www.elsevier.com/locate/jad

Journal of Affective Disorders 80 (2004) 101–114

Review

Psychotherapy of bipolar disorder: a review

Steven Jones*

University of Manchester, Manchester, UK

Received 14 November 2002; accepted 8 April 2003

Abstract

Background: Bipolar disorder is often only partially treated by medication alone, which has led to recent developments in

the adjunctive psychological treatment of bipolar disorder. This paper aims to examine the current evidence for effectiveness of

psychological interventions for bipolar disorder and to identify issues for future research in this area. Method: A review of

outcome studies of psychological interventions reported since 1990, including psychoeducation, cognitive-behavioural,

interpersonal and social rhythm and psychoanalytic therapy. Results: The research to date indicates that a range of psychological

approaches appear to benefit people with bipolar disorder. The clearest evidence is for individual CBT which impacts on

symptoms, social functioning and risk of relapse. Limitations: Many studies lack appropriate control groups and standardised

measures of symptoms and diagnosis. Better designed studies would reduce the risk of over-estimates of effect sizes and

subsequent failure to replicate. Further developments of psychotherapy need to be based on clear theoretical models of bipolar

disorder. Conclusions: Many current studies are uncontrolled and of poor quality leading to a risk of over-estimating

effectiveness of some interventions. Suggestions are made for future research including improving quality of studies, basing

treatment developments on clear theoretical models and identifying specific treatment components for particular phases of the

bipolar illness course.

D 2003 Elsevier B.V. All rights reserved.

Keywords: Bipolar disorder; Psychotherapy; Theoretical models

1. Introduction Around 1/3 of bipolar patients continue to relapse

Bipolar disorder is a common psychiatric illness,

with prevalence rates of 1–1.5% (Bebbington and

Ramana, 1995; Weissman et al., 1988). It has a

relapsing course with high risk of self harm and

suicide and high social costs (Solomon et al., 1995).

0165-0327/$ - see front matter D 2003 Elsevier B.V. All rights reserved.

doi:10.1016/S0165-0327(03)00111-3

* Academic Division of Clinical Psychology, Second Floor

Research and Education Building, Wythenshawe Hospital,

Wythenshawe, Manchester M23 9LT, UK. Tel.: +44-161-291-

5897; fax: +44-161-291-5882.

E-mail address: steven.jones@man.ac.uk (S. Jones).

despite prophylactic lithium treatment (Solomon et

al., 1995; Burgess et al., 2001). In addition, figures

for other pharmacological alternatives are either the

same or worse, leaving significant numbers of bipo-

lar patients exposed to continued risk of both relapse

and associated acts of self harm or suicide (Good-

win, 1999).

The evidence of substantial genetic involvement

(Goodwin and Jamison, 1990) and the received

clinical wisdom that people with bipolar disorder

are ‘well’ between episodes seems to have militated

against investigations of non-biological forms of

S. Jones / Journal of Affective Disorders 80 (2004) 101–114102

intervention until recently (Scott, 1995). Although

genetic findings indicate heritability, they also pro-

vide evidence for a significant role for other factors.

Life events and other stressors impact on risks for

both initial onset of illness and relapse (Johnson

and Roberts, 1995; Johnson and Miller, 1997;

Ramana and Bebbington, 1995). This has led to

models emphasising the role of a diathesis (or

vulnerability) which may be of genetic/biological

origin and stress (which serves to modulate the

likelihood of illness onset). These models are in

many ways similar to the influential diathesis–stress

model of schizophrenia, first proposed by Nuech-

terlein and Dawson (1984). A simple form of this

approach for bipolar disorder is outlined in Lam et

al. (1999) and in Fig. 1.

Goodwin and Jamison (1990) argued that sensitiv-

ity of the circadian system (which serves to maintain

rhythms of physiological functioning within a 24

h period), which is probably genetically determined,

is a key vulnerability factor for bipolar disorder.

Additionally, Healy and Williams (1989) highlighted

Fig. 1. Basic diathesis– stress model of bipolar disorder.

the importance of the individual’s interpretation of

circadian changes in mediating illness onset.

More recently, Jones (2001) has argued that such a

vulnerability might be integrated with recent psycho-

logical models of emotion. This integration indicates

how circadian fluctuations might be translated into

symptoms of bipolar disorder and argues for the

importance of both psychological and social factors.

