| Abstract|| |
Several reasons justify the need for nonpharmacological interventions for bipolar disorder (BD) in women. This review focuses on psychosocial therapies for BDs in women. The research evidence for a wide range of psychosocial interventions for the management of BDs in women has been presented. All the interventions have some common components like targeting disease management, information regarding illness, and coping skills. There also are distinctive features like cognitive restructuring and self-rated mood charts in cognitive behavior therapy, regulation of sleep/wake cycles and daily routines in interpersonal sleep regulation therapy, and communication skill training in family treatments. Many psychosocial interventions hold promise as adjunctive therapies for bipolar patients. In India, there is a considerable dearth of literature in this area due lack of skilled staff for psychosocial interventions. Future trials need to: Clarify which populations are most likely to benefit from which strategies; identify putative mechanisms of action; systematically evaluate costs, benefits, and generalizability of effects, and record adverse effects.
Keywords: Bipolar disorder, cognitive behavior therapy, group, interpersonal, psychoeducation, psychosocial, women
|How to cite this article:|
Naik SK. Management of bipolar disorders in women by nonpharmacological methods. Indian J Psychiatry 2015;57, Suppl S2:264-74
| Introduction|| |
The emergence of medical model of treatment for bipolar disorder (BD) for more than three decades has led to various somatic interventions, including pharmacologic agents and nonpharmacologic interventions such as electroconvulsive therapy, magnetic seizure therapy, magnetic stimulation, bright light therapy, sleep deprivation, and psychosocial interventions. These are documented to be efficacious in treatment. This review focuses on the psychosocial interventions because there is growing interest in the field evident by increasing number of studies providing support for their efficacy in improving the outcome of bipolar illness.
Is there a need for psychosocial interventions?
The need for psychosocial interventions for BD arose due to the following reasons:
- Despite treatment, up to half of the patients did not achieve recovery from an acute episode 
- Up to half of the recovered patients experienced recurrences during a 2-year follow-up 
- A significant population of women with BD (37% during pregnancy and 14% during both pregnancy and postpartum) experience mood episodes  and the risk of relapse is up to 61.5% in women not receiving prophylactic treatment following 3 months after delivery 
- There is incomplete inter-episodic recovery and marked impairment with only 25% achieving full recovery of function 
- Adding to this, is the problem of poor compliance with treatment which is shown by the finding that only about 40% of patients are fully adherent to medication regimens in the year following the episode 
- The course of BD is strongly affected by life events,  life stress,  social support,  expressed emotion (EE)  and modulation of these factors are likely to result in better outcome
- Mixed episodes and rapid cycling are more common in women which are difficult to manage even with available medications ,
- The decisions regarding the treatment of BD during pregnancy must balance the risks associated with untreated depression or mania versus possible teratogenic effects of mood-stabilizing medications. 
- A study reported 35% of affected participants having a strong family history of BD were "not willing to have children" or "less willing to have children" as a result of perceived stigma 
- The estimated cost of BD in 1991 in the USA was estimated to be £45 billion and £2 billion in a study in the United Kingdom (UK). , Although limited work has been carried out in India on the economic burden of mental illness, a study of small sample of BD in the urban area found that the costs incurred for medicines and consultations for patients were Rs. 558 and the caregiving costs varied from Rs. 500-2000 depending on the earning capacity of the caregiver besides a significant amount of money spent on traditional healers and travel to the health care facility. The maximum monetary loss faced by these primary caregivers was computed to be Rs. 1500-2000 per month. 
In view of the huge amount of healthcare costs thrust upon by the illness it is apt to plan for novel modalities or existing modalities as an adjunct to the available somatic interventions with the aim to reduce the costs.
| Psychosocial Interventions|| |
The phenomenology did not show any significant gender variation in a study involving 682 outpatients and 1037 inpatients of manic episode/BD in a nationwide register in Denmark during the period 1994-2002.  Although most of the studies of psychosocial interventions for mood disorders have a good representation of women, very few have examined the differential effects of psychotherapy on women and men. The studies that have examined the gender variations in response to psychotherapy have shown minimal differential effects.  There has been significant research in psychosocial interventions for mood disorders in women with depression during pregnancy and puerperium, ,, mood disorders associated with premenstrual  and perimenopausal  period, but very few have focused on BD.
