Psychosocial Interventions in Bipolar II Disorder

10 Psychosocial Interventions in Bipolar II Disorder

Danielle M. Novick, Ph.D.

Holly A. Swartz, M.D.

Bipolar II disorder (BD II) is a challenging psychiatric condition with unmet somatic and psychosocial treatment needs. Characterized by a depression burden that exceeds that of bipolar I disorder (BD I) (Dell’Osso et al. 2017), BD II is associated with significant morbidity (Forte et al. 2015) and impairment (Solé et al. 2012). Although many individuals seeking treatment for BD II turn to medication first, evidence-based pharmacotherapy options for BD II are limited (Swartz and Thase 2011). Thus, it is important to consider also the role that psychosocial interventions may play in the management of BD II. In this chapter, we present a rationale for using psychotherapy for adults with BD II, either alone or in combination with pharmacotherapy. Next, we provide an overview of the current evidence supporting the efficacy of different psychotherapies in BD II and discuss the results of our systematic literature review, which focused on identifying randomized controlled trials (RCTs) of psychotherapy including individuals with BD II. We then present a case example and clinical recommendations and conclude with a discussion of our review.

Rationale for Psychotherapy in Bipolar II Disorder

There are compelling reasons to consider psychotherapy as a principal tool in the management of BD II, either alone or as an adjunctive to pharmacotherapy. Because of its fluctuating course and the predominance of depressive episodes over hypomania, BD II is difficult for both patients and providers to understand and therefore recognize (see Chapter 1, “Diagnosing Bipolar II Disorder”). As a result, the illness may go undiagnosed for decades (Ghaemi et al. 2000). Individuals may have trouble distinguishing hypomania from euthymia (Perlis 2005), and they may struggle to develop a core sense of self (Inder et al. 2008). Functional impairments associated with the disorder may be severe (Rosa et al. 2010), resulting in substantial and persistent vocational and interpersonal difficulties. Psychotherapy targets all these domains.

Psychotherapy interventions that help individuals to understand the symptoms and course of BD II may enable individuals to manage their illness more effectively through early recognition of episodes and acquisition of strategies to target both symptoms and functioning. Interventions that help individuals develop skills needed to manage the psychosocial, neurocognitive, vocational, and interpersonal consequences of BD II may decrease illness burden and limit associated impairment. Finally, individuals may prefer psychotherapy to pharmacotherapy (McHugh et al. 2013), and, unlike for individuals with BD I, psychotherapy alone may be a reasonable alternative for some with BD II (Swartz et al. 2018). Thus, there is a compelling rationale to incorporate psychotherapy into a management plan for BD II.

Overview of Evidence Supporting Efficacy of Psychotherapy for Bipolar II Disorder

Data supporting the efficacy of bipolar-specific psychotherapies as treatments for BD II are limited. To date, there have been only four reports from randomized controlled trials of psychosocial interventions that focus exclusively on individuals with BD II (Colom et al. 2009a, 2009b; Solé et al. 2015; Swartz et al. 2012a, 2018). Because of the dearth of studies on this topic, we must rely on information garnered from trials that include subsets of individuals with BD II, in addition to those diagnosed with BD I or other bipolar disorders. Data derived from these “hybrid” trials can be used to infer information about the role of psychotherapy in the management of BD II and inform current practice as we await additional studies focused specifically on BD II populations. Our evaluation of the extant literature, therefore, necessarily relies on both “BD II–only” studies and those that include a subset of individuals with BD II.

Psychotherapy Treatments for Bipolar II Disorder: Systematic Literature Review of Randomized Controlled Trials

To better understand the role of psychotherapy for BD II, we conducted a systematic literature review of all RCTs, focused on adults (age ≥18), including acceptability and feasibility studies. We conducted searches using the search terms “bipolar disorder” and “psychotherapy” by applying Boolean algorithms with PsycInfo databases. Results were restricted to those published between January 1, 2014, and February 1, 2018, in a journal, in the English language, and focused on adults. We restricted the lower limit of the search parameters for publication date to January 1, 2014, since we previously conducted a review of psychotherapy for all bipolar disorder subtypes that covered the period through December 31, 2013 (Swartz and Swanson 2014), and could easily combine prior results with the current search results. We identified 69 studies relevant for inclusion. Since we were particularly interested in the BD II subset, when information was not reported for the sample by subtype, we contacted the corresponding authors of relevant manuscripts to request outcomes by subtype. Fifty-three percent (15/28) of authors contacted responded to our request for additional information. We further limited the sample to studies in which ≥10% of the sample met criteria for BD II and included at least 10 participants with BD II. After applying these criteria, we included in the review 35 reports of 27 RCTs. Results of these trials are summarized in Table 10–1, and detailed information about individual studies is provided in the text for those trials in which results were reported separately for BD II participants.

