Bipolar affective disorder is a long-term, episodic psychiatric condition. The prognosis of this disorder is often reserved, due to inadequate therapeutic modalities. This will lead to an evolution with predominantly mixed episodes, shortening the inter-episodic periods with age, with exacerbation of cognitive deficits, somatic comorbidities and the risk of suicide. The unfavorable evolution of bipolar affective disorder is associated with severe alteration of interpersonal and family relationships, social dysfunction, and altered quality of life of the patient, family and relatives(1).
Achieving adequate therapeutic management involves ensuring a balance between efficacy, tolerance and safety. Improving therapeutic compliance requires ongoing monitoring of patients, as well as an adequate patient’s education on the characteristics of the disorder and the role of the treatment. Long-term therapeutic management depends on comprehensive medical care, which ensures the collaboration of all those involved in the mental health services, through an adequate model of care(2).
Thus, an appropriate therapeutic plan must take into account the following elements(3):
the treatment of patients with bipolar affective disorder includes pharmacotherapy associated with psychotherapeutic methods;
monitoring of physical parameters;
support services for bipolar patients, including mental health services and other social or professional services;
modalities by which the families of these patients learn to manage this disorder and ensure mutual support.
In bipolar affective disorder, ensuring compliance with treatment is essential as these patients are among the most noncompliant of all psychiatric patients, because even during the inter-episodic periods, the extraversion and the confidence in their health determine them to exclude the possibility of relapses, and it is difficult to accept the therapy, abandoning it after variable periods. Also, in the depressive episode, noncompliance is based on the feeling of inutility and uselessness, the lack of confidence and hope on the therapeutic measures. To this, it is added the influence of the side effects of the medication and the delay regarding the presence of positive results(4).
Psychoeducational measures are effective both in the acute phase and in preventing recurrences from bipolar affective disorder. Relapses and recurrences may be due to patients’ noncompliance with treatment, adverse effects of medication, or lack of family support. Thus, an important factor in preventing relapse could be the identification of early symptoms, the prodromes characteristic of manic or depressive episodes(5).
Since the 1990s, it has been found that most bipolar patients experience, throughout their lives, numerous affective episodes, which generate psychosocial disabilities. Kraepelin’s statement that affective disorder has a good prognosis is no longer valid in the postmodern era. In general, patients with numerous symptomatic relapses, as well as those with chronic forms, resistant to lithium therapy or not compliant with treatment, are considered not to benefit from adequate therapeutic management. Combining pharmacotherapy with psychotherapy is the best therapeutic way(6,7).
Studies to date have shown that cognitive therapy favors reducing the number of relapses and increasing the period of time in which they occur, with increasing compliance with treatment(8). Cognitive-behavioral therapy has proven effectiveness both in the acute phase and in preventing relapses and recurrences of the depressive episode of unipolar disorder, therefore good results are expected to reduce relapses in bipolar disorder. Thus, patients will learn new coping skills, recognition of prodromes symptoms and early signs that precede an acute episode. Recent studies have shown that there are prodromes for both manic and depressive episodes, and patients with bipolar disorder can identify them. It seems much easier to see the prodromes of the manic episode, probably due to the fact that they have a more sudden, dramatic appearance, while the depressive ones have an insidious appearance(9).
The association of cognitive-behavioral therapy with pharmacotherapy has led to a reduction in relapses, compared to the use of pharmacotherapy only, according to the studies of Lam from 2003 and Scott in 2001(10,11). However, the studies performed were pilot studies, with a small number of patients. In a study conducted by Fava, on 15 patients with bipolar affective disorder, in whom relapses had occurred while they were on lithium prophylaxis, the association of cognitive-behavioral therapy led to a reduction of residual symptoms and an improvement of lithium prophylaxis results, but this study had no therapeutic comparator group (Fava et al., 2001)(12). In another randomized study conducted by Perry et al. in 1999, patients were taught to detect the early symptoms of the disease and, thus, see a therapist sooner than other patients.
This has been achieved by improving symptom self-monitoring and learning coping strategies, which have led to reduced relapses(13). Cognitive-behavioral therapy has also proven useful in the depressive episode of bipolar disorder. Goldstein et al. investigated the effects of cognitive-behavioral therapy in bipolar depression. He concluded that bipolar depressive symptoms can be reduced with the help of techniques specific to cognitive-behavioral therapy(14).