There is increasing evidence that psychosocial interventions are effective adjuncts to pharmacotherapy in the stabilization and prevention of episodes of BD.  A meta-analysis of 7 randomized trials conducted prior to 2003 concluded that adjunctive psychotherapy is more effective than medication alone in relapse prevention.  The recent 15-site Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) found that bipolar patients receiving medication along with different psychosocial interventions recovered from depressive episodes on an average of 110 days faster than patients receiving medication and minimal psychoeducation (PE).  A recent review found that 17 of 18 randomized control trials showed that individual, family, group and systematic care treatments are effective in combination with pharmacotherapy in delaying relapses, stabilizing episodes, and reducing episode length. 
There are various psychotherapeutic interventions used in the treatment of BD which are as follows:
Defense specificities have only recently been investigated systematically with regard to several clinical diagnoses, such as affective and personality disorders. The defense specificities in BD encompass a set of 5 immature defenses, of which omnipotence is linked with symptom level. The level of the therapeutic alliance is predicted by mature defenses.  Although the most comprehensive review of psychoanalytic thought on BD is summarized by Frieda Fromm-Reichmann's group, some recent studies have also been conducted. ,,
The effectiveness of long-term outpatient psychodynamic group psychotherapy including Psychoeducation (PE) was examined in a study, which found that at 1-year follow-up, the group members had significantly less depressive symptoms, increased number of days well per week and were less likely to be in a mood episode compared to controls. However, it did not find any significant benefit on manic symptoms. 
Education regarding illness and its treatment when applied to mental disorders is called as PE. The aspects of education are incorporated in most of the psychotherapeutic modalities.
A randomized control study in a group of 69 remitted outpatients of BD compared PE to no added intervention and found that the time to manic relapse and total number of days spent in manic episode was significantly lower than the controls, but no significant benefit in patients with depressive episodes. It was also reported that the social and occupational functioning was significantly improved at 18 months. 
Group PE provides a supportive, interactive setting in which patients learn about their disorder and how to cope with it. A randomized clinical trial included 62 BD patients with comorbid substance use disorders and randomly assigned the subjects to either 20 weeks of integrated group therapy or an intensive drug abuse counseling group.  The group receiving integrated group therapy spent half the number of days using alcohol. However, it did not prevent episodes of BD.
A randomized controlled trial included 120 bipolar I and II disorder subjects in remission for at least 6 months. , The subjects received 21 sessions of either group PE or nonstructured group meetings and followed up at 2-year and 5 years. The PE group had a longer time to recurrence, fewer recurrences of any type, less time spent acutely ill, and lower median number of hospitalization in hospitalized subjects. Post hoc analyses using data on 20 (out of 120) Diagnostic and Statistical Manual 4 th Edition (DSM-IV) BD II patients were undertaken. The psycho-educated group (n = 8) as compared to unstructured support group controls (n = 12) had lower mean number of hypomanic episodes and depressive episodes, fewer days spent in mood episodes and higher mean levels of functioning after 5 years.  The sub-analysis of data from a larger study showed that mean serum lithium levels were significantly higher and more stable in subjects receiving PE (n = 49) when compared to controls (n = 44). 
A single-blind, randomized, prospective clinical trial compared a group of remitted fully compliant DSM-IV bipolar I patients (n = 25) receiving group PE with a group with similar characteristics (n = 25) and found lower recurrence (60% vs. 92%), decreased number of depressive episodes in psycho-educated patients.  In a sub-analysis of the study including DSM-IV bipolar I subjects with comorbid personality disorder, the results showed lower recurrence (67% vs. 100%), higher time to relapse and a significantly lower mean number of total manic and depressive relapses, and decreased number of hospitalization days in the group receiving PE (n = 22) compared to controls (n = 15) receiving nonstructured intervention during a 2-year follow-up period.  Although the individuals subjected to PE had twice as many planned outpatient appointments, the emergency consultation utilization and inpatient care cost reduced (15% vs. 40%) in comparison to unstructured support group interventions in controls. This demonstrates the importance of taking a long-term overview of the cost versus benefits of adjunctive psychological therapy in BDs. 
An open trial of Life goals Program consisting of manual-based two phase group program included 29 patients.  The Phase I contained 5 weekly structured psycho-educational sessions focusing on the identification of illness pattern of the patient and development of an action plan for dealing with the symptoms. The Phase II of the program focused on the attainment of functional goals utilizing mainly cognitive behavioral tools with interpersonal group elements. The subjects were found to increase their knowledge regarding illness, and 69% completed the Phase I of the study. After 18 months in Phase II, 70% of the subjects were able to attain their functional goal in the mean duration of 7 months.
