0. Cognitive Behavioral Treatment of Bipolar Disorder
The original version of these slides was provided by
Michael W. Otto, Ph.D. with support from NIMH Excellence in Training Award at the Center for Anxiety and Related Disorders at Boston University
(R25 MH08478)

1. Use of this Slide Set
Presentation information is listed in the notes section below the slide (in PowerPoint normal viewing mode).
References are also provided in note sections for select subsequent slides

2. Diagnostic Considerations
Manic Episode
1 week high, euphoric, or irritable mood plus 3 (4) of the following:
exaggerated feelings of importance
little need for sleep
racing thoughts
pressured speech
distractibility
increased goal directed behavior (agitation)
reckless behavior
Hypomanic Episode
4 days of high, euphoric, or irritable mood plus 3 (4) symptoms (no impairment, psychotic features, need for hosp.)
DSM-IV criteria

3. Diagnostic Considerations
Bipolar I
At least one manic or mixed episode
May or may not have depressive episode, but most do (71% of sample)
3.5 more likely to have depressive symptoms than manic/hypomanic (Judd et al., 2002)
Bipolar II
At lease one hypomanic episode and one or more depressive episodes
38 times more likely to have depressive symptoms than hypomania (Judd et al., 2003)
Bipolar I vs II status is only inconsistently predictive of shorter term outcomes (cf., Judd et al., 2003; Miklowitz et al., 2007; Otto et al., 2006).
Bipolar episodes often emerge with several episodes of depression before emergence of an initial manic or hypomanic epidose (e.g., Suppes et al., 2001).
Even though manic or hypomanic episodes may not dominate (in terms of duration) the clinical picture as much as depression, manic episodes can still confer dramatic disability and insults to role functioning and quality of life due to the long term effects of select manic behaviors (e.g., devastating financial decisions, marital infidelity, anger episodes, drug-use behaviors).
Judd et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry Jun;59(6):530-7.
Judd et al. A prospective investigation of the natural history of the long- term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry Mar;60(3):261-9.
Judd et al.. The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders? J Affect Disord Jan;73(1-2):19-32.
Miklowitz et al. Intensive psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry Sep;164(9):
Otto et al., Prospective 12-month course of bipolar disorder in out- patients with and without comorbid anxiety disorders. Br J Psychiatry Jul;189:20-5.
Suppes et al. The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients.  Journal of Affective Disorders , 45 – 59.

4. Characteristics of Patients With Bipolar Disorder
Prevalence
1-2% of the population
Age of Onset
Late teens to early 20s (earlier age of onset is associated with a worse course; Perlis et al. 2006).
Sex Ratio
Equal, but more rapid cycling among women
Comorbidity
Anxiety, Substance Use, ADHD
Course
75% relapse 4-5 years, half in 1 year (the proportion of days ill predicts episode frequency the next year; Perlis et al., 2004)
The slide presents common course characteristics. However, some research groups propose more liberal definitions of bipolar disorder (and more bipolar subtypes) and report correspondingly higher rates of the disorder (Akiskal et al., 2000).
Akiskal et al. Re-evaluation the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. Journal of Affective Disorders (Suppl 1), 5s – 30s.
Perlis et al. Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry Feb;163(2):
Perlis et al. Long-term implications of early onset in bipolar disorder: Data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biological Psychiatry , 875 – 881.

5. Comorbidity in Bipolar Disorder (assessed in 1000 patients enrolled in STEP-BD)
These data are from the large-scale Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD); project. Bipolar disorder is associated with high comorbidty rates, particulary for anxiety and substance use disorders (with psychosis also occurring during episodes for some patients). Comorbid disorders have a clear cost to the course of disorder. For example, comorbid anxiety disorders are associated with a slower recovery from bipolar episodes, a higher likelihood of relapse, and lower quality of life/role functioning; with stronger associations with more than one anxiety disorder is present (Otto et al., 2006)
Kogan et al., Demographic and diagnostic characteristics of the first patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Bipolar Disord Dec;6(6):460-9.
Otto et al., Prospective 12-month course of bipolar disorder in out- patients with and without comorbid anxiety disorders. Br J Psychiatry Jul;189:20-5.
Kogan et al., 2004