TABLE 10–1.A summary of psychosocial treatment trials for bipolar disorder including participants with bipolar II disorder
Author	Treatment method	Duration treatment; follow-up	Sample	State at entry, other criteria	Overall outcome
Individual and group psychoeducation
Colom et al. 2003a, 2009a, 2009b^a	Group PE or support group	21 sessions; 2 years, 5 years	2003: n=120 BD II=20 (17%) BD I=100 2009: n=99	Euthymic	At 2 years, Group PE was associated with significantly lower relapse rates, lower hospitalization rates, and much less time spent acutely ill. At 5 years, Group PE continued to be associated with significantly fewer recurrences and less time spent acutely ill in the BD II group.
Kallestad et al. 2016^a	Individual PE or group PE	PE: 3 sessions Group: 18–20 sessions; 27 months, 8 years	n=85 BD II=45 (53%) BD I=40	Any	Group PE was associated with significantly longer time to hospitalization. Prerandomization characteristics, and not intervention group, explained variance. Group PE cases without substance use had longest survival and had small but significant reduction in hospital use. BD II had worse outcomes than BD I.
Morriss et al. 2016	Group PE or peer-support	21 sessions; 2 years	n=304 BD II=61 (20%) BD I=243	Euthymic	No significant differences.
Parikh et al. 2015^a	Group PE or individual CBT	PE: 6 sessions CBT: 20 sessions; 72 weeks	n=204 BD II=57 (28%) BD I=147	Full or partial remission	No significant differences. BD I and II outcomes were not different.
Zaretsky et al. 2008	PE+CBT or PE	PE: 7 sessions PE+CBT: Addition of 13 CBT sessions; 1 year	n=79 BD II=27 (34%) BD I=52	Euthymic or minimally symptomatic	PE+CBT was associated with significantly fewer days of depressed mood and fewer increases in antidepressant dosage.
Individual and group cognitive-behavioral therapy and cognitive therapy^b
Gomes et al. 2011	Group CBT or TAU	18 sessions; 2 years	n=50 BD II=12 (24%) BD I=38	Euthymic	Group MBCT did not significantly increase time in remission or decrease number of episodes. Group CBT had significantly longer median time to first relapse.
Jones et al. 2015	RCBT or TAU	Up to 18 sessions; 1 year, small proportion up to 15 months	n=67 BD II=14 (21%) BD I=53	Within 5 years of onset of BD	Group RCBT significantly improved personal recovery up to 12 months and increased time to relapse up to 15-month follow-up.
Meyer and Hautzinger 2012^a	CBT or supportive therapy	20 sessions; 2 years	n=76 BD II=16 (21%) BD I=38	Current mood episode	CBT showed a nonsignificant trend for preventing any affective episode. No significant differences in relapse rates were observed overall, but BD II group had worse outcomes than BD I group.
Miklowitz et al. 2007a	CBT, FFT, IPSRT, or PE CC	CBT, FFT, and IPSRT: 30 sessions CC: 3 sessions; 9 months, 12 months	n=293 BD II=90 (31%) BD I=197 NOS=5	Current depressive episode	At 9 months, CBT, FFT, and IPSRT all were associated with better total functioning, relationship functioning, and life satisfaction scores. No differences among CBT, FFT, and IPSRT were found. At 12 months, CBT, FFT, and IPSRT were associated with more rapid recovery and greater likelihood of being well during any study month. BD II and I outcomes were not different.
Perich et al. 2013	Group MBCT or TAU	8 sessions; 1 year	n=95 BD II=35 (37%) BD I=59 NOS=1	Euthymic or minimally symptomatic	No significant differences.
Interpersonal and social rhythm psychotherapy^c
Inder et al. 2015, 2017	IPSRT or specialist supportive care	12 weekly, then biweekly, and then monthly sessions, or as needed; 18 months, 3 years	n=100 BD II=17 (17%) BD I=78 NOS=5	Any, aged 15 to 36 years	No significant differences.
Swartz et al. 2012a^a	IPSRT or quetiapine pharmacotherapy	12 sessions; 12 weeks	n=25 BD II=25 (100%)	Depressed	No significant differences.
Swartz et al. 2018^a	IPSRT+placebo pharmacotherapy or IPSRT + quetiapine pharmacotherapy	20 sessions; 20 weeks	n=92 BD II=92 (100%)	Depressed	IPSRT+quetiapine yielded significantly faster depression and hypomania improvement. No significant difference in response rates was found. Preference for psychotherapy was significantly associated with better outcomes with therapy alone.
Integrated care management
Bauer et al. 2006	CC or TAU	83 sessions; 3 years	n=306 BD II=41 (13%) BD I=265	Current episode requiring acute psychiatric hospitalization, history of prior hospitalization	CC group had significantly fewer weeks in an affective episode, especially mania. CC was associated with significant improvements in some areas of functioning and quality of life. No significant differences in symptomatic outcome and mean symptom levels were found.
Simon et al. 2006	Systematic care management or TAU	Up to 48 sessions; 2 years	n=441 BD II=105 (24%) BD I=336	Any	Systematic care management group exhibited significantly less severe mania and spent less time in a manic or hypomanic episode. No significant intervention effect on severity or time in depression was found.