A total of 102 BD (type I and II), outpatients who were euthymic for >3 months were recruited from two Italian Departments of Mental Health.  All subjects received standard psychiatric care including pharmacologic treatment along with 21 sessions of weekly group PE. The mean numbers of hospitalizations, the mean number of days of hospitalization were significantly lower compared to controls during the follow-up of 1-year.
Family therapy and family psychoeducation
Family-focused therapy (FFT) seeks to reduce the high levels of stress and conflict in the families of bipolar patients, thereby improving the patient's illness course.
In a randomized controlled trial in the Colorado Treatment/Outcome Project, 101 bipolar patients (after onset of a manic, mixed, or depressed episode) were assigned to FFT (21 sessions of PE, communication training, and problem-solving skills training) and pharmacotherapy or a less intensive crisis management (CM) (two sessions of family education along with crisis intervention) and pharmacotherapy for a period of 9 months. , The patients undergoing FFT had fewer relapses (11/31, 35% vs. 38/70, 54%), longer survival intervals (mean ± standard deviation, 73.5 ± 28.8 weeks vs. 53.2 ± 39.6 weeks), better medication adherence, and greater reductions in depressive, but not manic mood symptoms, than patients undergoing CM during the 2-year follow-up period.
A randomized controlled trial including 53 bipolar I patients hospitalized for a manic episode examined FFT and pharmacotherapy versus an individual therapy and pharmacotherapy.  The individual therapy was similar to the FFT in the frequency of sessions, the length of the intervention period and psycho-educational elements. There was no difference reported on the outcome measure of recurrence among the groups at the end of 1-year. However, 28% recurrence and 12% re-hospitalization was reported in the group receiving FFT in comparison to 60% recurrence and 60% re-hospitalization in the group receiving individual therapy after a 2-year treatment period. The mean survival time prior to recurrence was also longer in the FFT group.
The primary family caregivers of 46 patients with bipolar I (n = 40) or II (n = 6) disorder, diagnosed by the Structured Clinical Interview for DSM-IV Axis I Disorders, were assigned randomly to receive either: (i) A 12-15-session family-focused, cognitive-behavioral intervention designed to provide the caregiver with skills for managing the relative's illness, attaining self-care goals, and reducing strain, depression, and health risk behavior (family-focused treatment-health promoting intervention [FFT-HPI]); or (ii) an 8-12-session health education intervention delivered via videotapes. Randomization to FFT-HPI was associated with significant decreases in caregiver depressive symptoms and health risk behavior.  Greater reductions in depressive symptoms among patients were also observed in the FFT-HPI group. Reduction in patients' depression was partially mediated by reductions in caregivers' depression levels. Decreases in caregivers' depression were partially mediated by reductions in caregivers' levels of avoidance coping.
Couples/partners focused therapy
A randomized control trial including 39 partners of BD patients receiving PE (five sessions) improved significantly in comparison to controls. However, no change in mood, compliance, and measures of interaction in partner or patient was reported.  A controlled trial studying the impact of multi-couple psycho-educational group of BD patients with 29 couples in the intervention group and 23 on a waiting list found more changes from high EE to low EE in the intervention group in comparison to the controls. They also reported fewer admissions in those with low EE.  A randomized control trial in a sample of 33 inpatients/outpatients of BD and their spouses who underwent 25 psycho-educational manual-based sessions for individual couples on weekly or biweekly basis showed significant improvement in functional outcome and treatment adherence. However, the clinical symptoms did not improve significantly. 
Multifamily psychoeducation groups
A total of 92 patients with bipolar I disorder who met the criteria for an active mood episode and were living with or in regular contact with relatives or significant others were randomly assigned to individual family therapy plus pharmacotherapy, multifamily group therapy plus pharmacotherapy, or pharmacotherapy alone, which were provided on an outpatient basis. , When the subjects were assessed monthly for up to 28 months, no significant difference was noted between the groups with regard to time to recovery or time to recurrence. The patients from families with high conflict or low problem-solving skills receiving either of family therapy had half as many depressive episodes per year and spent less time in depressive episodes as compared to the group receiving pharmacotherapy alone. However, no effect was found on manic symptoms with either of the family interventions. When the subjects (n = 53, 58%), who had recovered from the index mood episode, were assessed only 5% of the subjects receiving adjunctive multifamily group therapy required hospitalization, compared to 31% of the subjects receiving adjunctive individual family therapy and 38% of those receiving pharmacotherapy alone indicating that adjunctive multifamily group therapy may confer significant advantages in preventing hospitalization for a mood episode. 