It therefore follows that effective interventions in

these areas are likely to be of benefit to individuals

with bipolar disorder.

Bipolar patients often have high levels of subsyn-

dromal symptoms in between episodes (Gitlin et al.,

1995). The presence of subsyndromal symptoms has

also been associated with increased risk of relapse

(Keller et al., 1992). Also, high rates of comorbidity

with axis 2 (personality) disorders (O’Connell et al.,

1991; Kay et al., 1999), which are by their nature

persistent, indicates that this is a disorder in which

problems persist beyond discrete episodes. Therefore,

interventions which impact on such symptoms should

reduce morbidity levels in bipolar disorder.

In the 1990 National Institute of Mental Health

(NIMH) report Prien and Potter called for the devel-

opment of new psychosocial treatment approaches for

bipolar disorder. This review summarises progress

since 1990. Clinical and methodological priorities

for future clinical research in this area are highlighted.

A broad criterion has been used for this review

because of the early state of the literature. Hence, in

addition to formal experimental studies, case studies

are reported as the only available source of data for

individual psychoanalytic approaches.

2. Review of psychotherapy approaches

This review will consider the evidence for the

following psychological interventions in turn: (i)

psychoeducation; (ii) cognitive-behaviour therapy

(CBT; individual and group); (iii) interpersonal and

social rhythm therapy; (iv) family therapy and (v)

psychoanalytic therapy (individual and group), where

such outcome data are available. Studies were identi-

fied by searching psychinfo and medline between

1990 and 2002 and by hand searching for individual

references indicated from other sources such as con-

ference proceedings.

ve Disorders 80 (2004) 101–114 103

2.1. Psychoeducational interventions

Psychoeducational interventions aim to provide

patients with information about the nature of their

illness and its treatment. Their focus is often towards

enhancing engagement with traditional treatment and

pharmacotherapy in particular. Types of intervention

under this heading vary from brief didactic presenta-

tions to extended interventions which provide infor-

mation and facilitate discussion on issues relevant to

bipolar disorder. These issues normally include com-

pliance with medication, avoidance of drugs of abuse,

identification of symptoms of relapse and manage-

ment of stress and anxiety.

Five psychoeducational studies were identified, one

of which was mainly focused on partners of bipolar

patients (Peet and Harvey, 1991; Van Gent and Zwart,

1991, 1993; Soares et al., 1997; Vieta and Colom,

1997). Two uncontrolled studies provided either brief

(Soares et al., 1997) or extensive (Vieta and Colom,

1997) psychoeducational interventions. Both studies

reported increases in knowledge following treatment.

Soares et al. (1997) also reported improvements in

attitudes towards lithium. There was however no direct

assessment of changes in medication adherence fol-

lowing intervention. Vieta and Colom (1997) reported

a trend towards improved adherence to lithium but only

in a sub-group (patients without a co-morbid person-

ality disorder) of an already small sample.

Both controlled studies of patients evaluated brief

interventions. The minimal intervention of Peet and

Harvey (1991) was reported to result in improvements

in knowledge and self-reported medication adherence,

which were maintained at 3 months. However, Van

Gent and Zwart (1993) found only subjective reports of

‘benefit’ and a change in an idiosyncratic subscale of

SCL-90 following their five-session intervention.

Van Gent and Zwart (1991) conducted a similar

intervention with partners of patients with bipolar

disorder, finding increased knowledge post-interven-

tion and at 6 months. No impact on medication adher-

ence was observed.

Psychoeducation, as an adjunct to pharmacothera-

py, may have promise. However, to date most studies

have design limitations and have often not used

outcome measures specifically relevant to patients

with bipolar disorder. Furthermore, for those measures

which have been used, symptom change is limited.

S. Jones / Journal of Affecti

There is also little direct evidence of changes to

medication adherence, in spite of it being a primary

target of this form of intervention. Resolution of these

issues awaits larger scale studies of sufficient power to

test the effectiveness of manualised psychoeducation

approaches. These would require a randomised con-

trolled (RCT) design using outcome measures directly

relevant to the bipolar symptomatology.

