The present study is best conceptualized as a content analysis of modern, empirically-supported psychosocial interventions for bipolar disorder. Through a survey of 31 principal investigators and clinicians who worked on the 14 randomized trials of adjunctive psychotherapy published between 1999 and 2007, we were able to identify key treatment ingredients that did and did not statistically distinguish between cognitive-behavioral, family, interpersonal, group psychoeducational, individual psychoeducational, and control treatments.
There were two treatment ingredients that characterized nearly all of the active treatments compared with TAU, notably, problem-solving about community functioning and strategies to cope with the stigma of mental illness (e.g., how to explain the disorder to other people). Thus, the core components of modern psychosocial approaches to bipolar disorder attempt to enhance the goals of pharmacotherapy by teaching coping skills for managing psychosocial stressors, recurrences, and the social stigma of the disorder.
Other ingredients distinguished specific treatments from one another. Not surprisingly, cognitive restructuring and behavioral activation clearly separated CBT from the other interventions. Sleep/wake cycle stabilization and regularization of daily routines were most closely associated with IPSRT, although CBT and group psychoeducation also emphasized sleep and lifestyle regularity. As expected, communication training was mainly a feature of the family interventions. Communication training was originally introduced into family psychoeducation models as a way of altering high levels of expressed emotion and/or negative family interactional behavior, which are associated with poorer prognoses in bipolar disorder and schizophrenia.25,26
The content of the control interventions (especially when provided as TAU) is rarely described in detail in the publications from these trials. TAU appears, on average, to contain some of the ingredients of active treatments, including psychoeducation about medications, adherence, and side effects; and community advocacy (e.g., facilitating the patient’s communication with the treating psychiatrist). While these ingredients are clinically sensible and important, the present study suggests that, when used alone, they do not have a sufficient impact to yield the augmented effects seen with the investigational treatments. Moreover, TAU interventions were most clearly distinguished from the active interventions by the absence rather than the presence of certain key ingredients. These included teaching patients to solve problems regarding stressful life events, to better cope with the stigma of mental disorders, to communicate effectively, to challenge dysfunctional cognitions, to regulate sleep/wake cycles, to track symptom fluctuations through a mood chart, and to develop relapse prevention plans. These components, therefore, are candidates for the “active ingredients” by which the experimental interventions may confer augmented clinical benefits compared to TAU.
This study had several limitations. First, the data were obtained through self-reports from investigators and clinicians regarding the therapeutic ingredients that they believed constituted the active treatments at their sites. Investigators and primary clinicians are probably the most reliable sources of information about the content of manual-based psychosocial interventions as actually delivered in randomized trials. We did not, however, directly observe treatment sessions or rate session audiotapes for adherence to the clinicians’ manuals. Hence, the data may reflect what the respondents believe treating clinicians should have done to be in accord with the manuals, rather than what they actually did. Of course, observer ratings of session audiotapes can introduce other biases. For example, an observer can miss the clinical context that kept a clinician from introducing a particular intervention in a session, such as when a clinician avoids assigning behavioral activation tasks to a depressed patient who has previously voiced feeling like a failure when performing these tasks.
Secondly, the questionnaire may not have adequately assessed subtleties in the ways that interventions were delivered across the modalities and sites. Although most of these group, family, and individual treatments are associated with clear, rigorous, and well-operationalized manuals (e.g., 6-9,22
), practice often varies considerably even within a manualized protocol. The ratings of personal practice may have been contaminated to a greater or lesser degree by social desirability effects. A study of evidence-based psychosocial interventions in community settings, among clinicians who did not rely on treatment manuals, might have yielded different results.
Third, we did not assess nonspecific factors such as the quality of the therapeutic alliance, which has been identified as a key element in outcomes of psychotherapies and pharmacotherapy for unipolar depression or psychosis.27-29
We also did not examine personal characteristics of the therapists—such as age, gender, theoretical orientation, or previous experience with research protocols—that might have influenced the degree to which clinicians emphasized one feature over another in implementing manual-based treatments.
Fourth, the fact that a clinician identified an ingredient (e.g., use of mood charting, relapse prevention planning) as a key characteristic of treatment (e.g., in CBT) does not necessarily suggest that this ingredient was clinically valuable for patients, or that the treatment operated through this mechanism. We did not examine the clinical effectiveness of specific therapeutic foci and procedures, which would be necessary in order to enhance the power of our current approach.
Finally, the results from randomized trials suggest that these active psychosocial treatments differ in their relative impact on the depressive versus the manic pole of the disorder. Specifically, FFT and CBT appear to have a greater impact on depressive than manic symptoms,5,6,8,19
whereas individual and group psychoeducational approaches appear more effective in reducing the length of manic than depressive episodes.9,11-13,17
Future studies should attempt to identify the core ingredients of treatments as a function of their relative impact on the polarity of episodes.
Despite these limitations, the findings presented here are a first step towards allowing clinicians to choose among the variety of strategies described in evidence-based treatments. They also provide direction to investigators wishing to develop or revise psychosocial interventions for bipolar disorder. Specifically, education about signs and symptoms, reviewing medications and expected side effects, and community advocacy are not likely to be sufficient for maximal impact, whereas problem-solving about specific psychosocial stressors and anti-stigma components are likely to augment treatment effects over those of care as usual. Moreover, specific treatment components (e.g., sleep/wake cycle stabilization, cognitive restructuring, mood charting, relapse prevention planning, family communication training), when incorporated into a desired treatment orientation (e.g., cognitive, family, interpersonal, or group or individual psychoeducation) may augment the power of these modalities.
More systematic prospective measurement of the process variables in any intervention would greatly inform the design of the next generation of treatment/outcome studies. Ideally, future studies would examine specific strategies at the individual patient level to determine what interventions were most helpful at which stages of the disease process. Possibly, a treatment representing an amalgam of the most effective core interventions for bipolar disorder at various stages of the illness would prove more effective than any of the specific treatments studied to date in single-center trials.5,30