6. Diagnostic Issues – Major Depression
Youth hospitalized for severe depression (young and severe) – 41% experienced manic/hypomanic episode over next 15 years (Goldberg et al., 2001)
Depression + Substance Use Disorder
Depression + Borderline Disorder
Depression + psychosis (schizoaffective disorder)
This slide is used to underscore the difficulty of making a bipolar diagnosis. Bipolar patterns may emerge over time in individuals who initially had only unipolar depression. Also, depression plus substance use disorders, psychosis, or borderline personality disorder may add apparent hypomanic or manic symptoms to the clinical picture. Differentiation of the comorbid unipolar conditions from bipolar disorder takes time and effort, and at times (given proper consent), use of additional information providers such as family members.
Goldberg et al. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry Aug;158(8):

7. Presentation with Psychosis
Is it mania?
Schizophrenia?
Substance Induced?
Schizoaffective?
History and family help
Similar to the last slide, some of the diagnostic challenges to a bipolar diagnosis are listed here.

8. An Abundance of Distress and Disability
Family, job, personal
Post-episode studies
6 months after: 30% unable to work; only 21% worked at their expected level (Dion et al., 1988)
1.7 years after hospitalization: 42% had steady work performance (Harrow et al., 1990)
Relatively high rates of suicide in bipolar disorder (predicted prospectively by days depressed and previous attempts; Marangell et al., 2006)
Dion et al. Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hosp Community Psychiatry Jun;39(6):652-7.
Harrow et al. Outcome in manic disorders. A naturalistic follow-up study. Arch Gen Psychiatry Jul;47(7):
Marangell et al. Prospective predictors of suicide and suicide attempts in 1,556 patients with bipolar disorders followed for up to 2 years. Bipolar Disord Oct;8(5 Pt 2):

9. Psychosocial Treatment

10. Topics
What is the evidence for the efficacy of psychotherapy for bipolar disorder?
What are the targets of treatment?
What are the elements of treatment?
In recent years, there has been increasing research on the role of psychosocial variables in shaping the course of bipolar disorder (BPD). BPD may have rich biologic underpinnings, but psychosocial variables can play a significant role in determining the course of the disorder, and the ultimate treatment outcome. This section provides an overview of the role and outcome of adjunctive psychotherapy for the management of bipolar disorder. 1

11. Psychosocial Treatment for Bipolar Disorder
Initial Encouragement:
Psychosocial Predictors of Bipolar Course
Incomplete Efficacy of Mood Stabilizers
Practice Characteristics
Majority of bipolar patients are engaged in some sort of psychosocial care
Direct Evidence
Promising outcomes from well-controlled trials
BPD may have rich biologic underpinnings, but psychosocial variables can play a significant role in determining the course of the disorder, and the ultimate treatment outcome.
In the last two decades, psychosocial treatments have emerged as a new and important force for the management of bipolar disorder. Prior to this recent period of growth, psychosocial treatment for bipolar disorder was relegated to a supportive role or a strategy to enhance medication adherence. Encouraged both by the limits of the efficacy of pharmacotherapy alone, and by evidence of a significant role for psychosocial stress and interpersonal issues in altering the course of bipolar disorder, new structured and focused psychosocial treatments for bipolar disorder have emerged, been studied, and have shown promising outcomes. 1

12. Role of Psychosocial Factors in Bipolar Disorder
Psychosocial stressors impact the course of bipolar disorder:
Family stress (expressed emotion)1
Negative life events 2
Cognitive style 3
Sleep disruptions 4
Anxiety comorbidity 5
1 Miklowitz et al. (1988)
2 Johnson & Miller, (1997); Ellicott et al. (1990)
3 Reilly-Harrington et al., 1999
4 Malkoff-Schwartz et al. (1998)
5 Simon et al. (2004); Otto et al. (2006)
Despite the biological orientation toward bipolar disorder, psychologic stressors have been shown to be significant predictors of outcome. Four key variables are: family stress, negative life events, cognitive style, and sleep disruptions.
The quality of family relationships appears to be a strong predictor of outcome in bipolar disorder. Specifically, family relationships that are characterized by high levels of expressed emotion (EE) appear to be particularly predictive of poor outcome.
EE is a measure of family dysfunction that refers to critical or hostile attitudes of emotional over involvement exhibited toward a psychiatrically ill family member by key family members.
In 2 longitudinal, prospective studies, Miklowitz and colleagues found that after an index manic episode, patients who returned to a family that exhibited high levels of EE were 5 times more likely to relapse over a 9- to 12-month period than were those who returned to low-EE families. This finding was an independent correlation; it was not affected by demographics, medication regimen, adherence, or number of previous episodes. 2