The caregivers (62 parents and 45 partners) of 113 medicated euthymic bipolar outpatients were randomized to receive 12 sessions of group PE focusing on knowledge of BD and training in coping skills. The patients were assessed monthly during both the intervention and the 12 months of follow-up, but they did not attend the group intervention. It was found that the PE group intervention that focused on the caregivers of bipolar patients carried a reduction of the percentage of patients with any mood recurrence and longer relapse-free intervals. When different types of episodes were analyzed separately, the effect was significant for both the number of patients who experienced a hypomanic/manic recurrence and the time to such an episode. 
A review aimed to investigate the effectiveness of family interventions in the treatment of BD compared with no intervention and other forms of intervention.  Seven randomized control trials were included in the review, involving a total of 393 participants. All the included studies assessed psycho-educational methods, and one study also assessed a type of systems psychotherapy. In all trials, participants continued to receive pharmacotherapy treatment along with the family interventions. It was not possible to perform meta-analyses for primary outcomes due to the diversity of interventions, outcome measures and endpoints used across studies. Five studies compared a variety of family interventions, involving caretakers, families or spouses, against no intervention, with individual findings indicating no significant added effect for family interventions. Three of the included studies compared one type or modality of family intervention against another family intervention, with inconsistent findings. The authors concluded that there was only a small and heterogeneous body of evidence on the effectiveness of family-oriented approaches for BD, and it is not yet possible to draw any definite conclusions to support their use as an adjunctive treatment for BD.
Interpersonal and social rhythm therapy
The interpersonal and social rhythm therapy (IPSRT) approach which is an adaptation of interpersonal psychotherapy for depression was designed with the objective of resolving key interpersonal problems, conflicts, and deficits and stabilizing the pattern of social rhythms such as sleep-wake cycle, exercise, and socialization. The technique developed by Frank et al. consists of four phases.  (a) Initial phase of weekly sessions focusing on assessment of illness and social rhythms and PE lasting weeks to months, (b) intermediate phase of weekly sessions focusing on developing social rhythms therapy and interpersonal therapy based strategies for dealing with the stressors lasting several months, (c) preventive phase of monthly sessions continuing for at least 2-year, (d) termination phase of 4-6 monthly sessions concludes the therapy.
A randomized control trial on IPSRT versus no added intervention including 42 subjects reported no significant benefit of the intervention when compared to control.  However, the study indicated that manic patients were significantly more likely to achieve clinical remission than the depressed patients (100 vs. 59%) and did so significantly more rapidly.
A study included 175 bipolar I patients who were randomly assigned to either pharmacotherapy or weekly sessions of IPSRT or pharmacotherapy with weekly clinical management sessions. The patients when recovered were again randomly assigned to the modalities during a maintenance phase of 2-year. The authors reported that patients receiving IPSRT during the acute phase showed longer inter-episodic interval. IPSRT was shown to be more effective in the delay of recurrences when the patients stabilized their social rhythms during the acute phase treatment. However, when IPSRT was started in the maintenance phase of treatment, it did not show any beneficial effect.  The data, when subjected to secondary analyses, showed the strong beneficial effect of IPSRT on the recurrence of depressive episodes.  It also showed a three-fold reduction on suicide attempts during the acute phase and 17.5 fold reduction during maintenance phase treatment. 
A study using IPSRT as mono-therapy for the acute treatment of bipolar II depression found that after 12 weeks the subjects responded to IPSRT mono-therapy although 41% dropped out of or were removed from the study and 18% did not respond to treatment. At 20 weeks, 53% had achieved a response and 29% achieved a full remission of symptoms. 
A randomized control trial aimed to describe the effect of acute treatment with IPSRT on occupational functioning over a period of approximately 2.5 years did not find any significant effect.  However, the participants initially assigned to IPSRT showed more rapid improvement in occupational functioning than those initially assigned to intensive clinical management which was primarily accounted for by greater improvement during the acute treatment phase. The improvement also showed a gender effect favoring women.
Cognitive behavioral therapy
The basic cognitive-behavioral approach and techniques of addressing dysfunctional attitudes and cognitive schemata in depression have been applied to BD.
In a review of 45 trials conducted up to September 2005 on clinical and economic effectiveness of interventions for prevention of relapse with BD, the authors reported of evidence suggesting that cognitive behavioral therapy (CBT), in combination with usual treatment, is effective for the prevention of relapse. It was reported that the group PE and possibly family therapy might also have roles as adjunctive therapy for preventing relapse. 
A randomized controlled trial tested adolescents by individually delivering a manualized cognitive behavioral intervention and concluded that the treatment strategy is feasible and efficacious. 
