The *American Journal of Psychiatry* has just released an article
scheduled to appear in a future print edition of the journal:
“Adjunctive Psychotherapy for Bipolar Disorder: State of the Evidence.”

David J. Miklowitz, Ph.D. is the author.

Here’s how the article starts:

[begin excerpt]

Despite significant strides in the pharmacological treatment of bipolar
disorder, most bipolar patients cannot be maintained on drug treatments
alone. Up to 50% of bipolar I patients do not recover from acute manic
episodes within 1 year, and only 25% achieve full recovery of function
(1). Rates of recurrence average 40%-60% in 1-2 years even when patients
undergo pharmacotherapy (2). Patients spend as much as 47% of their
lives in symptomatic states, especially depressive states (3).
Furthermore, only about 40% of patients are fully adherent with
medication regimens in the year following an episode (4).

The ceiling on the effectiveness of pharmacotherapy has led to
systematic investigations of the role of environmental stressors, and
the corresponding role of adjunctive psychosocial treatments in the
course of the disorder. Stressful life events and high levels of
familial expressed emotion are robust predictors of mood recurrences and
delayed episode recovery in bipolar illness (5, 6). Furthermore, 17 of
18 randomized, controlled trials (Table 1) have shown that individual,
family, group, and systematic care treatments are effective in
combination with pharmacotherapy in delaying relapses, stabilizing
episodes, and reducing episode length.

Reviews (7-9) have concluded that psychoeducation is the active
ingredient in most forms of psychotherapy for bipolar illness: a
didactic, information-oriented approach to the illness. A close look at
the trials, however, reveals important differences in the content and
structure of the various treatments and significant differences between
studies in the targeted patient populations, the nature of the control
conditions, and the relevant outcome variables. Notably, some
psychosocial modalities emphasize early recognition of mood symptoms,
whereas others emphasize interpersonal relationships, communication
skills, and stress management. Some forms of psychotherapy are effective
when initiated during periods of sustained recovery, whereas other forms
are effective when initiated immediately after an acute episode.

This article will examine the evidence for adjunctive psychosocial
interventions for bipolar disorder, with a focus on five questions: 1)
which treatments work at which stages of the illness? 2) how long should
treatments last, and how enduring are their effects? 3) do the same
treatments modify depressive and manic symptoms? 4) which functional
domains (i.e., social, work, or family functioning or quality of life)
are enhanced? 5) By what mechanisms do psychosocial treatments operate?
The primary hypothesis is that treatments that emphasize medication
adherence and relapse prevention strategies are more effective in
controlling manic symptoms, whereas treatments that emphasize cognitive
and interpersonal coping skills are more effective in controlling
depressive symptoms.

[end excerpts]

Here’s how the Discussion section starts: “Psychotherapy is an effective
adjunct to pharmacotherapy in relapse prevention and episode
stabilization among bipolar patients. The active treatments reviewed
here are associated with 30% to 40% reductions in relapse rates over 12-
to 30-month periods. Although not as well studied, patients who receive
intensive psychosocial treatment have better functional outcomes than
those who receive routine pharmacological care over 1-2 year periods.
Beneficial effects of group, systematic care, family, CBT, and
interpersonal and social rhythm therapy approaches can be observed for
at least 1 year after their termination. Across studies, treatment
models containing 12 or more sessions consistently perform better than
comparison treatments of three or fewer sessions. Although no particular
modality emerged as superior to others, the results suggest that the
modalities operate through different change mechanisms, and in turn
affect different outcome variables.”

The author note states: “Address correspondence and reprint requests to
Dr. Miklowitz, Department of Psychology, Muenzinger Building, University
of Colorado, Boulder, CO 80309-0345; m i k l o w i t z [at] c o l o r a d o . e d u .”

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