13. Pharmacotherapy for Bipolar Disorder
Advances in the field, but among patients taking medications:
Half relapse first year
Three-quarters relapse over several years
Continued role impairment between episodes
Poor medication adherence
(Gitlin et al., 1995; Keck et al., 1998; O’Connell et al., 1991; Tohen et al., 1990) 2

14. Focused Psychosocial Treatments for Bipolar Disorder
The product of diverse theoretical orientations, but with a high degree of similarity in strategies.
In particular, randomized trials have shown support for
Cognitive Behavioral Therapy (CBT)
Interpersonal and Social Rhythm Therapy (IPSRT)
Family-Focused Treatment (FFT)

15. Common Treatment Elements Among CBT, IPSRT, FFT
Psychoeducation providing a model of the disorder and risk and protective factors (e.g., the role of sleep and lifestyle regularity).
Communication and problem-solving training aimed at reducing familial, relationship, or external stress.
Review of strategies for the early detection and intervention with mood episodes (including increased support, pharmacotherapy, more-frequent monitoring).

16. Some of the Influential, Psychosocial Clinical Trials
Medication adherence1
Detection of prodromal episodes, early intervention2
Individual CBT for Relapse Prevention3
Individual IPSRT for Relapse Prevention4
Family Interventions for Relapse Prevention5
Group Psychoeducation for Relapse Prevention6
Individual CBT for Episode Treatment 7
Intensive CBT, IPSRT, or FFT for Bipolar Depression 8
Three specific types of psychotherapy show evidence of efficacy in bipolar treatment: Cognitive-Behavioral Therapy (CBT), Family-Focused Treatment (FFT), and Interpersonal and Social Rhythm Therapy (IPSRT). In addition, structured group psychoeducation has shown efficacy (Colom et al., Br J Psychiatry, 2009; Parkh et al., J Clin Psychiatry, 2012).
Clarkin J., Carpenter, D., Hull, J., Wilner, P., & Glick I. (1998). Effects of a psychoeducational intervention for married patients with bipolar disorder and their spouses. Psychiatric Services, 49, 531 – 533.
Cochran, S. (1984). Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. Journal of Consulting and Clinical Psychology, 52, 873 – 878.
Frank, E., Kupfer, D., Thase, M., Mallinger, A., Swartz, H., Fagiolini, A., et al. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62, 996 – 1004.
Lam et al. Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention - a systematic review. Bipolar Disorder 2009, 11(5):
Lam, D., Bright, J., Jones, S., Hayward, P., Schuck, D., Chisholm, D., & Sham, P. (2000). Cognitive therapy for bipolar illness – A pilot study of relapse prevention. Cognitive therapy and Research, 24, 503 – 520.
Lam, D., Watkins, E., Hayward, P., Bright, J., Wright, K., Kerr, N., et al. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60, 145 – 152.
Miklowitz et al. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program. Arch Gen Psychiatry Apr;64(4):
Miklowitz et al. Intensive psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry Sep;164(9):
Miklowitz, D., George, E., Richards, J., Simoneau, T., & Suddath, R. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904 – 912.
Rea, M., Tompson, M., Miklowitz, D., Goldstein, M., Hwang, S., & Mintz, J. (2003). Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 71, 482 – 492.
Scott, J., Garland, A., & Moorhead, S. (2001). A pilot study of cognitive therapy in bipolar disorders. Psychological Medicine, 31, 459 – 467.
Scott, J., Paykey, E., Morriss, R., Bentall, R., Kinderman, P., Johnson, T., et al. (2006). Cognitive-behavioral therapy for severe and recurrent bipolar disorders. British Journal of Psychiatry, 188, 313 – 320.
1. Cochran (1983)
2. Perry et al. (1999)
3. Lam et al. (2000), Lam et al. (2003); Scott et al. (2001)
4. Frank et al. (1997); Frank et al. (1999)
5. Miklowitz et al. (2003); Rea et al. (2003); Simoneau et al. (1999); also Clarkin et al. (1998)
6. Colom et al. (2003)
7. Scott et al. (2006)
8. Miklowitz et al. 2007 5