A randomized control study of individual cognitive behavioral intervention delivered in six sessions to improve compliance included 28 outpatients for a period of 6 months and found that the intervention group scored better than the control group on some, but not all, medication adherence measures. However, the differences disappeared after a period of 3 months. 
In a randomized control study of 25 outpatients who received either the manual-based intervention or no added treatment for a period of 6 months focusing on standard cognitive approaches along with PE about the illness, behavioral skills for coping with prodromal symptoms and functional sequelae of the illness found that the subjects in the intervention group had fewer total and hypomanic episodes and higher social function. The authors, however, found no difference with regard to depressive episodes. 
A total of 103 patients of BD randomly assigned to pharmacotherapy with CBT sessions for a period of 6 months or pharmacotherapy and routine care only. The results over 1-year period favored the CBT group in patients having decreased relapse (44% vs. 75%), fewer hospitalizations, a lesser number of hospitalization days, better treatment adherence and social functioning.  At follow-up after 30 months relapses were less only for depressive patients. 
When bipolar patients who were euthymic or mildly symptomatic were randomly assigned to either medication with 6 months of CBT (20 sessions) or medication with brief PE, it was found that the group with medication and CBT showed lower depression scores at 6 months and tended to have longer times to depressive relapses over 18 months, but did not differ in overall relapse rates. 
A multi-site UK study of 253 high-risk bipolar subjects were administered CBT over 26 weeks and did not find any significant change in the outcome measures.  Although, a post hoc analysis showed that persons receiving CBT showed delaying recurrences among patients with fewer than 12 episodes at the inception of the study. Therefore, the authors concluded that 22 sessions of CBT may not be effective for most people seen in general adult psychiatry settings and suggested that in lower-risk subgroup CBT may be very helpful.
The effects of CBT, in addition, were examined by a randomized control trial in 79 euthymic or minimally symptomatic BD I and II patients. , The patients received 7 individual sessions of PE derived from a structured manual-based CBT and half of the patients additionally received 13 individual sessions of CBT. The results revealed no differences in relapse or re-hospitalization rates. The patients enrolled in CBT, however, had 50% fewer days of depressed mood and fewer antidepressant dose change over the period of study.
A prospective open trial of a small sample studied for 9 months, a group cognitive behavioral approach focusing on PE and development of a patient-specific cognitive-behavioral plan for illness management, and indicated that the treatment package was effective for at least some patients who improved on several clinical and/or functional measures. 
An open trial study of 11 bipolar depressed outpatients with cognitive-behavior with Basco-Rush adaptation manual-based approach for 20 weeks, reported that the subjects improved on several variables like clinical symptoms, automatic thoughts, but did not show any improvement in dysfunctional attitudes. 
One randomized controlled trial  reported that patients who received 12-14 sessions of CBT were less likely to have depressive episodes and had better social functioning than patients in routine care for 30 months. The addition of group CBT to maintenance pharmacotherapy resulted in objective and subjective indices of impairment showed improvement after 14 weeks and despite the fact that mood symptoms were controlled at entry into the study, psychosocial functioning increased significantly at the end of treatment. 
A clinical trial evaluated the effectiveness of manualized cognitive behavioral group therapy integrated into routine care on a psychiatric inpatient unit and to compare the impact of the intervention on schizophrenia, major depression, BD, or personality disorder patients.  The percentage of total readmissions declined from 38% to 24% of which 17% were compulsory in 2001 compared with 0 in 2005. There was also statistically significant improvement in patient satisfaction, and ward atmosphere compared with baseline.
Mindfulness-based cognitive therapy
A new psychological treatment mindfulness-based cognitive therapy for people with BD focusing on between-episode anxiety and depressive symptoms showed an immediate effect on anxiety and depressive symptoms among bipolar participants with suicidal ideation or behavior, by reductions in residual depressive symptoms relative to controls. 
