The United States is home to some 5.7 million adults with bipolar disorder — and far too few of them receive care from psychologists, many experts say.
"My practice hours are often full," says Russ Federman, PhD, a psychologist in Charlottesville, Virginia, who specializes in treating patients with the condition. "And I find there aren't enough psychologists I can refer to who also specialize in providing bipolar disorder treatment."
Most health-care professionals think of bipolar disorder as an illness solely in need of prescription medicine. But over the last decade, research has shown that psychosocial therapy is an effective treatment for the disease when combined with mood-stabilizing medications.
"Bipolar disorder suffers from this history of being seen as an über-biologically driven disorder, with the assumption likewise that the treatment has to be biologically driven," says Boston University psychologist Michael Otto, PhD, who specializes in the treatment of mood disorders. "It's time we undo that history."
Psychosocial treatments
Bipolar disorder is characterized by dramatic swings in mood and energy levels, from very low depressive periods to extremely high manic episodes. During periods of mania, people might feel very "high," have increased energy or activity levels, talk quickly, be agitated and irritable, feel they can do many things at once and do risky things such as spending recklessly or engaging in unsafe sexual acts. Some people with the disease experience less severe (but still potentially problematic) manic periods known as hypomanic episodes. Symptoms most often arise between the ages of 15 and 19, but the disease can begin in childhood or as late as the 40s or 50s.
Mood-stabilizing medications such as lithium have long been used to treat and prevent bipolar disorder's dramatic mood shifts, and for good reason. "Mood stabilizers appear to be very important as a core element of treatment," Otto says.
Many people with bipolar disorder take antidepressants in addition to mood stabilizers, although two large studies have suggested antidepressants may not be effective for treating bipolar depression.
But medication isn't the only solution. "Psychosocial treatment deserves much more attention," Otto says.
To date, researchers have demonstrated the effectiveness of three varieties of psychosocial treatments as adjuncts to medication for treating bipolar disorder:
- Cognitive behavioral therapy focuses on a person's thoughts and actions, and helps them change unhealthy behavior patterns. It can help people cope with the symptoms of bipolar disease and recognize signs of an impending mood shift.
- Family-focused therapy, as the name suggests, heavily involves family members in treatment. Alongside patients, parents or spouses are taught to understand symptoms and recognize warning signs of a looming manic or depressive episode. Patients and family members also learn communication skills and disease-management strategies.
- Interpersonal and social rhythm therapy aims to help people improve their moods by working to stabilize a patient's sleep and other biological and social routines while improving the quality of his or her interpersonal relationships.
(David Miklowitz, PhD, a psychologist at the UCLA Semel Institute who specializes in family-focused therapy for bipolar disorder, co-authored a review of the evidence for treatments of bipolar disorder in The Lancetopens in new window in 2013).
Long tail of disruption
While each of the three treatments takes a different approach, they share many features. "What's nice about these models is that while they all have unique theoretical underpinnings, they share some common core components," says Tina Goldstein, PhD, a psychologist at the University of Pittsburgh who specializes in the treatment of youth with bipolar disorder.
One of those core components is psychoeducation, which involves teaching the patient (and often his or her family members) about the symptoms of the illness, what the course of the illness looks like and what treatments are available.
Psychotherapy can also help patients adhere to their medication regimens. Medication adherence is a problem for many diseases, and bipolar disorder is no exception. Risk factors for poor adherence range from substance abuse and forgetfulness to a belief that medications aren't really necessary. "Some people enjoy the hypomanic or manic periods and don't want to ruin them by taking medicines," Miklowitz adds.
Research shows that worse adherence is more common in the early stages after diagnosis, when acceptance of the disease tends to be lowest. Psychologists can help patients and family members accept both the diagnosis and the treatment.
Another important piece of psychoeducation is helping patients and family members understand what other factors affect the cycling of the disease. Stress, poor sleep, and drug or alcohol use, for example, can all tip a person toward a bipolar episode. "Making your patient an expert at managing stress, getting regular sleep and regular exercise is such an important element of treatment," Otto says.