17. Cognitive-Behavioral Therapy (CBT) for Medication Adherence (Cochran, 1984)
Relapse Prevention
6 sessions of adjunctive CBT vs standard clinical care4
At end point and at 6-month follow-up, CBT patients had
Greater medication adherence
Lower hospitalization rates
Cognitive-behavioral therapy (CBT) has a long history of successfully treating unipolar depression, and more recent evidence suggests that it is effective in severe and treatment-resistant cases as well. For example, Fava et al (1997) applied CBT to a small sample of unipolar depressed patients who failed to respond to pharmacotherapy and achieved a 63% response rate with high maintenance of treatment gains during the next 2 years. CBT has also been successfully applied to severely depressed inpatients. These and other findings with severe unipolar depression provide some encouragement that CBT can be successfully applied to the depressed phase of bipolar disorder.
An early application of CBT to bipolar depression was published by Cochran in She examined the outcome of a brief (6-session) program of CBT that focused primarily on aiding adherence to medication. Adjunctive CBT was found to improve adherence significantly and was associated with a lower hospitalization rate at the end of the treatment trial and at a follow-up assessment 6 months later. From the perspective of managed care, these are potentially dramatic results, where the investment in 6 sessions of outpatient treatment results in the saving of hospitalization costs later.
Cochran S. J Consult Clin Psychol. 1984;52: 6

18. Lam et al. - An Early CBT Success
103 bipolar patients randomized to CBT or TAU
12-18 sessions individual CBT
Information
Monitoring of mood & cognitions (early intervention)
Management of sleep and routine
Attention to “making up for lost time”
8 dropout in each condition
TAU: Treatment As Usual
It is interesting that Lam et al. designated making up for lost time as a target for intervention, underscoring the potential importance of this maladaptive strategy of trying to make up for the cost of mood disorders and related disability – a strategy that potentially adds great stress and extra meaning to goal pursuit and goal frustrations.
Lam et al., 2003, Arch Gen Psychiatry, 60:

19. Medication Adherence Percent of Patients
Medication adherence was enhanced by CBT, but this is not the source of the effects noted on the next slide (medication use was statistically controlled).
Lam et al., 2003, Arch Gen Psychiatry, 60:

20. Clinical Outcome (days ill over 1 year)
Mean Days in Status
Lam et al., 2003, Arch Gen Psychiatry, 60:

21. Survival Analysis (N = 103)
Lam et al., 2003, Arch Gen Psychiatry, 60:

22. Family-Focused Treatment
Elements
Psychoeducation about bipolar disorder
Communication-enhancement training
Problem-solving training1
Outcome
Adjunctive FFT appears to effect1
Depressive symptoms
Manic symptoms
Rehospitalization times
Another psychotherapeutic approach, family-focused treatment (FFT) utilizes the family in treatment. Treatment goals include psychoeducation, communication-enhancement training, and problem-solving training, with all of these treatment efforts aimed primarily at reducing expressed emotion in the families of patients with bipolar disorder. It is important to keep in mind that expressed emotion is an identified risk factor for relapse in bipolar disorder.
As compared to a case management control condition at a 2-year follow-up assessment, FFT was found to offer significant protection against relapse, with reductions in both poles of the disorder (although changes were greater for depressive than manic symptoms) as well as increased time to rehospitalization. Interestingly, these benefits of treatment were not linked with changes in expressed emotion; apparently, other elements of treatment (e.g., education, problem solving, etc) may mediate the treatment effects.
Miklowitz DJ, et al. Arch Gen Psychiatry. 1988;45: 10

23. Cumulative Survival Rate
1-Year Survival Rates Among Bipolar Patients in Family-Focused Treatment versus Case Management
Miklowitz DJ, et al. Arch Gen Psychiatry. 1988;45: 1
CM, N=51
FFT,N=28
0.8
0.6
Cumulative Survival Rate
0.4
0.2 5 10 15 20 25 30 35 40 45 50 55
Week of Follow-Up
Wilcoxon Test, c2 (1) = 4.4, p = .035

