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Bipolar disorder (BD) is a complex potentially devastating illness, associated with losing 14 years of effective activity and dying 9 years early. There are substantially elevated risks of substance abuse and suicidal behavior; a recent study indicated a 16% additional risk for suicide attempts for BD and comorbid substance abuse. Studies of the course of BD indicate that, if anything, the pattern of relapse and recurrence worsens as the individual ages. Pharmacotherapy of BD presents complex challenges, because of the need to treat effectively the different phases (e.g. manic, depressed and subsyndromal) of the disorder. A number of recent guidelines have drawn together evidence from available research. The British Association for Psychopharmacology (BAP) guidelines recognized the shortage of high quality studies and the need to combine scientific data with clinical experience in their recommendations. BAP, World Federation of Societies of Biological Psychiatry (WFSBP) and American Psychiatric Association (APA) guidelines all recognize the importance of lithium, valproate, oral antipsychotics and benzodiazpenes as treatment options in mania and mixed states. None of the guidelines recommend antidepressant monotherapy for bipolar depression, but rather the use of antidepressant and antimanic agents in combination. Both APA and BAP guidelines recommend lithium or valproate as front-line medications for long-term treatment. However, although both medications are effective in randomized controlled trials (RCT) relapse rates of 37–40% are reported.
Furthermore, partial or non-adherence to long term treatment is reported in up to 50% of BD patients. Important factors in adherence include management of medication side-effects and also the beliefs that patients have about their illness and medication. If more effective treatments (including better adherence to available pharmacological treatment) are to be delivered, it is necessary to understand how psychological and social factors impact on the course of BD. Patelis-Siotis concluded that researchers should _pursue the understanding of cognitive processes in BD which would allow us to refine and develop cognitive behavior therapy (CBT) interventions unique to this disorder. This review will consider the role of these factors before reviewing current individual and family approaches to BD. This information will then be discussed in relation to future psychological intervention research.
Individual psychological factors
An important issue is whether particular neurocognitive deficits extend into euthymic periods of BD. Quraishi and Frangou’s systematic review highlighted the presence of deficits in sustained attention, inhibitory control and verbal memory in remitted BD. However, they suggested executive functioning deficits (planning, concept formation, shifting of set), may not be abnormal in fully remitted BD. More recently, Martinez-Aran et al. identified verbal memory and frontal executive deficits across manic, depressed and euthymic BD in comparison with healthy controls. Significant deficits in verbal memory and some measures of executive functioning in euthymic BD persisted after controlling for level of subsyndromal symptoms. These authors suggested that these trait deficits might have an important negative impact on illness course. Furthermore, because number and duration of previous episodes were associated with severity of verbal memory impairment it was proposed that neurotoxic effects of stress-related hypercortisolaemia might be responsible for these cognitive deficits through triggering hippocampal and prefrontal damage. Sobczak et al. reported executive functioning and verbal memory deficits in first-degree relatives of BD 1 patients, which worsened after acute reduction in central 5-HT activity. Sobczak et al. suggested 5-HT mediated frontal lobe dysfunction as an important marker for BD 1 disorder. Lopez-Figueroa reported serotonergic dysregulation consistent with decreased 5HT levels in the dorsolateral prefrontal cortex of BD patients.
Taveres et al. have argued that the performance of depressed and manic patients is most clearly differentiated on _hot_ cognitive tasks (which include affective material). Thus, manic and depressed patients show biases on an affective _go/no-go_ task compared with controls; manic patients to positively valenced material and depressed to negative targets. Furthermore, the performance of depressed subjects was impaired by negative feedback, but not if this feedback had high information content. Tavares et al. have argued that performance on tasks of this type are also subserved by the prefrontal cortex.
Studies of social cognition have reported dysfunctional assumptions and attributional biases in BD. Scott found higher levels of interpersonal dependency (sociotropy) and stronger beliefs in needs for social approval and perfectionism in euthymic BD than controls. Scott and Pope reported that within a BD group, dysfunctional attitudes were most apparent in depression, but scores were also elevated in hypomania. It also appears that BD patients make attributions for negative events which are as depressogenic as those of unipolar depressives and that individuals with a tendency towards BD have particular coping styles with respect to mood change.
Thomas and Bentall reported hypomania scores in an undergraduate sample were predicted by rumination, distraction and engagement in dangerous activities [using an expanded version of the Nolen-Hoeksema Coping Styles Questionnaire]. Self-reported depression scores were associated with ruminative style only, consistent with previous reports. This pattern of results has recently been replicated in a further behavioural high-risk sample.
Other studies have indicated a role for personality factors in BD, including neuroticism, interpersonal sensitivity and conscientiousness. These trait factors indicate the importance of approaches that address long-term vulnerabilities, in addition to efforts to achieve initial symptomatic improvements. Psychosocial approaches therefore need to both equip the individual with strategies over the long-term and facilitate environmental changes that may have protective effects for the individual.
Family and social factors
As with depression and schizophrenia, another relevant aspect of psychosocial stress is family atmosphere. Dore and Romans found 92% of partners struggled to maintain their relationship and 62% felt they would not have begun the
Efficacy of individual CBT and family work A number of studies have explored the effectiveness of psychological and family interventions. This evidence has been recognized in BAP, APA and WFBP guidelines which all identify a role for structured psychological therapy in the adjunctive treatment of BD.
Colom et al._s recent RCT study of group psycho education indicated significant impact on relapse rates and plasma results indicative of higher lithium medication compliance at 2 years follow-up. Five reports of controlled studies of
There are two recently published reports of RCTs which have used family focused treatment (FFT) a psycho educational approach which also trains patients and relatives in family communication and problem solving. These studies by Miklowitz et al. and Rea et al. reported fewer relapses in FFT patients compared with controls. Again, although effective, these studies still reported substantial numbers of patients relapsing in the FFT condition [35% in Miklowitz et al.].