2.2. Cognitive behaviour therapy

2.2.1. Individual CBT

There is substantial evidence for the effectiveness

of CBT for depression (Roth and Fonagy, 1996;

Gloaguen et al., 1998). The application of these

approaches to bipolar disorder has been slower and

until recently there were few outcome studies. Since

1990 there have been six published reports of indi-

vidual CBT for bipolar disorder, summarised in Table

1 (Perry et al., 1999; Satterfield, 1999; Zaretsky et al.,

1999; Lam et al., 2000, 2003; Scott et al., 2001).

Satterfield’s (1999) single case study reported

improvements in mood, anxiety and hopelessness fol-

lowing CBTof a rapid cycling bipolar disorder patient.

However, data were not statistically analysed, there

was no follow-up and different mania ratings were used

in the two stages of the intervention. Duringmedication

only, information on mania was based on self-report

and physician ratings whereas during CBT the Young

Mania Scale (Young et al., 1978) was used.

Five controlled studies have been published since

1990, four of which have employed an RCT design,

the other a comparison group of unipolar depressed

patients. The RCT studies differed in their approaches.

Perry et al. (1999) employed a research assistant to

help patients to identify prodromal symptoms and

access available services through development of

action plans. In contrast, both Lam et al. (2000,

2003) and Scott et al. (2001) used experienced clini-

cians to deliver comprehensive cognitive behavioural

interventions. In Perry et al. reduced relapse was

observed for manic episodes only, Scott et al. ob-

served stronger effects for depression, Lam et al.

(2000) identified reductions in total episodes and

hypomanic episodes, whilst Lam et al. (2003) found

evidence of reductions in numbers of episodes of

depression, mania and hypomania. All studies

reported improvements in mood and social function-

Table 1

Individual cognitive behaviour therapy for bipolar disorder

Number of Type of control Main Intervention Outcome Follow-up

participants group assessments

Perry et al. (1999) 69 bipolar Random SCID 17–20 sessions of prodrome

identification

Fewer manic relapses. Longer

time to firstmanic relapse.

12 and 18 months

out-patients allocation –TAU MRC-Social and development of action plans Improved social functioning

and employment

outcomes maintained

Satterfield (1999) One rapid cycling Participant baseline BDI, BAI 14 months combining Improved mood

(mania and depression)

None

bipolar patient data BHS, GAF Basco and Rush (1996) CBT approach Reduced anxiety

Young Mania Scale with interpersonal psychotherapy Reduced hopelessness

Zaretsky et al. (1999) 22 (11 depressed bipolar, Unipolars received SADS-L 20 sessions using Improved mood in both None

11 unipolar) standard CBT Hamilton Basco and Rush (1996) groups –BDI/Hamilton/ATQ

ATQ, DAS therapy manual

BDI

Lam et al. (2000) 25 bipolar patients (not Random TAU MAS, ISS, BDI 12–20 sessions Fewer relapses Differences maintained

in an acute mood state) BHS, MRC Psychoeducation, CBT, Mood stability increased at 6 months follow-up+

Early warnings and coping prodromes and action plans, Better social functioning better coping with

Med compliance Q stabilising routines Improved medication adherence prodromes

Lam et al. (2003) 103 bipolar patients Random TAU As above As above As above As above

Scott et al. (2001) 42 bipolar patients Random W/L control SADS-L, GAF Up to 25 sessions Fewer relapses especially Significant impact on

PDQ-R, WASA Psychoeducation, CBT, for depression relapse for 18 months

after starting

ISS, BDI prodromes and action plans, BDI/ISS/GAF improvements CT vs. 18 months prior

SCL-90 stabilising routines

ATQ, Automatic Thoughts Questionnaire (Hollon and Kendall, 1980); BAI, Beck Anxiety Inventory (Beck et al., 1988); BDI, Beck Depression Inventory (Beck et al., 1961); BHS, Beck

Hopelessness Scale (Beck et al., 1975); DAS, Dysfunctional Attitudes Scale (Weissman and Beck, 1978); EWC, Early Warnings and Coping Questionnaire (Lam and Wong, 1997); GAF, Global

Assessment of Functioning (American Psychiatric Association, 1994); Hamilton, Hamilton Rating Scale for Depression (Hamilton, 1960); ISS, Internal States Scale (Bauer et al., 1991); MAS, Mania

