Talking Your Way to Health?: Psychotherapy for Bipolar

Posted on July 30, 2012 by

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Sometimes bipolar disorder (BD) can be a tough row to hoe.

There are intermittent hospitalizations, mood instability even when you think you’re at your best, medications with side effects that don’t bear speaking about–and a wee bit of stigma, too.

And not everyone returns to full functioning after an episode. BD is the 6th leading cause of disability–world-wide. (Am I cheering you up here?)

And nowadays, it seems, the best you can do is to find yourself in the hands of a “psychopharm jock,” someone who knows each medicine, abstruse as it may be, plus its chemical formulation, plus at least 37 of the most common 95 side effects it’s fairly likely to cause.

Aforesaid jock creates a cocktail, which the two of you tweak on and off for years–and there you have your treatment plan for your BD.

But what about treatment beyond medication? After you’ve taken 2 of these and 3 of those twice a day, plus the one that counteracts the side effects of the third one, is there anything left to move you along to a better place in conjunction with the Abilify and the Seroquel and the Depakote and the Cogentin and the Celexa?

Is there any value to good old talk therapy?

For years the focus in BD treatment has been on medication management, which really is the mainstay of bipolar maintenance. If you thought you could read this and find me telling you to come off your meds, you can officially count yourself as sorely disappointed.

All I can do is let you know that if you’re just being managed by a meds guy, you might be missing something in your treatment.

In fact, in a 2008 study in The American Journal of Psychiatry, the researchers found that

“Despite significant strides in the pharmacological treatment of bipolar disorder, most bipolar patients cannot be maintained on drug treatments alone. Up to 50% of bipolar I patients do not recover from acute manic episodes within 1 year, and only 25% achieve full recovery of function. Rates of recurrence average 40%-60% in 1–2 years even when patients undergo pharmacotherapy.”

Their conclusion?

“Furthermore, 17 of 18 randomized, controlled trials  have shown that individual, family, group, and systematic care treatments are effective in combination with pharmacotherapy in delaying relapses, stabilizing episodes, and reducing episode length.”

For years psychotherapy was almost ignored in favor of meds management, but one of these major–and significant–large, randomized controlled studies (is there any other kind worth mentioning?) from 2007, “Intensive Psychosocial Intervention Enhances Functioning in Patients With Bipolar Depression: Results From a 9-Month Randomized Controlled Trial,” yielded results that insisted we take another look at the way we manage bipolar.

The researchers studied 152 depressed outpatients with bipolar I or bipolar II, all receiving medication. 84 of these patients were randomly assigned to a psychotherapeutic intervention (30 sessions over 9 months of interpersonal and social rhythm therapy, cognitive behavior therapy [CBT], or family-focused therapy), and 68 (if my math is correct) patients were randomly assigned to ‘collaborative care’, which included a self-care workbook (which sounds fairly on the dull side, even when contrasted with CBT, which is not the single most dynamic therapy I’ve ever encountered), an educational videotape, which included information about the diagnosis, course, treatment, and self-management of bipolar disorder (I hope they provided popcorn and Big Gulps), and three sessions that “focused on implementing self-management tools (e.g., mood and sleep monitoring) and developing an individualized relapse prevention plan.” Big snore.

Ready for the shocking results? (Sometimes I just love research studies–it’s like, ‘Wow, I wonder what they’ll find! Maybe giving someone a book and showing them a movie about monitoring their sleep will help people just as much as 30 sessions with a trained professional! I just can’t wait to find out the results. . . .)

Anyway, here’s the upshot:

Patients in intensive psychotherapy had better total functioning, relationship functioning, and life satisfaction scores over 9 months than patients in collaborative care, even after pretreatment functioning and concurrent depression scores were covaried.

That honestly seemed like a no-brainer–and the graph clarifies the results for you, in case you’ve fallen asleep while I’ve been sharing my deep thoughts on the research process.

I mean, if you had to pick a color to be in this graph, wouldn’t you pick to be blue?

Right–that’s the point.

Dr. Michael Thase, professor of psychiatry at the University of Pennsylvania, and not an author on the study, supported the findings based on his own experience.Said the good doctor,

“Psychotherapy seems to be particularly good in protecting against the depressive part of bipolar disorder. Therapy has measurable long term effects in patients with bipolar. It cuts down on relapses and improves work attendance.”

Cutting down on relapses by talking to a therapist, instead of adding on yet another atypical? I’m all for that.

So are you sold? Great.

I assume a few hurdles remain.

Like. . .who’s going to pay for it. While the need for therapy in treatment of BD is becoming more accepted, it still remains easier to get coverage for meds management than for therapy. But try out your insurance provider, see who’s in network–and see if they’re any good. Often something is better than nothing.

Then, what are you looking for?

How glad I am that you asked.

HealthMagazine suggests you look for a therapist who can help you in the following four areas:

  • Work with you to set up a solid structure for each day;
  • Set up a plan to avoid overstimulation–and, for goodness sakes, to get enough sleep (often this alone can prevent a manic attack. Really);
  • To resolve family conflicts that contribute to symptoms (this is a challenge, and many people would rather chew off their left arms than meet with their parents or children or spouses in family therapy. But a good psychotherapist can make such a difference in your life by easing the constant stress created by dysfunctional relationships, that it’s worth the unpleasantness.); and
  • Help you learn to recognize the warning signs of manic and depressive episodes.

[I can't help myself here. I've said it numerous times and here I am berating my readers again. Mood charting is absolutely key in this last step, and you don't have to do it with pen and graph paper any more, like they did in the stone age. There are numerous apps to help you keep up with your mood patterns [see, for example, "There's a Bipolar App For That, Part I: Tracking Your Moods" for some--cheap!--ideas]. It will help you help your psychiatrist and your therapist help you.]

So I’ve saved this piece of unpleasantness for last, but I couldn’t leave this post in good conscience without saying this. I’m sorry–but even excellent psychotherapeutic interventions will not replace your need for medications. It’s ugly and unpleasant and disheartening–but it’s the plain truth.

Psychiatric Disorders.com has a realistic visual of what treatment’s probably going to look like–and although lifestyle changes and psychotherapy play crucial roles, medications remain a central part of healing.

So what about all this talk about therapists and talking, you’re wondering?

Well, what they can do is help make you feel so much more supported while you’re going through the medication mess that sometimes arises, help you create a life structure that may even lessen your dependence on the heaviest of your meds, and maybe even bring peace between you and old mom, who’ve kept up the battle for decades now, much to both of your detriments.

Finally burying the hatchet has to be worth a copay, irritating as it is.

And I’d say between competent medication management, a regular sleep structure, a good relationship with an experienced psychotherapist–and a healthy dose of chocolate when all else fails, you should have the support you need to achieve more than you might have thought possible.

**As an interesting addendum, with an alternative point of view, take a look at an intriguing piece by the blog “bi[polar] curious” entitled “Is Therapy Pointless for the Unmedicated Bipolar Patient?