial administered by the Group
Health Cooperative organization of Washington State. Simon et al. (2006) randomly
assigned 441 patients to a 2-year collaborative chronic care program or TAU (medication management visits). The probability of a new manic episode was significantly
lower in the collaborative care group over 2 years, and these patients spent fewer
weeks in manic episodes. There were no effects of collaborative care on depression severity or depressive recurrences.
The Barcelona trial, an influential study of group psychoeducation, compared 21
sessions of structured group psychoeducation with 21 sessions of unstructured sup
portive group therapy (standard care). Group psychoeducation according to the Barcelona model involves 90-minute patient groups run by two clinicians experienced in
treating bipolar disorder (Colom et al. 2009). The goals are to educate the patients on
the nature, causes, and treatment of bipolar disorder; the importance of monitoring
one’s moods; medication adherence; detection of prodromal symptoms of recurrence;
and healthy lifestyle choices regarding sleep, diet, and substance use. The sessions
usually include a 30- to 40-minute didactic presentation on one topic followed by an
exercise and group discussion related to the topic.
All patients in the Barcelona trial (N=120) received standard pharmacotherapy,
and all were in symptomatic remission at entry (Colom et al. 2003). Compared with
those receiving standard care, those receiving group psychoeducation experienced
fewer relapses and recurrences; increased time to relapse for depressed, hypomanic,
manic, and mixed episodes; and lower rates of hospitalization. These findings were
maintained for 5 years following the end of treatment (Colom et al. 2009). This study
is important in suggesting not only that psychoeducation is effective in a group for
mat but also that belonging to a group is not by itself sufficient; group treatment
needs to be structured and oriented toward strategies for managing the illness.
A smaller 12-month RCT conducted in Brazil compared 16 sessions of the Barcelona
group’s psychoeducation program with 16 sessions of support and relaxation training
for remitted bipolar I or bipolar II disorder patients (de Barros Pellegrinelli et al. 2013).
Patients in the two groups did not differ in reductions in mood symptoms or improvements in psychosocial functioning over 12 months. Most of the patients had
highly chronic depression (i.e., 10 or more episodes), suggesting that group treatment
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may be less effective among more chronic patients. Other differences from the Barcelona trial, such as the shorter treatment protocol (16 vs. 20 sessions) and the smaller
sample size (N=55) and shorter follow-up, may have also affected these results.
In a study in Denmark, Kessing et al. (2014) randomly assigned 158 patients who
had recently been discharged from the hospital with bipolar disorder (often only a
single episode of mania) to either a 2-year intervention program at a specialized out
patient mood disorders clinic or standard psychiatric treatment in a different clinic.
Patients in the specialty clinic began with acute treatment of depressive or manic
symptoms involving three group psychoeducation sessions plus regular pharmaco
therapy sessions for 6 months. Pharmacotherapy was delivered by trained physicians
who followed international practice guidelines. When patients were fully or partially
recovered from their index episode, they transitioned to maintenance group therapy
consisting of 12 weekly group sessions, 3 booster sessions, and a 3- to 6-month discharge group focused on preparation for transfer to a community practitioner. Patients
in the standard outpatient clinic condition received treatment in a local community
mental health center or from a local psychiatrist or general practitioner, with pharmacological treatment based on the preferences of the physician rather than on treatment
guidelines. These patients were not generally offered individual or group psychoedu
cation. All patients were followed for up to 6 years after discharge (average follow-up
of 2.5 years).
The rates of rehospitalization among younger patients (ages 18–25; n=29) in the
specialty service were lower than rates among patients in the standard treatment
group, but these differences did not reach significance in the older patients (n=129),
who composed the majority of the sample. Interestingly, the patients in the specialty
service were more likely to be treated with (and were more adherent with) mood sta
bilizers and antipsychotics than patients in the standard care clinics, particularly
those in the 18- to 25-year age group. Although many of the primary results did not
reach conventional levels of significance, comparisons of effect sizes indicated that
the more intensive specialty outpatient services, which focused on psychoeducation
and evidence-based pharmacotherapy, were more effective in younger than in older
patients.