Group functional remediation
Solé et al. 2015^a; Torrent et al. 2013	Group FR or group PE or TAU	21 sessions; 6 months	n=53 of 239 BD II=53 (100%)	Subsample of Torrent et al. 2013 diagnosed with BD II; euthymic at study entry	No significant group differences. Changes in global psychosocial functioning trended similarly to those in original study; present study may have been insufficiently powered. Unlike in the original study, FR was associated with significant decrease in depressive symptoms in the BD II subgroup.
Technology-assisted interventions
Barnes et al. 2007, 2015	Online PE+CBT or Internet control condition	20 sessions over 12 months; 1 year	n=233 BD II=29 (12%) BD I=204	No acute mania	No significant differences.
Bilderbeck et al. 2016; Miklowitz et al. 2012	Electronic mood monitoring+ in-person therapist-administered PE or electronic mood monitoring+ self-directed PE	5 in-person sessions over 12 weeks with electronic mood monitoring; 1 year	n=121 BD II=42 (35%) BD I=79	Euthymic	No significant differences.
Depp et al. 2015	In-person PE+electronic mood monitoring with feedback loop or in-person PE+paper-and-pencil mood monitoring	4 PE sessions, then 10 weeks of daily mood monitoring; 6 months	n=82 BD II=10 (12%) BD I=72	No severe depressive or manic symptoms	PRISM was associated with a significantly greater reduction in depressive symptoms at 6 and 12 weeks but not at 24 weeks; no impact on manic symptoms or functional impairment.
Faurholt-Jepsen et al. 2015	In-person TAU+electronic mood monitoring with feedback loop or Placebo smartphone	Daily; 6 months	n=67 BD II=22 (33%) BD I=45	No severe depressive or manic symptoms	No significant effect on depressive or manic symptoms. MONARCA associated with more sustained depressive symptoms.
Hidalgo-Mazzei et al. 2016, 2017	Online pre- and postpersonalized electronic psychoeducation	3 months; 3 months	n=51 (2 excluded) BD II=13 (27%) BD I=33 NOS=3	Euthymic	Completing SIMPLe was associated with significantly improved biological rhythm regularity sleep, social rhythms, eating patterns, predominant rhythm. No significant effect on activities.
Lauder et al. 2015	Online MoodSwings or online MoodSwings Plus	1 module every 2 weeks for 10 weeks then 3 booster sessions; 12 months	n=130 BD II=63 (49%) BD I=67	Any	No significant differences for mania or depression relapse rates. MoodSwings Plus group had lower levels of mania.
Todd et al. 2014	Online recovery-focused PE+CBT or in-person TAU	10 modules, 6 months of access; 6 months	n=122 BD II=30 (25%) BD I=86	Any	PE+CBT was associated with greater improvement in psychological and physical domains of quality of life, well-being, and recovery.
Other individual and group interventions
Fagiolini et al. 2009	Specialized care for bipolar disorder (SCBD)+enhanced clinical intervention (ECI) or ECI	SCBD+ECI: 12 weekly, 8 biweekly, then monthly sessions; 2 years	n=463 BD II=87 (19%) BD I=313 Other=63	Current mood episode	SCBD+ECI was associated with significantly greater improvement in quality of life.
Castle et al. 2010	Collaborative therapy program: MAPS or phone calls	15 sessions; 1 year	n=84 BD II=21 (25%) BD I=62 NOS=1	No acute episode of mania or depression	Collaborative therapy program was associated with longer time to relapse and less time unwell. No significant differences in posttreatment symptoms.
Van Dijik et al. 2013	Dialectical behavior therapy skills with mindfulness or wait list	12 sessions; 6 months	n=24 BD II=14 (58%) BD I=10	Euthymic, depressed or hypomanic	Dialectical behavior therapy skills with mindfulness was associated with a trend toward fewer depressive symptoms and fewer hospitalizations and emergency visits.
Weiss et al. 2007	Integrated group therapy or group drug counseling	20 sessions; 3 months	n=62 BD II=10 (16%) BD I=50 NOS=2	Any, diagnosis of substance dependence other than nicotine	Integrated group therapy group had better substance use outcomes but more depression and mania symptoms. No significant difference for number of weeks ill.
Note.CBT=cognitive-behavioral therapy; CC=collaborative care; ECI=enhanced clinical intervention; FFT=family-focused therapy; FR=functional remediation; IPSRT=interpersonal and social rhythm therapy; MBCT=mindfulness-based cognitive-behavioral therapy; NOS=not otherwise specified; PE=psychoeducation; RCBT=recovery-focused CBT; SCBD=specialized care for bipolar disorder; SIMPLe=smartphone application; TAU=treatment as usual. ^aReports outcomes specifically for BD II. ^bSee also Parikh et al. 2015 under “Individual and Group Psychoeducation.” ^cSee also Miklowitz et al. 2007 under “Individual and Group Cognitive-Behavioral Therapy and Cognitive Therapy.”