Psychoeducational measures can be divided into three categories, according to Colom and Vieta(15):
a) awareness of the disorder, early detection of prodromal symptoms, increased treatment compliance;
b) stress control, avoidance of substance use and abuse, regular and controlled lifestyle, prevention of suicidal behavior;
c) awareness of past and future emotional episodes and social consequences, improvement of specific social, interpersonal activities in the periods between the affective episodes, confrontation with the subsyndromic residual symptomatology and its consequences, improving well-being and increasing the quality of life.
All of the measures from the first category can be considered partial objectives and their non-fulfillment can mean the failure of psychoeducation. Each of these categories of objectives, taken separately, can be considered themselves specific objectives to be achieved by the patients with bipolar disorder, but all three together make this program, proposed by these authors, solid, more effective, including the costs involved in the long term. The objectives in the third category are part of the so-called excellent scenario, the completion of the program, after successfully completing the other two categories(15).
Psychoeducational measures can be based on the relapse exercise method (“relapse drill”), which takes the model from the one realized in 1985 by Alan Marlatt and Judith Gordon for the prevention of relapses in case of alcohol addiction(16). In case of patients with bipolar disorder, this exercise involves the dynamic follow-up of measures to be followed to prevent a catastrophic event and consists in identifying prodromal symptoms, making a list of preventive measures, performing procedures that they have in mind, and detailed measures of prevention. These measures will involve family members, but also the psychiatrist or family doctor, because together with them there will be established all the details regarding the moment when the prodrome appears, and it is necessary to ask the doctor for help and even to discuss about hospitalization. Usually, patient’s support tends to be provided by close relatives, family members, whether we are talking about the care of patients with mental disorders or chronic disabling medical conditions. But, on the other hand, it will have as a consequence an important impact in terms of their functionality and psychological stress(16,17).
Usually, the first psychotherapy sessions aim to educate the patient about bipolar disorder, the characteristics of the treatment to be followed, the importance of compliance with treatment, the particularities of emotional symptoms and their close monitoring. Patients can be taught to perform activities according to a well-established schedule: for the prevention of the manic episode, it is recommended to engage in calm activities, increase the rest period, reduce the exiting factors, stimulants, and reduce the number of activities; for the depressive episode – occupying time with an increasing number of activities, so that later they can make a plan for carrying out activities at work(18).
The treatment phases and the objectives of psychotherapy sessions (according to Basco and Rush, 1996) are(19):
Cognitive therapy has been studied in particular regarding the increase of bipolar patients’ compliance with mood stabilizer therapy, and behavioral therapy can be effective during the in-hospital treatment of manic patients. Supportive psychotherapy is indicated during the acute phases and in the early period of remission. It is more commonly indicated in chronic bipolar patients, in whom there are significant residual inter-episodic symptoms and social impairment(20).
Group therapy is useful in the social reintegration of patients, in influencing denial and defensive grandeur, and in dealing with various problems of manic patients (loneliness, fear of mental illness, shame, loss of control). Family therapy consists of psychotherapeutic methods regarding the mental disorders and interfamily relationships, like family and marital counseling, changing communication systems, therapy of family emotional life, multifamily therapies, family crisis therapy(21).
The main indications for psychotherapy are the following(22):
the need to understand and accept long-term therapy
the need for association with pharmacotherapy
refusal of medication
avoidance of adverse effects related to the administration of antidepressants, such as agitation or rapid cycling
long-term maintenance therapy phase.
Psychotherapy can be recommended for all patients, especially psychoeducational measures, cognitive therapy or other structural therapies. Studies related to psychosocial therapies and therapeutic guidelines support the idea of using psychotherapy as an adjunctive therapeutic method to pharmacological therapy. Patients with bipolar disorder have relapses in up to 40% of cases in the first year, 60% in the second year, and 73% in the next five years(23). The combination of psychotherapy with mood stabilizer medication and especially psychoeducational measures will reduce the number of hospitalizations and the number of relapses, as well as increase compliance with treatment and improve overall symptoms. Psychosocial interventions will help the patient with a number of problems related to understanding the mental disorder itself, self-confidence and compliance with treatment. It will also help the patient to avoid stigmatization, ensure a proper sleep schedule and limit access to various substances that can have a negative influence on mood by informing one about the aspects of this mental disorder(24).