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Section 16
Psychosocial Interventions with Bipolar Clients

Question 16 found at the bottom of this page
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Psycho-education
Medication compliance remains an area of concern for many patients and the professionals involved in their care and it is also one which education has sought to address. In a study carried out by Peet & Harvey (1991), 60 lithium clinic attendees were recruited to take part in a 6-week education program about lithium. Patients were randomly assigned to an education or a control group. Those in the education group showed substantial and significant increases in their knowledge about lithium together with a more favorable attitude towards lithium. However, work carried out some years earlier by Frank et al. (1985) found that a 1-day education workshop for patients and their families resulted in no cases of medication compliance.

Similar research in schizophrenia has shown that changes in attitude and knowledge does not necessarily lead to improved compliance and may well require the formal implementation of so called ‘compliance therapy’ (Kemp et al., 1996).

Family interventions
Miklowitz & Goldstein (1990) evaluated behavioral family management with a group of manic depressive patients recently hospitalized for an episode of mania. They found that of the nine family treatment cases only one relapsed (11 %) over a 9-month post-hospitalization period, compared to 14 out of 23 cases (61 %) from their naturalistic outcome study. Glick et al. (1994) carried out a cross national study of 24 in-patients with severe affective illness. Those patients who received individual and family psychoeducation demonstrated better coping with the episode, and their overall outcome was better 12-18 months after discharge. Clarkin et al. (1990) in a large-scale randomized controlled trial considered the outcome of 169 patients offered in-patient family intervention (IFI) 18 months after discharge. Of the 21 bipolar patients in this group, 12 were allocated IFI and nine to the control (usual inpatient treatment program). The results demonstrated that bipolar patients showed significantly improved social, family, work, leisure and role performance and improved family attitudes towards treatment were identified.

Psychological therapy
Jacobs (1982) reports the use of cognitive therapy techniques to reduce post-manic and post-depressive dysphoria. He reported that the application of cognitive therapy was ‘successful’ in both groups. Cochran (1984) studied the efficacy of a cognitive approach to medical non-compliance in out-patient lithium-treated patients. She used a modified cognitive--behavioral intervention (adapted from Beck et al., 1979) to challenge cognitions that impeded compliance. The results demonstrated an immediate improvement post treatment in the intervention group. This was maintained at a 6-month follow-up. Moreover, the intervention group were significantly less likely to have major compliance problems, to terminate lithium treatment against medical advice, or to be hospitalized.

Group therapy
There are a small number of uncontrolled studies of group therapy of various persuasions. Shakir et al. (1979) and Volkmar (1981) offered a therapy group to 15 bipolars who were also lithium responsive; many of these patients (10) had a poor history of compliance. The group, which was organized on the lines of that advocated by Yalom, ran for a number of years. Following a 2-year attendance at the group Shakir and colleagues reported significant changes in the patients’ level of functioning compared to the 2-years prior to attending the group. They also noted that following a 51-week attendance at the group, admission rates fell. Only three individuals were admitted to hospital over the period of 2 years and the average time spent in hospital fell to 3 weeks. Similar findings were reported from Kripke & Robinson (1985). Palmer & Williams (1995) in an exploratory study evaluated CBT in a group of Bipolars who were also receiving pharmacotherapy. The group was run weekly over a period of 17 weeks. The results indicated that for some, the intervention was successful in improving symptomatology and overall social adjustment, although the improvement varied across individuals.
- George, Sandra; Towards an Integrated Treatment Approach for Manic Depression; Journal of  Mental Health; Apr98, Vol. 7 Issue 2, p145.

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Personal Reflection Exercise #2
The preceding section contained information about psychosocial interventions for bipolar clients.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 16
According to Cochran, what is the most effective form of therapy for increasing medication compliance in bipolar patients? Record the letter of the correct answer the Answer Booklet.