Rating Scale (Bech et al., 1978); MRC Social, MRC Social Performance Schedule (Hurry et al., 1983); PDQ-R, Personality Disorder Questionnaire (Dowson, 1992); SADS-L, Schedules for Affective

Disorders and Schizophrenia –Lifetime Version (Endicott and Spitzer, 1978); SCID, Structured Clinical Interview for DSM-III-R (Spitzer et al., 1990); SCL-90, Symptoms Checklist 90 (Derogatis and

Cleary, 1977); Self Control, Self-Control Behaviours Schedule (Rosenbaum, 1980); Young Mania Scale (Young et al., 1978); WASA, Work and Social Adjustment Scale (Marks et al., 1993).

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S. Jones / Journal of Affective Disorders 80 (2004) 101–114 105

ing and gains were maintained at follow-up, which

varied between 6 and 18 months.

Zaretsky et al. (1999) provided CBT designed for

bipolar disorder to bipolar depressed patients and

‘standard’ CBT to unipolar depressed patients. Sig-

nificant improvements in mood followed treatment in

both groups. There were no between group differ-

ences or follow-up assessments. Zaretsky et al. (2001)

are conducting an RCT comparing CBT with a brief

psychoeducational intervention although details and

results of this study have yet to be published.

Both open and controlled trials have shown evi-

dence of effectiveness of individual CBT in bipolar

disorder. However, all of the trials are relatively small

and larger scale studies are needed to indicate the

reliability of promising findings. Also, randomised

controlled studies have not yet included a control

condition matched for therapist time.

2.2.2. Group CBT

Two published papers reporting group CBT for

bipolar disorder were identified, both uncontrolled

(see Table 2). Palmer et al. (1995) used a single group

repeated measures design whilst Patelis-Siotis et al.

(2001) provided a manualised group CBT treatment to

38 bipolar patients. Both interventions were of similar

duration and both reported symptomatic improve-

ments, although neither study reported any follow-

up data.

The lack of control or follow-up data again hinder

interpretation of these findings. It is not clear what

changes might have been observed in these groups

naturally over this time period, nor how gains might

persist after active treatment. This is important, as

CBT claims to provide patients with skills which

people then apply to their lives over time. Such

changes would be expected to begin during treatment,

but if the approach is effective they should then persist

if the patient has internalised the approach. The small

amount of information on group CBT indicates that

this may have promise and that controlled studies with

appropriate follow-up periods are needed.

2.3. Interpersonal and social rhythm therapy (IPSRT)

The IPSRT approach evolved from interpersonal

therapy (IPT; Klerman et al., 1984). As with IPT,

treatment focuses on one of four problem areas (grief,

interpersonal role transition, role dispute and interper-

sonal deficits). Issues in each of these areas are

addressed by a range of approaches including eliciting

and defining the salient problem area, followed by

supported grieving/emotional processing and problem

solving around practical consequences. Frank et al.

(2000) suggests these issues present differently in

bipolar compared with unipolar patients. As with

CBT, there is substantial evidence for the effective-

ness of IPT in the treatment of unipolar depression

(e.g. Elkin et al., 1989, 1995). In addition to the

traditional elements of IPT, IPSRT focuses on the

regularity of daily activities. It prioritises the mainte-

nance of structure and routine in such activities in

spite of fluctuations in mood, such as those caused by

life events. The IPSRT approach draws on the insta-

bility model of bipolar disorder proposed by Goodwin

and Jamison (1990). As with CBT, IPSRT is seen as

an adjunct to pharmacological treatment of bipolar

disorder. This approach is described in detail in Frank

et al. (1994).

To date there are only two published reports of

controlled studies using IPSRT, both of these from

Frank and co-workers (Frank et al., 1997, 1999),

summarised in Table 3. The first study reported on

the impact of IPSRT on social rhythms, indicating that

therapy stabilised rhythms relative to clinical manage-

ment (CM) controls. The second report found no

differences in symptoms between patients receiving

IPSRT and those receiving CM. More recently, Frank

(2001) has suggested that, although IPSRT did not

impact on either time to remission or time to relapse, it

did have a significant impact on subsyndromal symp-

toms. Over a 14-month period those receiving IPSRT

spent longer euthymic and less time in a depressed

state, than controls. There were no differences with

respect to manic state. The full results of the RCT trial

have yet to published and thus current conclusions are

tentative.