24. Six Objectives of FFT Help the patient and her or his relatives to:
Understand the nature of bipolar disroder and cyclic mood disturbances.
Accept the concept of vulnerability to future episodes
Accept a crucial role for mood-stabilizing medication for symptom control
Distinguishing between personality and bipolar disorder
Recognize and develop coping skills for managing the stressful life events that trigger recurrences of bipolar disorder
Reestablishing role and interpersonal functioning after a mood episode

25. Interpersonal and Social Rhythm Therapy
Educate patient about bipolar disorder
Identify current interpersonal problem areas (e.g., grief, disputes, role transitions, interpersonal deficits)
Initiate social rhythm metric
Frank et al. Biological Psychiatry
A third “brand” of psychotherapy is Interpersonal Social Rhythm Therapy (IPSRT). This treatment combines traditional elements of Interpersonal therapy (targeting resolution of difficulties in interpersonal relationships) with attention to tracking of daily events. This “social rhythm metric” is used to help patients keep track of daily events such as activities, sleep, eating schedule, etc.
Initial results were recently presented by Ellen Frank, PhD, and suggest that IPSRT may help protect bipolar patients from depressive relapse. 11

26. Group Psychoeducation vs. Standard Care
21 Weeks of Randomized Treatment, 2-year follow-up
120 outpatients in remission for 6 months
Standard Care
Treatment algorithms
Monthly sessions
Serum levels of medications assessed
Group Treatment minute sessions
Outcome
Recurrences at endpoint: 38% in group vs. 60% in SC
Recurrences at 2 years: 67% in group vs. 92% in SC
Colom F, et al. Arch Gen Psychiatry. 2003;60: 5

27. Psychoeducation? Psychoeducation What is bipolar illness Symptoms
Treatments
Serum levels
Early detection of episodes
Risk reduction - substance use
Lifestyle regularity
Stress management
Problem solving
This was a VERY ACTIVE and STRUCTURED psychoeducation program. Note the elements of treatment. This treatment should be differentiated from other psychoeducation programs that offer education alone.
Long term follow-up data is also encouraging for this structured psychoeducation, as per the following study:
Colom et al. Group psychoeducation for stabilised bipolar disorders: 5-year outcome of a randomised clinical trial. Br J Psychiatry Mar;194(3):260-5.
Colom F, et al. Arch Gen Psychiatry. 2003;60: 5

28. CBT, IPSRT, FFT vs. Collab Care for Bipolar Depression Miklowitz et al
CBT, IPSRT, FFT vs. Collab Care for Bipolar Depression Miklowitz et al., 2007, Archives Gen Psychiatry
In this study, a total of 293 outpatients with bipolar I or II disorder and depression and treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n = 130), a brief psychoeducational intervention.
This study is especially important, because intensive psychosocial treatment (CBT, IPSRT, or FFT) succeeded where pharmacotherapy did not, that is, once patients were on a mood stabilizer, adding an antidepressant did not improve outcome (Sachs et al., 2007), whereas adding intensive psychotherapy did (above).
Miklowitz et al. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program. Arch Gen Psychiatry Apr;64(4):
Sachs et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med Apr 26;356(17):

29. No Significant Differences Among the Intensives: CBT, IPSRT, FFT

30. Given this Evidence... ...What are Some Targets for Psychotherapy?
Medication adherence
Early detection and intervention
Stress and lifestyle management
Treatment of bipolar depression
Treatment of comorbid conditions
In summary, there is a variety of evidence encouraging the application of psychosocial treatments to bipolar disorder.
Psychosocial events are potential moderators of episode onset.
Trial data provides consistent support for the efficacy of select psychotherapies for bipolar disorder.
Given this evidence, attention should be directed to the following:
Medication adherence
Early detection and intervention of episodes
Relapse risk factor (stress and lifestyle management)
Treatment of bipolar depression
Treatment of comorbid conditions 12

31. Medication Non-Adherence in Mood Disorder
98 patients taking mood stabilizers (80% bipolar)
50% non-adherence rate last year
30% non-adherence last month (<70% adherent)
Predictors of non-adherence:
denial of severity of illness
previous non-adherence
greater illness duration
(Scott & Pope, 2002, J Clin Psychiatry, 63: ) 12

