Mental health articles

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Cognitive behavioural treatment for bipolar disorder

The biological model of bipolar disorder has been dominant for some years, and it is only recently that attempts to change the course of the disorder using cognitive behavioural methods have been attempted. The main psychotherapeutic approach has involved the use of psychoeducational programmes to prepare people to cope with relapse. In one evaluation of this approach, Scott et al. randomly allocated people with bipolar disorder into treatment with lithium either alone or in combination with cognitive therapy. The cognitive therapy involved three elements:

an educational phase to prepare people for the cognitive approach

a focus on cognitive behavioural methods of symptom management including establishing regular activity patterns and time management, as well as challenging dysfunctional thoughts

anti-relapse techniques involving developing strategies for managing medication, coping strategies to deal with stress, or seeking help at times of the onset of signs of relapse.

Each intervention lasted six months. By this time, those in the combined intervention showed more improvements on measures of general functioning and depression than those in the drug treatment group. The data on relapse were equally impressive. Those who received the combined intervention were 60 per cent less likely to relapse than those in the drug-only condition. Lam et al. (2003) found that cognitive therapy plus drug therapy also proved more effective than drug therapy alone. Over a one-year follow-up, those who received the additional intervention experienced fewer relapses and hospitalizations, with relapse rates of 44 per cent in the cognitive therapy group and 75 per cent in the drug-only group. Subsequent analysis showed a reduction of effect over time, with smaller (but still significant) gains maintained to three-year follow-up (Lam et al. 2005). A further approach to working with individuals has involved the use of mindfulness, which has been shown to reduce anxiety and residual depressive symptoms between acute episodes over a short period.

More studies are required to determine its impact on relapse rates. A second therapeutic approach has involved working with families – justifi ed by reports such as Kleindienst et al.– who showed the role of family dynamics in relapse. Miklowitz et al. reported an intervention designed to improve communication, problem-solving and coping strategies training within the family, comparing this with standard care and a brief two-session family intervention. At two-year follow-up, those receiving the family therapy experienced fewer relapses than the standard care group (71 per cent versus 47 per cent). The benefits were greater for those living in a high expressed emotion environment. Rea et al. compared family and individual psycho-educational interventions and found that the family intervention was superior in the long term. Relapse rates were 60 per cent among those who received the individual intervention and 28 per cent of those who received the family intervention.

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