Current evidence indicates that this type of inter-

vention has a significant impact on stability of social

routine and can lead to longer periods of euthymia. It

is however not clear why, given these effects, there is

no impact on relapse rates. The absence of a relapse

rate effect contrasts with findings from the individual

CBT literature above. This issue is pertinent given

that the amount of clinical time in the CBT trials is

substantially less than that for IPSRT (12–20 sessions

Table 2

Group cognitive behaviour therapy for bipolar disorder

Group Number of participants Type of control group Assessments Intervention Outcome Follow-up

Palmer et al. (1995) Four bipolar Single group repeated ISS 17 weekly and 6 Improvements in None

out-patients measures SAS monthly CBT mood and social

SCL-90 sessions adjustment

Patelis-Siotis et al. (2001) 49 bipolar Open trial GAF 14 weekly sessions Pre/post changes None

out-patients MOS in GAF and MOS

Hamilton

Young Mania Scale

GAF, Global Assessment of Functioning (American Psychiatric Association, 1994); Hamilton, Hamilton Rating Scale for Depression (Hamilton, 1960); ISS, Internal States Scale

(Bauer et al., 1991); MOS, Medical Outcomes Survey (McHorney et al., 1993); SAS, Social Adjustment Scale (Weissman and Bothwell, 1976); SCL-90, Symptoms Checklist 90

(Derogatis and Cleary, 1977); Young Mania Scale (Young et al., 1978).

Table 3

Interpersonal and social rhythm therapy for bipolar disorder

Number of participants Type of control group Assessments Intervention Outcome Follow-up

Frank et al. (1994) 38 bipolar

patients

Random assignment to SRM 52 weeks interpersonal Improved social rhythms, Intervention ongoing

medication clinic control Amended

HRSD

psychotherapy and stabilising no symptom differences throughout study period

MAS of social rhythms between groups

Frank et al. (1999) 82 bipolar

patients

Random assignment to Amended

HRSD

2 years inc. active intervention, No differences in relapse Intervention ongoing

clinical management

control

MAS as above–ongoing preventative

phase

rates between conditions throughout study period

AHRS, Amended HRSD–(Amended Hamilton Rating Scale for Depression; Thase et al., 1991); MAS, Mania Rating Scale (Bech et al., 1978); SRM, Social rhythm metric (Monk et

al., 1990).

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S. Jones / Journal of Affective Disorders 80 (2004) 101–114 107

over 6 months vs. regular treatment over 2 years).

Frank (2000) has argued that her data indicate that

CM itself is a potent low-dose psychotherapy. How-

ever, further research needs to be done with both

forms of intervention using designs which test for

basic effects, as well as for effects relative to other

treatments.

2.4. Family psychoeducational interventions

Research into the role of expressed emotion (EE)

amongst families of patients with schizophrenia indi-

cates that a high EE environment is associated with

substantially increased risk of relapse (Butzlaff and

Hooley, 1998) and that family-based interventions to

reduce levels of EE have a significant impact on

relapse risk (Falloon et al., 1985; Tarrier et al.,

1989; Zhang et al., 1994). More recently, research

has investigated the extent to which similar issues are

relevant for people with bipolar disorder. Similar

effects of hostile, critical and emotionally over-in-

volved family atmosphere on relapse rates of bipolar

patients have been observed (e.g. Honig et al., 1997;

Miklowitz et al., 1988).

The family-focused treatment (FFT) approach of

Miklowitz and co-workers was reported to cause

reductions in relapse rates, relative to controls, in

two randomised controlled studies (Simoneau et al.,

1999; Miklowitz et al., 2000) summarised in Table 4.

Both reports indicate that FFT is superior to a condi-

tion in which families received brief psychoeducation

and emergency counselling (when requested by fam-

ily, usually in response to suicidal crises or significant

family conflicts), the former in relation to relapse rates

and the latter in relation to level of affective symp-

toms. The Simoneau data are from a subgroup of the

Miklowitz study, and thus should not be interpreted as

independent. Honig et al. (1997) compared a similar

family psychoeducational intervention with waiting

list controls and found that 9/12 high EE relatives in

the treatment group switched to low EE by the end of

treatment. No change in psychiatric symptoms was

reported as a result of this intervention.

