Evidence-Based Reviews

Promoting treatment adherence in patients with bipolar disorder

Current Psychiatry. 2011 July;10(7):45-53

References

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Psychosocial strategies used in BD include psychoeducation, cognitive-behavioral therapy (CBT), family-focused interventions, and interpersonal and social rhythm therapy (IPSRT) (Table 3).^28-30 Psychoeducation alone or combined with other interventions can decrease the risk of relapse and hospitalization and improve adherence.²⁸ In a 2-year study of 50 euthymic BD patients treated with lithium who participated in a brief hospital-based psychoeducation program, Even et al³¹ found patients’ knowledge about lithium but not their attitudes changed significantly after the program. The changes persisted 2 years after the intervention, with a trend toward a decreased hospitalization rate.

Clinical Point

A meta-analysis found CBT had a medium effect size on adherence in bipolar disorder

Miklowitz³² reported on 293 BD patients randomized to receive collaborative care (3 psychoeducational sessions delivered over 6 weeks) or 1 of 3 types of intensive psychotherapy: CBT, IPSRT, or family-focused therapy. Attrition was similar for both groups. Compared with those receiving collaborative care, significantly more patients receiving intensive psychotherapy recovered after 1 year, and did so in shorter time.

In a 3-year, multi-site Veterans Administration (VA) study, 306 BD patients received psychoeducation and support from nurse care coordinators who were responsible for access, continuity of care, and information flow to psychiatrists or usual care according to VA guidelines.³³ Compared with the usual care group, patients who received psychoeducation and support from nurse care coordinators had shorter duration of manic episodes and improved function and quality of life. A meta-analysis³⁰ of 12 randomized controlled trials of CBT in BD showed a medium effect size of CBT on adherence at 6 months post-treatment.

Table 2

FDA-approved medications for adult bipolar disorder

Bipolar disorder indication	Medications
Acute treatment of mania/mixed episodes	Aripiprazole,^a,b asenapine,^a carbamazepine extended release,^a divalproex sodium,^a lithium,^a quetiapine,^a risperidone,^a-c ziprasidone^a,b
Depressive episodes	Olanzapine/fluoxetine,^a quetiapine^a
Maintenance treatment	Aripiprazole (as monotherapy and as adjunct to lithium or divalproex sodium),^a,b asenapine,^d lamotrigine,^a lithium,^a olanzapine,^a-c quetiapine (as adjunct to lithium or divalproex sodium),^a risperidone,^e ziprasidone (as adjunct to lithium or divalproex sodium)^a
^apill form ^bintramuscular for acute agitation ^cdisintegrating tablet ^dsublingual tablet ^elong-acting injectable

Table 3

Psychosocial interventions for bipolar disorder

Intervention	Description	Results in bipolar disorder	Optimal stage of illness for intervention
Individual and family psycho-education^28,29	Strategies to educate the patient about the illness, medications, side effects, and relapse prevention	Decreases relapse, (particularly manic episodes) and hospitalizations. Increases adherence	Manic episodes
Cognitive-behavioral therapy^28-30	Focuses on understanding patient’s perceptions of illness and treatment. Equates resistance with exploring, rather than challenging resistance to take medication. Identifies and modifies negative automatic thoughts about medication. Motivation techniques useful in comorbid substance use	Decreases clinical symptoms. Increases adherence, quality of life, and social functioning	Depressive episodes
IPSRT^28,29	Uses motivational interviewing and CBT techniques to stabilize daily routines and resolve interpersonal problems	Prevents relapse	Depressive episodes
Family-focused therapy^28,29	A combination of psychoeducation, communication, and problem-solving skills training	Reduces mood symptoms, number of depressive relapses, and time depressed. Increases adherence	Depressive episodes
IPSRT: interpersonal and social rhythm therapy

Related Resource

Deegan PE. The importance of personal medicine: a qualitative study of resilience in people with psychiatric disabilities. Scand J Public Health Suppl. 2005;66:29-35.

Drug Brand Names

Aripiprazole • Abilify
Asenapine • Saphris
Bupropion • Wellbutrin
Carbamazepine • Carbatrol, Tegretol
Carbamazepine extended- release • Equetro
Clozapine • Clozaril
Divalproex • Depakote, Depakote ER
Fluoxetine • Prozac
Fluvoxamine • Luvox
Lamotrigine • Lamictal
Lithium • Eskalith, Lithobid
Mirtazapine • Remeron
Olanzapine • Zyprexa
Olanzapine/fluoxetine • Symbyax
Paroxetine • Paxil
Quetiapine • Seroquel, Seroquel XR
Risperidone • Risperdal
Risperidone long-acting injectable • Risperdal Consta
Selegiline • Eldepryl, Emsam
Valproate • Depacon
Venlafaxine • Effexor
Ziprasidone • Geodon

Disclosures

Dr. Foster receives research/grant support from the American Psychiatric Foundation, the National Institute of Mental Health, and Sunovion Pharmaceuticals.

Dr. Sheehan and Ms. Johns report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.