Group psychoeducation appears to be a cost-effective approach for the long-term
maintenance of bipolar disorder in euthymic adults. Further research is needed to de
termine whether younger patients who are early in the course of their disorder are
better candidates for psychoeducation or CBT than older and more chronic and recurrent patients. The extent to which the effects of group psychoeducation are mediated
by improved medication adherence is also worthy of investigation.
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Family Interventions
In the late 1980s, evidence emerged that family attributes such as high expressed
emotion (EE) in caregivers (i.e., high levels of criticism, hostility, or emotional overinvolvement) and negative interactional behaviors between patients and their parents/
caregivers were associated with a more recurrent course of bipolar illness and poorer
social functioning (Miklowitz et al. 1988; Priebe et al. 1989). High levels of EE have
many causes among caregivers, but one appears to be their understanding of the illness: parents and spouses who are rated high in EE tend to attribute negative behaviors
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by the patient to internal and controllable causes (e.g., willfulness, personal choice),
whereas parents and spouses rated low in EE are more likely to attribute these behav
iors to less controllable factors, such as the presence of an illness (Hooley and Miklowitz 2018; Wendel et al. 2000).
Family-focused therapy (FFT) was developed to address family risk factors such
as high EE (Miklowitz 2010). The objectives of FFT are to reduce family stress by 1) in
creasing family members’ understanding of the illness, including how to recognize
early warning signs of new episodes and how to intervene to help prevent relapse (psy
choeducation); 2) enhancing constructive caregiver/patient communication through
rehearsing skills such as active listening, making requests for changes in another per
son’s behavior, and balancing positive and negative feedback (communication training); and 3) improving family problem-solving skills (identifying and defining
problems, generating and evaluating solutions, implementing solutions) to enhance
family and community functioning.
FFT is administered in the stabilization period following an acute manic or depressive episode. during which the focus is on assisting patients in returning to their preillness level of functioning. Typically, therapists meet with individual families (patient,
parents or spouse, siblings) in weekly and then biweekly sessions that can extend to
6 or 9 months. Longer protocols (i.e., 21 sessions over 9 months) are recommended for
patients who have fully syndromal manic and depressive episodes, whereas shorter
protocols (12 sessions over 4 months) are recommended for children or adolescents in
high-risk states (i.e., those with major depressive disorder or subthreshold forms of
bipolar disorder who have a family history of bipolar I or bipolar II disorder).
As reviewed by Miklowitz and Chung (2016), there have been five randomized
trials of FFT in adults with bipolar I or bipolar II disorder, two in adolescents with bi
polar I or bipolar II disorder, and two in high-risk children or adolescents. In the various RCTs, FFT was combined with pharmacotherapy and compared with brief
psychoeducation, individual supportive therapy, or other evidence-based psychoso
cial treatments, also combined with pharmacotherapy. In two trials, FFT was compared with comparably intensive individual therapies (see discussion of STEP-BD
study later in this chapter). Across studies, FFT was associated with lower recurrence
rates, greater reductions in depression and mania severity scores, and better psychosocial functioning over periods of 1–2 years compared with brief psychoeducational
therapy.
There are several mechanisms by which family psychoeducation and skills training may lead to better outcomes of bipolar disorder. When families receive education
about bipolar disorder, they are in a better position to recognize when the patient is
developing prodromal symptoms of new episodes, and more likely to contact physicians and follow prevention plans focused on stress reduction. Trials that have examined family communication as a mechanism of action have concluded that FFT is
associated with increases in positive/constructive communication in both caregivers
and patients and decreases in family conflict (O’Brien et al. 2014; Simoneau et al. 1999;
Sullivan et al. 2012).
Overall, RCTs have supported the use of FFT plus pharmacotherapy in the outpatient treatment of adults with bipolar disorder (Yatham et al. 2018). FFT may be particularly effective for the reduction and stabilization of depressive symptoms among
patients, with some of the trials finding stronger effects of FFT in patients with high-
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