Although there are a number of conference reports

of beneficial effects of family intervention there are no

other published studies undertaken after 1990.

As with individual intervention research, there is

limited information on persistence of gains at follow-

up or on gains above and beyond other types of

psychological intervention. However, the results to

date are encouraging in their effect on relapse. Rea et

al. (1998) did report an interesting finding of better

outcome for FFT after 2-year follow-up than for

individual therapy, but this is based on a conference

presentation and a published report is not currently

available.

2.5. Psychoanalytic psychotherapy

2.5.1. Individual

There is currently very little published research

concerning individual psychodynamic psychotherapy

for bipolar disorder. Since 1990 four published studies

of psychoanalytic psychotherapy were found (Deitz,

1995; Jackson, 1993; Kahn, 1993; Salzman, 1998),

summarised in Table 5, all case reports. Interventions

differed, with Jackson’s report being the most tradi-

tional psychoanalytic approach, whereas others

reported treatments in which insight into the interac-

tion between personality and stress in bipolar disorder

was emphasised, as was the role of medication.

Each report suggests that a psychoanalytic/psycho-

therapeutic approach to bipolar disorder might be

effective, but there is sparse evidence to support such

assertions. Rather, the current data seem to be impres-

sionistic and based on very small (N=1–3) sample

sizes. To properly evaluate the usefulness of this type

of approach requires trials in which independent

measures of symptoms and functioning are obtained

before, during and after the active treatment periods.

Cameron (1989) noted the importance of developing

and investigating models for the application of psy-

chodynamic psychotherapy in bipolar disorder. This

seems to still be an important issue 13 years on.

2.5.2. Group

Four reports of group psychotherapy with some

measure of outcome were found (Retzer et al., 1991;

Cerbone et al., 1992; Hallensleben, 1994; Kanas and

Cox, 1998), summarised in Table 6. Each group

described either a psychoanalytic or systemic focus

within treatment. Additionally, there were significant

elements within each approach dealing with active

management of symptoms, through understanding the

illness and through adherence to medication. All

reports were open trials, and only Cerbone et al.

Table 4

Family psychoeducational interventions for bipolar disorder

Number of participants Type of control group Assessments Intervention Outcome Follow-up

Honig et al. (1997) 52 bipolar patient – relative Waiting list control FMSS Eight sessions involving 9/12 high EE carers None

pairs BPRS psychoeducation and coping became low EE after

skills with patient and relative intervention

Simoneau et al. (1999) 44 bipolar patients and Randomised allocation CFI 21 sessions Experimental group lower 3 months

their relatives Two sessions of

psychoeducation+PRN

KPI psychoeducation SADS affective symptoms SADS affective symptoms

supportive problem solving SADS-C Communication-enhancement still lower. More positive

Problem-solving skills interactions on KPI

Miklowitz et al. (2000) 101 bipolar patients and Patients received two family CFI 21 sessions Fewer relapses Gains maintained at

close relatives education sessions and SADS-C Family focused treatment: Less depression in 3 months after

crisis management PRN MTS Psychoeducation treatment group treatment

Self report adherence Communication

Problem solving

BPRS, Brief Psychiatric Rating Scale (Dingemans et al., 1983); CFI, Camberwell Family Interview (Vaughn and Leff, 1976); KPI, Category System for Partner Interaction (Hahlweg et al., 1984); FMSS, Five

minute speech sample (Magana et al., 1986); MTS, Maintenance Treatment Scales (Keller, 1988); SADS-C, Schedule for Affective Disorders and Schizophrenia Current (Spitzer and Endicott, 1978).