Facilitated integrated mood management
The development of a novel psycho-educational treatment, Facilitated Integrated Mood Management,  was primarily guided by UK Medical Research Council's guidelines on developing and evaluating complex interventions. It is a five-session treatment (i) First, addressing the relapse symptoms, (ii) second, dealing with review of risk and protective factors, (iii) third, emphasizing about daily rhythm and sleep/wake regulation, (iv) fourth, reviewing the role of medications and substance/alcohol abuse, and (v) Fifth, finalizing the mood management plan. The participants have to complete at least 1-month of daily monitoring of mood using text or E-mail messaging and weekly monitoring of mood in the True colors system for monitoring mood by responding to validated self-rating scales of mood (Altman Self-Rating Mania Scale and Quick Inventory of Depressive symptoms-Self Report Scale) by the same medium. The participants were 16 years or older diagnosed to be BD (I and II) not in an acute episode of mania or mixed illness, under care with a psychiatrist, willing to use mobile phone text messaging or web form E-mail. The sample consisted of 29 suitable subjects (out of 114 subjects from the outpatient mood disorders program of Warneford Hospital, University of Oxford, UK) of which 19 consented for participating in the study. The participants consisted of 68.4% female and 31.6% male subjects. The patients had a compliance rate of 88% showing relatively stable mood score during the 4 months follow-up period. The care in the study could be administered by clinicians with minimal experience in the field and is cost effective. Patients' knowledge of mood management strategies increased significantly between the first and last weeks of treatment.
| Systematic Care or Collaborative Care|| |
A Veterans Affairs study team created a care model conceptually similar to the lithium clinics of the 1970s to improve treatment effectiveness in clinical practice, but augmented by principles of more recent collaborative care models for chronic medical illnesses. , This intervention consisted of improving patients' self-management skills through PE; supporting providers' decision making through simplified practice guidelines; and enhancing access to care, continuity of care, and information flow through the use of a nurse care coordinator. The 3-year, 11-site randomized effectiveness trial including 306 bipolar I patients showed that the intervention significantly reduced weeks in the affective episode, primarily mania. There were broad-based improvements demonstrated in social role function, mental quality of life, and treatment satisfaction, with most benefits accruing in years 2 and 3 suggesting a delayed effect of PE and facilitated collaboration with care providers. However, the reductions in mean manic and depressive symptoms were not significant.
A 2-year systematic intervention program, including a structured group psycho-educational program consisting of monthly telephone monitoring of mood symptoms and medication adherence, feedback to treating mental health providers, facilitation of appropriate follow-up care, and as-needed outreach and crisis intervention was provided to 441 patients randomly assigned to receive either the multi-component intervention program or to continued care as usual.  A person blinded research interviews were conducted every 3 months to assess mood symptoms using the longitudinal interval follow-up examination. The intervention significantly reduced the mean level of mania symptoms and the time with significant mania symptoms which were found only in a subgroup of 343 persons with clinically significant mood symptoms at the baseline assessment. However, no significant intervention effect on the mean level of depressive symptoms or time with significant depressive symptoms was reported. The incremental cost of the intervention showed modest increases in the cost in comparison to the clinical gains.
| Comparison Between Psychosocial Interventions|| |
A randomized controlled study evaluated the efficacy and added benefit of adding a course of CBT to a standard course of brief PE, as maintenance therapy for BD and reported significant benefit in the reduction of number of days spent in depressed mood, and less increases of antidepressant use as compared to the subjects receiving PE alone.  There were no group differences in hospitalization rates, medication adherence, psychosocial functioning, or mental health use which led the authors to conclude that even after optimization of medication treatment, a longer course of adjunctive CBT may offer some additional benefits over a shorter course of PE alone for the maintenance treatment of BD.
A Canadian trial compared six group PE sessions with 20 sessions of individual CBT, both with pharmacotherapy, in 204 patients in full or partial remission.  There were no differences recorded over 72 weeks in symptom burden or recurrence.
STEP-BD is a large National Institute of Mental Health clinical research program designed to study treatment effectiveness with both naturalistic and randomly assigned treatment protocols. There were 15 sites from across the USA which included 293 referred depressed outpatients with bipolar I or II disorder treated with protocol pharmacotherapy and randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psycho-educational intervention.  The collaborative care consisted of three-session in 6 weeks, whereas the intensive psychotherapy consisted of 30 sessions on the weekly/biweekly basis for 9 months according to protocols for FFT, IPSRT, and CBT. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs. 51.5%) and shorter times to recovery than patients in collaborative care. Patients in intensive psychotherapy were 1.58 times more likely to be clinically well during any study month than those in collaborative care. There were no statistically significant differences observed in the outcomes of the three intensive psychotherapies.
The authors extended their prior work to study the effects of psychosocial intervention on life functioning in bipolar depression in a total of 152 bipolar I or II depressed patients, all of whom received pharmacotherapy.  The subjects were randomly assigned such that 84 subjects received intensive psychotherapies and 64 received collaborative care. The outcome measure of functioning was examined in 4 domains including relationships, work/role performance, recreational activities, and life satisfaction during a 9-month period, which demonstrated better total functioning, relationship functioning, and life satisfaction in the group receiving intensive psychotherapies, although no differences between groups were observed for work/role functioning and recreational activities.
