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Abstract
Bipolar disorder afflicts 3 to 5% of the population with detrimental effect on life chances. Individuals with bipolar disorder face a lifetime risk for mood variations, often with devastating and even fatal consequences. It is the sixth most common cause of disability in the United States (Altman et al., 2006). Lifetime rates for completed suicide are 60 times higher than that for the general population, with a much higher rate of completed suicides for each attempt, 1:3 versus 1:30 (Baldessarini et al., 2006). Qual¬ity of life is often compromised for individuals with bipolar disorder. Lower wages, higher unemployment, work absenteeism, reliance on workmen’s compensation, higher rates of divorce, lower levels of educational attainment, higher arrest rates, and hospitalization are often the consequences (Gardner et al., 2006).
A very important change of paradigm in the treatment of bipolar disorders started a few years ago, when crucial findings on the impact of bipolar disorders on quality of life and social, cognitive and occupational functioning suggested that therapy targets should be changed from symptomatic recovery to functional recovery (Colom and Vieta, 2004).
Mood stabilizers are the basis of therapy for bipolar disorder, and current guidelines recommend the use of a mood stabilizer in all phases of treatment (Sachs et al., 2001).
A mood stabilizer is usually regarded as an agent that has efficacy against at least one aspect of bipolar disorder (mania, depression or mixed states), is effective as a prophylactic agent and does not worsen the illness (Sachs, 1996).
The most commonly used medication for the treatment of bipolar disorder is lithium, which is one of the oldest and frequently used mood stabilizing drugs available. Lithium has shown efficacy in the treatment of bipolar disorder symptoms throughout the course of the illness and may be particularly effective in preventing suicide (Fountoulakis et al., 2007).
A variety of anticonvulsants and antiepilepsy medications, such as valproic acid and carbamazepine, have also shown variable degrees of efficacy in mood stabilization (Sachs and Thase, 2000).
Increasingly, clinicians have begun to use second generation antipsychotics, such as aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone, for variable degrees of mood stabilization (Surja et al., 2006).
Many of these drugs have been tested and are FDA approved for acute stabilization in the manic phases (National Alliance on Mental Illness, 2007). Over time, some of these medications have obtained indications for and are being increasingly used in the maintenance phase of the illness (Buckley, 2008).
Psychotherapy can improve outcome when used in conjunction with pharmacotherapy. Adjunctive psychosocial therapies should be considered early in the course of illness to improve medication adherence, identify prodromes of relapse, decrease residual symptoms (particularly depressive) and suicidal behaviour, and help move patients towards a comprehensive functional recovery (Jones, 2004).
Psychoeducation is focused on providing information on the disorder, its treatment, and the social and family consequences of the disorder. When added to pharmacotherapy, RCTs have shown that group psychoeducation significantly increased the time to depressive, manic, hypomanic, and mixed recurrences and reduced relapse rates (Colom et al., 2003). Psychoeducation aimed at teaching patients to recognize prodromal symptoms of relapse was associated with improvements in time to first manic relapse, social functioning, and employment but had no effect on depressive relapse (Perry et al., 1999).
Cognitive-behavioural therapy: Here the focus is on cognitive restructuring and includes self-monitoring, strategies to deal with dysfunctional thoughts, and behavioural techniques to promote social functioning. Controlled trials comparing CBT to treatment as usual or wait listed controls in bipolar patients have demonstrated increased functioning and adherence, and decreased relapses, mood fluctuations, need for medications, and hospitalizations (Lam et al., 2003).
Interpersonal and social rhythm therapy (IPSRT) includes the traditional IPT focus on one of four problem areas (grief, interpersonal role transition, role dispute and interpersonal deficits) but extends into meticulous regulation of social and sleep rhythms. A large controlled trial demonstrated that therapy did not alter time to relapse but did have a significant impact on subsyndromal symptoms; patients spent more time euthymic and less time depressed relative to intensive clinical management (Frank et al., 2000).
Family psychoeducational therapy is based on the premise that a hostile, critical or over involved family atmosphere has a negative impact on relapse of bipolar disorder (Honig et al., 1997). In RCTs, family focused treatment was associated with fewer relapses and hospitalizations, and improvements in depressive symptoms and medication adherence compared with individual therapy or a family crisis management intervention (Rea et al., 2003).