Table 5

Individual psychoanalytic psychotherapy

Individual Number of participants Type of control group Assessments Intervention Outcome Follow-up

Jackson (1993) 1 Single case Interview Twice weekly ‘Encouraging’ Began further therapy

intensive individual after intervention with

psychodynamic therapy another analyst

over 2 years

Kahn (1993) 2 Single cases Interview Psychotherapy focusing on Unclear Not reported

stress and personality

Deitz (1995) 3 Single cases Interview Twice weekly sessions A pt ‘free of major episodes’ after A Maintained at 10 years

over 6 months 6 months of twice-weekly therapy

Self psychology- B pt ‘reduced medication, greater self B No follow up information

inc. mood monitoring acceptance’ after >1 year of twice-weekly

therapy

and self medication C pt acceptance of bipolarity and

role for medication

C Therapy ongoing at time of writing

Salzman (1998) 1 Single case Interview >2 years of individual

psychotherapy:

Greater mood stability Began further therapy after

overcoming denial intervention with another analyst

counter-transference

medication issues

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Table 6

Group psychoanalytic psychotherapy

Number of participants Type of control group Assessments Intervention Outcome Follow-up

Retzer et al. (1991) 20 bipolar and

10 schizo-affective

None Relapse rate Group therapy (no. of sessions

not defined):

Significant reduction in

relapse rate at 3 year

disorder patients ‘Interactional style measure’ living with the reality of

illness—increasing control

follow-up in both

diagnostic groups

Cerbone et al. (1992) 43 bipolar patients None Number of affective episodes Weekly group (6 –8 in each) Improvements on

all measures,

Outcome assessments

based on independent

Productivity Safe place—enhance recognition

of symptom

relative to pre-therapy raters evaluation for

12 months post-therapy

Interpersonal functioning changes and more proactive

Affective episodes scale

(O’Connell et al., 1985)

approach to treatment

Hallensleben (1994) 37 bipolar patients None Self reported benefit Weekly group (avg. 78 sessions) Most patients felt of benefit None reported

Consequences of illness (17 of 21 former group

Resisting hypomania members asked)

Depression and suicidal thoughts

Kanas and Cox (1998) 12 bipolar patients None Attendance rate 31 sessions 72% attendance None reported

Coverage of intended Group therapy: 81% topic coverage

topics Learning more about bipolar Greater cohesion

Learning to live with the illness Less avoidance and

Facilitating insight conflict

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(1992) used independent assessment of group mem-

bers. This study reported improvements on measures

of ‘productivity’ and social functioning which were

devised for the study and a measure of affective

episodes.

The Heidleberg group of Retzer and co-workers

reported favourable outcomes for a mixed group of

schizophrenic and bipolar patients. They found re-

duced average relapse rates at follow-up, relative to

pre-therapy in both diagnostic groups (Retzer et al.,

1991; Retzer, 1994), associated with changes in indi-

vidual and family views about the patient’s illness and

ability to influence symptoms. Retzer et al. (1991)

reported a 67% reduction in relapse rate for manic

depressive participants. The extent of this reduction

may however, in part, be associated with the way in

which relapse rate was calculated. The comparison

was between the period from first onset to start of

treatment and end of treatment to follow-up interview.

The first period tended to be several years longer than

the second, allowing greater likelihood of detection of

relapse in the former phase, which is also the period of

acute illness onset. Neither of these factors would be

satisfactorily controlled for by the use of ratios to

generate relapse rate figures. The other two reports

indicated positive outcomes in terms of patients’

reports of subjective benefit (Hallensleben, 1994)

and group attendance and coverage of intended topics

(Kanas and Cox, 1998).

These studies are again encouraging in that several

independent reports indicate that group approaches to

bipolar disorder appear to have clinically significant

impact on the course of the illness. However, none

provide any control group data, which renders inter-

pretation difficult. Also, given the high levels of input

required, with weekly sessions sometimes being pro-

vided over periods of several years, it is important to

evaluate what ‘dose’ of treatment is required for

maximum benefit. It would also be of interest to

assess the extent to which the outcomes are associated

with specific elements of therapy as opposed to non-

specific aspects of group membership (Yalom, 1975).

3. Discussion

This review indicates that, whilst there has been

some progress made in developing psychological

approaches to the treatment of bipolar disorder, there

is still much to be done. A recent meta-analysis of 26

RCTs of family and individual CBT for schizophrenia

indicated clear improvements in mental state and

reduction of relapse risk in those receiving psycho-

logical treatment (Pilling et al., 2002). Clearly, re-

search is still at an early stage in comparison with

studies of psychological treatments for schizophrenia

but future research can be usefully informed by

progress in that area. A number of important issues

need to be addressed if effective treatment options for

bipolar disorder are to be developed. These include

the following.