32. Relapse Prevention Patient as cotherapist Treatment contract
Training in early detection
Use of treatment team
Relapse prevention efforts are aided by making the patient a full member of the treatment team. The goal is to help the patient act as his or her own therapist, planning in euthymic periods for difficult times. This plan is aided by rehearsal of early detection of manic and depressive episodes, and rehearsal of early intervention strategies for every member of the treatment team. Treatment manuals emphasizing this approach include:
Otto et al. (2009). Managing bipolar disorder: A cognitive-behavioral approach (Therapist guide).
Otto et al. (2011). Living with bipolar disorder (expanded edition). New York: Oxford University Press.New York: Oxford University Press. 14

33. Individualized Treatment Contract
Why contract?
Formulate a plan for the future
How I know I am depressed
Plan during depression
I am manic when…
Plan during mania (include who initiates the plan)
Other modules
Substance abuse, Bulimia, Gambling, Budget, etc
One method to guide the patient’s relapse-prevention efforts is to use a treatment contract. Most importantly, this enables patients to participate in treatment planning and allows them to exercise choice and control. Elements of a treatment contract used in the Massachusetts General Hospital Bipolar Program include:
An introduction that clarifies the purpose of the contract (organization of the patient’s care). The patient initiates this process by selection of members of her/his treatment team (those people that she/he can rely on to help during difficult periods).
Identification (using a check list) of signs of hypomania.
Identification (using a check list) of signs of depression.
Specification of a plan for early action by the patient (e.g., call the psychiatrist, limit alcohol use, apply therapy skills).
Specification of a support person plan for early action (eg, call the psychiatrist, take away credit cards, take away keys).
Signature bars for the patient and her/his treatment team.
An example contract can be found in: Otto, M. W., Reilly-Harrington, N. A., Knauz, R. O., Henin, A., Kogan, J. N., & Sachs, G. S. (2011). Living with bipolar disorder (expanded edition). New York: Oxford University Press. 15

34. Mood Charting
Enables early and accurate identification of changes in mood
Allows for early intervention prior to severe episodes
Tracks medication doses and adherence to psychological treatment
Tracks hours slept and sleep/wake times
Notes daily psychosocial stressors that may serve as triggers for relapse
Mood monitoring is another strategy to aid the patient in becoming a more active agent in her/his care. Mood monitoring informs both the patient and clinician about changes in mood, and may be used to signal early therapeutic action.
It is important to monitor medication dosages, sleeping habits, and daily stressors. 16

35. Strategies for Hypomania
Explore medical solutions (e.g., dosage or medication changes)
Counteract impulsivity
Give car keys or credit card to someone to hold
“Make rules” about staying out late or giving out phone number
Avoid alcohol and substance use
Minimize stimulation
Avoid confrontational situations
Newman et al. Bipolar disorder: A Cognitive Therapy Approach. 2001
Cognitive-behavioral therapy (CBT) can then be applied to any of a number of problem areas, including the discussion and rehearsal of safety strategies to detect and interrupt a hypomanic episode at its inception. 18

36. Review of symptoms, progress, and problems Construction of the agenda
Cognitive-Behavioral Therapy for Bipolar Depression/Relapse Prevention Structure of Sessions
Review of symptoms, progress, and problems
Construction of the agenda
Discussion, problem solving, rehearsal
Consolidation of new information/strategies
Assignment of home practice
Troubleshooting of homework (including signposts of adaptive change)
. The term “signposts” refers to the indicators of adaptive change. Often, doing something new in response to old cues may leave patients feeling vaguely anxious or odd. Helping patients to persist in new patterns despite these feelings offers the potential of speeding therapeutic change.
The next series of slides are drawn from:
Otto, M. W., Reilly-Harrington, N. A., Kogan, J. N., Henin, A., Knauz, R. O., & Sachs, G. S. (2009). Managing bipolar disorder: A cognitive- behavioral approach (Therapist guide). New York: Oxford University Press.
Otto, M. W., Reilly-Harrington, N. A., Kogan, J. N., Henin, A., Knauz, R. O., & Sachs, G. S. (2009). Managing bipolar disorder: A cognitive- behavioral approach (Workbook). New York: Oxford University Press.

