More Than Medication -- Achieving Psychotherapy Goals in Patients With Bipolar Disorder in Challenging Settings.

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Although the use of medications is crucial to the effective management of bipolar disorder, there is increasing evidence that other modalities reduce relapse but often are neglected in the outpatient management of the patient with bipolar disorder.14 For example, both psychoeducation and cognitive-behavioral therapy (CBT) were found to be effective in a literature review of available evidence on reducing relapse rates, and there was some evidence supporting interpersonal rhythms therapy and family-focused therapy.1,2 Individuals with bipolar disorder have syndromal or subsyndromal symptoms of depression 40 to 50 percent of the time.3 A cognitive-behavioral psychotherapeutic approach was used in a recent prospective study done in London, England. One hundred and three people with bipolar disorder type I were followed for a 30-month period. They were divided into two groups: cognitive therapy and general supportive case management. Service utilization and total costs were measured at three-month intervals. The group receiving cognitive therapy had significantly better clinical outcomes in terms of reduction of overall service need and overall cost to the system. In another study, the efficacy of several adjunctive psychotherapies for the maintenance treatment of bipolar disorder was reviewed. Psychoeducation was found to be very helpful to enhance adherence and for early identification of prodromal signs.4

Despite studies showing that various modalities of psychotherapy significantly reduce relapse rates, treatment is often solely medication management. This may be due to the perceptions that psychotherapy can do little for the seriously mentally ill patient, the focus on psychopharmacology for control of each symptom (even if it means significant polypharmacy with troublesome side effects), and the constraints of reimbursement systems focused solely on somatic treatments with little time and continuity allotted for psychotherapy by psychiatrists.

The case we describe in this article illustrates the challenges of managing a recently diagnosed college graduate student with bipolar disorder. The patient showed improvement once she was better able to recognize early symptoms and allow her family to assist in treatment without her feeling controlled. Not uncommonly, this disorder strikes people in their young adult years—often in college as with this woman. Although members of this college-aged patient population are adults, often their families still are very much involved in their lives both financially and emotionally. This involvement often creates expectations of the treatment by the parents or guardians who, not so long ago, were the decision-makers for the healthcare of their children.