In the STEP randomized controlled trial of psychotherapy for bipolar depression, participants received up to 30 sessions of intensive psychotherapy (FFT, IPSRT, or CBT) or collaborative care, a three-session comparison treatment, plus pharmacotherapy.  A total of 269 patients (113 women) with a comorbid lifetime anxiety disorder (n = 177) or without a comorbid lifetime anxiety disorder (n = 92) were included. 66% participants with a lifetime anxiety disorder compared with 49% recovered over 1-year. However, there was no difference in recovery rates found in subjects without a lifetime anxiety disorder (64% vs. 62%). Participants with one lifetime anxiety disorder were likely to benefit from intensive psychotherapy compared with collaborative care (84% vs. 53%), whereas patients with multiple anxiety disorders exhibited no significant difference in response to the two treatments (54% vs. 46%).
A survey included all randomized clinical trials conducted between 1999 and 2007 to investigate whether different forms of psychotherapy consisted of overlapping versus modality-specific ingredients.  It identified five categories of active psychosocial treatment viz., individual PE, individual CBT, individual IPSRT, family PE, and group PE. These psychosocial treatments were distinguished from treatment-as-usual (TAU) by more frequent use of problem-solving skills and interventions to enhance patients' ability to cope with the stigma of mental illness. With regard to specific approaches, CBT made frequent use of cognitive restructuring and self-rated mood charts. The signature features like regulation of sleep/wake cycles, and daily routines of IPSRT were also regular features in the CBT and group PE interventions. The communication skill training was a distinctive feature of family treatments. The authors concluded that although the active psychosocial interventions for BD have common ingredients, they can also be distinguished from each other and from TAU by the degree to which specific strategies are emphasized.
| Indian Scenario|| |
The surveys done among psychiatrists in India have shown that only a small proportion of us practice any type of psychotherapy. Even among those who do psychotherapy, many describe their method as eclectic supportive psychotherapy. The possible reason for this state of affairs could be the lack of training opportunities, lack of time and economic factors.  In general, psychotherapy research studies in India are very limited. ,
Some psychosocial interventions like CBT, family PE in schizophrenia, schizoaffective disorder and group PE in substance use disorders have been conducted. Neki has suggested that instead of the nondirective psychotherapies developed in the west, psychotherapy which fits the Guru-Chela paradigm is more suitable for Indian culture.  CBT which is a directive, and problem-oriented brief psychotherapy, which uses the "Socratic" approach, seems to fulfill this criterion. CBT in a group of 51 subjects of schizophrenia or schizoaffective disorder resulted in marked improvement in overall adjustment and decrease in intensity of symptoms which reduced in a follow-up after 9 months leading the authors to conclude that the positive effects might not sustain for a longer period and requires repeated sessions. 
The role that families play in the support and care of a relative with a mental illness has gained increasing attention over the past 30 years. In India, the family is the primary caregiver for individuals with the physical or psychiatric illness. Families are assigned the role of primary caretakers because of the paucity of health professionals, and most Indian families would like to be meaningfully involved in all aspects of care of their ill relative.  The associated social stigma and misconception often prevent the family from seeking proper assistance.  Family PE programs have significant benefits in areas other than the symptom and relapse management for the family member with a chronic psychiatric disorder.  There have been attempts even with 1-day family PE program in patients with schizophrenia.  In two models of family PE conducted at the Schizophrenia Research Foundation the authors did not find any significant changes in psychopathology or burden scores, but significant gain in knowledge of caregivers and recommended informal family PE in the Indian setting. 
In a retrospective study of 54 clients aged 18-50 years diagnosed with either schizophrenia or bipolar affective disorder were included who stayed at the Richmond Fellowship Society "ASHA," a halfway home for more than 6 months.  The participants underwent psychosocial rehabilitation including interventions like skills training in activities of daily living, individual counseling, medical compliance strategies, family therapy, PE, etc. There was a marked improvement at the time of discharge in baseline scores.