37. Cognitive Restructuring and Skill Acquisition
Education (role and nature of thoughts)
Self-monitoring of thoughts
Identification of errors
Substitution of useful thoughts
Core beliefs and strategies
Skill acquisition
Assertiveness
Communication skills
Problem solving
Cognitive restructuring in bipolar depression looks like cognitive restructuring for unipolar depression. Indeed, there is evidence that standard unipolar depression strategies offer benefit to bipolar patients (Zaretsky et al, 1999, Canadian J Psychiatry, 44, ).
In cognitive-restructuring, thoughts are treated as “guesses” about the world and patients are taught to examine the evidence for or against a thought. Periods of negative moods are used to cue formal cognitive restructuring. In addition, attention is devoted to the development of more useful thinking (self-coaching) strategies. For patients with bipolar disorder, extra attention is devoted to the identification of hypomanic thinking patterns as a cue for restructuring and additional therapeutic attention.
Cognitive-behavioral therapy is a therapy of doing, and care is taken to ensure that patients have adequate skills for the demands of life. In many ways, bipolar patients must become experts at managing interpersonal stress as part of their overall therapeutic efforts. 20

38. Cognitive Restructuring
Examine the evidence for the thought
Generate alternative explanations
De-catastrophize
Debunk “shoulds”
Find the logical error
Test out its helpfulness

39. Questions Used to Formulate Rational Response
What is the evidence that the automatic thought is true? Not true?
Is there an alternative explanation?
What is the worst that could happen? Would I live through it?
What’s the best that could happen?
What’s the most realistic outcome?

40. Questions Used to Formulate Rational Response (Cont’d)
What is the effect of my believing the automatic thought?
What is the cognitive error?
If a friend was in this situation and had this thought, what would I tell him/her?

41. Respecting Hot Emotions
Interventions are in relation to, not in spite of, the patient’s current mood.
Train emotional regulation skills
Gain access to mood-state dependent cognitions

42. Activity Assignments: Bipolar Disorder
Management of sleep
Management of over/under activity
Management of destructive activities (substance use)
Resetting goals given limitations due to the disorder

43. Activity Assignments - 1
Independent Intervention or used in conjunction with cognitive restructuring
Help ensure that therapy is not over- focused on thinking rather than doing
Often requires a problem-solving analysis to understand patterns of over- and under- activity relative to the patient’s values

44. Activity Assignments - 2
Monitor current Activities
For change:
Start small (where the patient is)
Be specific
Rehearse elements in session
Define outcome objectively
Troubleshoot problems and signposts
Review cognitions (expectations, concerns)

45. Activity Assignments - 3
Review performance relative to objective criteria (and the degree of mood disturbance)
Assess the patient’s cognitive and emotional response to the assignment
Discuss further applications

46. Well-Being Therapy Phase
In this phase, therapeutic effort and monitoring is devoted to increasing periods of well being rather than reducing pathology.
It provides a way to consolidate gains around positive outcomes
An excellent strategy for fading out treatment
For more information on a well-being approach see: Fava & Ruini Development and characteristics of a well-being enhancing psychotherapeutic strategy: well-being therapy. J Behav Ther Exp Psychiatry Mar;34(1):45-63.
For application of a well-being phase to the treatment of bipolar disorder see: Otto et al(2009). Managing bipolar disorder: A cognitive-behavioral approach (Therapist guide).

47. End of Treatment Patient has skills to act as his or her own therapist
Patient focuses on well-being
Therapist contact fades 22

48. Cognitive-Behavioral Therapy for Comorbid Disorders
Anxiety disorders
Substance use disorders
Eating disorders
Treatment of comorbid conditions is a potential strategy for relapse prevention in bipolar disorder. Cognitive-behavioral therapy (CBT) has an impressive track record in managing some of the comorbid conditions that affect bipolar patients.
CBT is encouraged not only because it has among the highest effect sizes in the outcome literature for these conditions, but because it avoids medication complications specific to bipolar patients.
However, controlled trials of the effects of these interventions on the course of bipolar disorder are lacking. 21

49. New Directions in CBT for Bipolar Disorder Promoting Emotional Tolerance
Getting better with the rollercoaster of emotions
Learn to apply emotional acceptance plus problem solving in the context of strong emotions (anxiety, sadness, euphoria)
Initial evidence for mindfulness training in bipolar disorder – improvements in mood and cognitive symptoms
(Deckersbach et al., 2012, CNS Neurosci Ther).