Bipolar disorder is characterized by dramatic swings in mood
and energy levels, from very low depressive periods to extremely
high manic episodes. During periods of mania, people might
feel very “high,” have increased energy or activity levels, talk
quickly, be agitated and irritable, feel they can do many things
at once and do risky things such as spending recklessly or
engaging in unsafe sexual acts. Some people with the disease
experience less severe (but still potentially problematic) manic
periods known as hypomanic episodes. Symptoms most often
arise between the ages of 15 and 19, but the disease can begin in
childhood or as late as the 40s or 50s.
Mood-stabilizing medications such as lithium have long
been used to treat and prevent bipolar disorder’s dramatic
mood shifts, and for good reason. “Mood stabilizers appear to
be very important as a core element of treatment,” Otto says.
Many people with bipolar disorder take antidepressants in
addition to mood stabilizers, although two large studies have
suggested antidepressants may not be effective for treating
But medication isn’t the only solution. “Psychosocial
treatment deserves much more attention,” Otto says.
To date, researchers have demonstrated the effectiveness
of three varieties of psychosocial treatments as adjuncts to
medication for treating bipolar disorder:
• Cognitive behavioral therapy focuses on a person’s
thoughts and actions, and helps them change unhealthy
behavior patterns. It can help people cope with the
symptoms of bipolar disease and recognize signs of an
impending mood shift.
• Family-focused therapy, as the name suggests, heavily
involves family members in treatment. Alongside patients,
parents or spouses are taught to understand symptoms
and recognize warning signs of a looming manic or
depressive episode. Patients and family members also learn
communication skills and disease-management strategies.
• Interpersonal and social rhythm therapy aims to help
people improve their moods by working to stabilize a patient’s
sleep and other biological and social routines while improving
the quality of his or her interpersonal relationships.
(David Miklowitz, PhD, a psychologist at the UCLA Semel
Institute who specializes in family-focused therapy for bipolar
disorder, co-authored a review of the evidence for treatments of
bipolar disorder in The Lancet in 2013).
Long tail of disruption
While each of the three treatments takes a different approach,
they share many features. “What’s nice about these models is
that while they all have unique theoretical underpinnings, they
share some common core components,” says Tina Goldstein,
PhD, a psychologist at the University of Pittsburgh who
specializes in the treatment of youth with bipolar
One of those core components is
psychoeducation, which involves teaching the
patient (and often his or her family members)
about the symptoms of the illness, what
the course of the illness looks like and what
treatments are available.
Psychotherapy can also help patients adhere
to their medication regimens. Medication
adherence is a problem for many diseases, and
bipolar disorder is no exception. Risk factors for
poor adherence range from substance abuse and forgetfulness
to a belief that medications aren’t really necessary. “Some people
enjoy the hypomanic or manic periods and don’t want to ruin
them by taking medicines,” Miklowitz adds.
Research shows that worse adherence is more common in
the early stages after diagnosis, when acceptance of the disease
tends to be lowest. Psychologists can help patients and family
members accept both the diagnosis and the treatment.
Another important piece of psychoeducation is helping
patients and family members understand what other factors
affect the cycling of the disease. Stress, poor sleep, and drug or
alcohol use, for example, can all tip a person toward a bipolar
episode. “Making your patient an expert at managing stress,
getting regular sleep and regular exercise is such an important
element of treatment,” Otto says.
Early intervention and relapse prevention is another core
element. While psychosocial therapy can help treat bipolar
depression, Otto says, it’s not clear that it’s beneficial for treating
patients in the midst of a manic episode. Untreated, manic
episodes can last anywhere from days to months. Medications
are critical for bringing such episodes under control, Otto says.
Until patients’ moods have begun to stabilize with medications,
people aren’t typically receptive to illness management
strategies. Still, psychologists have an important role in teaching
Over the last decade, research has shown
that psychosocial therapy is an effective
treatment for the disease when combined
with mood-stabilizing medications.
Know the signs
APA’s Help Center offers “Recognizing the
signs of bipolar disorder.” Go to www.apa.org/