The sole study of a psychosocial intervention in a caregivers group of BD assessed the perceived benefits of group meetings of caregivers of those with schizophrenia and bipolar mood disorder and evaluated the utilization pattern. The study included the primary caregivers who stayed with the patients with schizophrenia and bipolar mood disorders with associated psychosocial problems and regularly attended the OPD of Department of Psychiatry, Father Muller Medical College, Mangalore, Karnataka. The psychosocial problems were assessed mainly in the areas of subjective family burden, compliance, knowledge regarding the illness and treatment, family distress, caretaker's attitude toward the client and the social support system. The group meetings were conducted for caregivers once a month for both the schizophrenia group and the bipolar mood disorder group for 45-60 min. Each group meeting followed a more or less structured format consisting of an initial phase of self-introduction, middle phase of reviewing the previous meeting, discussion on a selected topic and clarification of doubts, termination phase of summarizing the meeting. There were 46 participants (23 in each group) in the study which lasted for 17 months. The authors observed significant improvement in knowledge, family distress, strengthening of the support system and coping skills among the participants. In the bipolar group, 69.57% patients were poorly compliant, and 30.44% patient required supervision with medications before the caregivers attended group meetings. It was found that 52.18% patients had good compliance, and all the caregivers showed positive attitude toward patients after the group intervention. 
| Discussion|| |
Psychotherapy presupposes a collaborative practice approach between the patient, partner or family member and the therapist. Therefore, a good social support is critical for these interventions. However, if the social network is inadequate individual interventions might be more appropriate. All the interventions have some common components like targeting disease management, information regarding illness and coping skills with regard to dealing with the stigma of mental illness and problem-solving skills. Although there are common elements, there are distinctive features like cognitive restructuring and self-rated mood charts in CBT, regulation of sleep/wake cycles and daily routines in IPSRT, communication skill training in family treatments. Therefore, the interventions can be distinguished by the degree of emphasis placed in a specific strategy.
Some psychosocial interventions like CBT, ,, and group PE, ,, are more effective when patient has recovered from the index episode, whereas IPSRT ,,,, and systematic care are more effective in moderately and acutely ill patients.
CBT was found to be more effective when the subjects are fewer than 12 episodes.  FFT and CBT has more impact on depression than manic symptoms, ,, whereas individual and group PE was more effective in reducing the length of manic than depressive episodes. ,,,,, The systematic care models showed a decrease in the duration of manic episodes, , decrease in manic symptoms  than in depressive symptoms.
Family interventions have targeted EEs which has a significant effect on the course of BD and found mixed results. , Group PE in comorbid substance use disorder,  personality disorder  has been found to be effective.
Psychosocial interventions have been found to be effective adjuncts to the pharmacological treatment in BD. The various interventions reviewed have shown improved outcome in the reduction of relapse rates, stabilization of episodes, and functioning. Although no particular intervention has shown to be more effective than others, positive effects of the interventions are very promising. There has been an only modest increase in costs of intervention considering the clinical benefits.
| Gaps and Limitations|| |
Gaps in our knowledge about therapy for BD mirror those that exist whenever new treatments, including medications, are introduced into routine clinical practice. Many of these key questions relate to differences between efficacy and effectiveness of adjunctive therapies, the long-term durability of any benefits and mechanisms by which therapies achieve their effects. The studies reviewed have mostly targeted various outcome variables and had different inclusion criteria for subjects, duration of treatment and follow-up, making it difficult to generalize.
Interventions concerning the psychological management of bipolar depression and maintenance psychological treatments are going to be the most difficult to implement because of shortages of skilled staff, the absence of specific training and supervision, the requirements for staff to adopt practices that are quite different from what they are used to, and some uncertainty about whether these interventions are effective in the most severe patients. A detailed local understanding of the barriers to implementation and the resources and will to overcome them is necessary.
Although some literature regarding psychosocial interventions in antenatal depression, postnatal depression and depression during pregnancy exists, there is a considerable dearth of literature with a specific focus to women in BD.
| Future Directions|| |
The research on the benefits of psychological therapies in BDs has progressed dramatically in the last decade. The researchers investigating chronic care models should implement pragmatic trials for deciding regarding most effective intervention in clinical practice. There should be studies planned for establishing biological correlates like neural structure and function before and after the administration of psychological interventions.
In India, where the psychotherapy for mental disorder is still a far cry due to lack of training in the field, shortage of time in dealing with a large number of patients, there is need for all of us to put in more effort for long-term benefits in a chronic, disabling illness like BD.
Future trials need to: (i) Clarify which populations are most likely to benefit from which strategies; (ii) identify putative mechanisms of action; (iii) systematically evaluate costs, benefits, and generalizability; and (iv) record adverse effects. The application of psychosocial interventions with specific focus to populations deserves further study. Keeping in view, the significant effect of the illness on both mother and the child due to illness and its management, studies especially focusing on bipolar women needs to be planned.
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Sujit Kumar Naik
Department of Psychiatry, Chhattisgarh Institute of Medical Sciences, Bilaspur - 495 001, Chhattisgarh
Source of Support: None, Conflict of Interest: None