Early intervention and relapse prevention is another core element. While psychosocial therapy can help treat bipolar depression, Otto says, it's not clear that it's beneficial for treating patients in the midst of a manic episode. Untreated, manic episodes can last anywhere from days to months. Medications are critical for bringing such episodes under control, Otto says. Until patients' moods have begun to stabilize with medications, people aren't typically receptive to illness management strategies. Still, psychologists have an important role in teaching patients and their family members to spot early signs that mania might be emerging.
"Manic episodes can be brief, but there is such a long tail of disruption to one's life — the money spent, the affairs had, the cars crashed, the bosses alienated," Otto says. "Early intervention can head off the destructiveness of those episodes."
Psychologists also have a part to play after such events, helping patients recover from the distress of depressive or manic episodes. "These episodes are associated with quite a bit of stress — damage to the family or the marriage, work problems, problems getting back to school, functioning at home or functioning as a parent," says Miklowitz. "In all those things, therapy can help validate what people are going through, while encouraging them to consider solutions that help them to move forward."
Worth the effort
Despite the proven value of psychosocial therapy for people with bipolar disorder, the experts who contributed to this story all agree that too few psychologists understand the disorder and the ways psychologists can get involved in its treatment. "There's a certain reluctance of new people to move into the treatment of bipolar disorder, for a number of reasons," says Otto.
One reason for that hesitancy is that suicide rates are high among people with bipolar disorder, he says. "It can be daunting for some clinicians to take that into private practice."
Another concern is that psychologists who do this work typically need to have good working relationships with physicians and psychiatrists who can admit patients to hospitals, as is often necessary when they're experiencing manic episodes.
It can also take time and practice to understand some of the subtleties of the disorder, Federman adds. "When bipolar symptoms are strong enough, they stand out with clarity. If someone becomes manic, it is unmistakable," he says. But in its milder presentation, symptoms can be difficult to distinguish from other aspects of personality or other co-morbid conditions. "Bipolar illness exists against the background of who the person is in all their uniqueness. After years of experience, a clinician becomes familiar enough with the disorder to be able to distinguish between mild bipolar symptoms and subtleties of personality traits. But for someone without much exposure to the disorder, teasing out these distinctions can be quite challenging."
For psychologists with an interest in treating people with bipolar disorder, there are a number of recent books, treatment manuals and other resources available, Otto says. APA has also published a Proficiency in Psychologyopens in new window document on the assessment and treatment of serious mental illness.
Psychologists working in this area also advise developing working relationships with local psychiatrists for referring patients and discussing issues that arise. "Psychosocial treatment is one piece of a larger treatment approach, and it's helpful to become part of a treatment team, to have a collaborative relationship and an open dialogue with psychiatrists," Goldstein says.
Otto also recommends psychologists collaborate with patients to develop an emergency treatment plan early in the course of therapy. Such a plan would detail who and when the psychologist should call if he or she sees signs of an impending episode. "It's always hard for a therapist to be in a position to escalate the level of care," Otto says. "Having the patient co-plan what should be done makes life that much easier for the therapist, and greatly helps the patient feel they keep some agency when they're losing control."
While one-on-one therapy and family therapy are both important, support groups for people with bipolar disorder can also be very valuable, Miklowitz adds — particularly those with a psychoeducational focus. Federman offers two groups in his practice, one for university students and another for adult professionals. "When you live with bipolar disorder, you feel the stigma. You often don't feel well understood," he says. "When you sit in a group with five or six others who have the same struggles, it makes an enormous difference."
There's also a need for more research psychologists to take a closer look at bipolar disorder. Goldstein says that research on treating children with bipolar disorder is sorely lacking. Otto adds that much more needs to be done on treating common comorbid conditions, such as anxiety, that often coincide with bipolar disorder. More work on suicide prevention in this population is also needed, he says.
While it might take some practice and effort to familiarize oneself with the disease, the need is great. People with bipolar disorder are often misdiagnosed, Goldstein notes — research suggests that on average, it takes about 10 years before they receive the correct diagnosis.
"That can be really damaging because the earlier we can intervene, the more we can maximize outcomes over time," she says. "By educating ourselves to recognize and effectively treat bipolar disorder, the hope is that we can improve outcomes and maximize functioning for these people."
Know the signs
APA's Help Center offers "Recognizing the signs of bipolar disorder." Go to Recognizing Bipolar.