1. Standardisation of diagnostic and symptom meas-

ures so that appropriate comparisons can be made

between reports of clinical outcomes following

psychological treatment. At present, reports differ

widely between the use of routine clinical diagno-

sis and the use of trained assessors diagnosing on

the basis of structured clinical interviews. Similar-

ly, many reports included outcome measures that

were idiosyncratic. Such measures were either

developed specifically for that study with little

psychometric data (such as Vieta and Colom’s

(1997) information about illness questionnaire) or

were general measures which were not specifically

designed for the assessment of bipolar symptoms

(such as SCL-90 used by Van Gent and Zwart,

1991).

2. There is evidence from the CBT studies reviewed

that different interventions impact differently on

depression and mania. To date this has been in the

context of treatment packages which have set out

to address the disorder as a whole (e.g. Lam et al.,

2000, 2003; Scott et al., 2001). It would be

important to further clarify these effects, for

instance in groups pre-selected for the particular

pole of illness in which the intervention had

appeared to be most effective when used with a

mixed sample.

3. Because bipolar disorder is a complex illness, there

are different aspects at which treatments might be

targeted. Thus, the features of effective treatment

for relapse prevention and subsyndromal symp-

toms would be likely to be different from

approaches that might benefit people in acute

phases. Developing a clear picture of what

S. Jones / Journal of Affective Disorders 80 (2004) 101–114 111

approach is most effective in what phase of the

disorder will be crucial in developing treatments

that can have an impact on the course of bipolar

disorder.

4. Bipolar disorder as a diagnostic term includes a

variety of subtypes (American Psychiatric Associ-

ation, 1994). There is as yet no clear indication of

whether such subtypes (e.g. bipolar I or II, or rapid

cycling) have differential responses to psycholog-

ical treatments. With respect to specific mood

states, results have been mixed with, for instance,

Perry et al. (1999) reporting specific effects for

mania, but Scott et al. (2001) reporting stronger

effects for depression following individual CBT.

5. Studies need to meet appropriate scientific criteria.

This means that research needs to be carried out

with appropriate control groups and formal assess-

ment procedures, as well as appropriate follow

periods for assessment of effects after treatment.

Where single case approaches are to be used these

should employ appropriate experimental method-

ology to permit analysis of the significance of

clinical changes observed. Reviews by Schulz et al.

(1995) and Moher et al. (1998) indicate that even

with RCTs there can be substantial exaggeration of

treatment effects in poor quality studies. Similarly,

Tarrier (2001) has indicated that effect sizes for

CBT studies are over-estimated by f40% in poor

quality trials. Unless quality criteria are met there is

a significant risk of failure to replicate treatment

effects due to under-powered studies.

6. It is crucial for the further development of effective

psychosocial interventions that work is based on

clear theoretical models of bipolar disorder. These

models need to encapsulate the diathesis–stress

features of the disorder, but also its cyclical

‘bipolar’ course. Goodwin and Jamison’s (1990)

biopsychosocial approach emphasised the impor-

tance of vulnerability of the circadian system to

disruption in onset and recurrence of bipolar

disorder. This ‘instability’ model was important

in the development of IPSRT and also influenced

much of the behavioural and scheduling elements

of current CBT interventions. However, the

evidence to date for IPSRT is not strong in terms

of reducing risk of relapse. Therefore it appears

that factors in addition to instability are likely to be

important. Healy and Williams (1989) suggested

that it might be valuable to consider the manner in

which circadian disruptions were interpreted as a

possible target for psychological interventions.

More recently Jones (2001) has presented a model

which attempts to integrate the evidence for

circadian disruption with a current model of

emotion (SPAARS, Power and Dalgleish, 1997).

This model indicates a number of important

potential areas for future research. It suggests that

psychological interventions provided at an early

stage, when cognitions and beliefs may be more

accessible and before emotional outputs have

become automatised, are likely to be most potent.

It also postulates that internal attributions for

physiological disruptions associated with circadian

change are important in triggering both depressive

and manic prodromes. This again would indicate

that targeting such attributions for psychological

treatment may be fruitful. There is much work to

be done to evaluate the extent to which this

particular approach explains the diversity of

phenomena experienced within bipolar disorder.

However, approaches such as this which generate

clear testable clinical hypotheses are likely to be

crucial in the further development of psychological

approaches in the treatment of this potentially

devastating disorder.

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