Among the 27 RCTs, sample sizes ranged from 24 to 463 participants, including individuals with BD I, BD II, and other bipolar disorder or BD II only. In total, 1,051 individuals with BD II were included in these reports, representing almost 24% of the study population (N=4,394). Mood state at entry for these studies was quite variable and included individuals who were depressed, euthymic, and “in any mood state” at baseline. Duration of follow-up varied from 3 months to 8 years. Outcomes were almost uniformly favorable among those assigned to active psychotherapy, although studies that included active comparators typically reported no differences in outcomes between groups (Inder et al. 2015; Parikh et al. 2015; Swartz et al. 2012a). In all protocols except two (Swartz et al. 2012a, 2018), all participants received medications (typically mood stabilizers) in addition to psychotherapy, suggesting that the observed effects of psychotherapy were in addition to those of baseline pharmacotherapy. In what follows we discuss each type of psychotherapy for which there is at least some information about its use in BD II, because they included at least 10 participants with BD II and reported outcomes by BD subtype.

Psychoeducation

Psychoeducation (PE) consists of structured sessions that focus on empowering individuals to better understand their bipolar illness, recognize and manage symptoms, and adhere to pharmacotherapy. It can be administered individually or in a group format, or recently, remotely through a telephone, smartphone, or web platform (see subsection “Technology-Assisted Interventions” below). PE can be administered as a stand-alone treatment or combined with strategies from other evidence-based interventions.

We identified five studies with face-to-face individual (Kallestad et al. 2016; Zaretsky et al. 2008) or group (Colom et al. 2003; Morriss et al. 2016; Parikh et al. 2015) PE as the active intervention. One group (Zaretsky et al. 2008) studied PE in combination with cognitive-behavioral therapy (CBT). Individuals with BD II made up between 17% and 53% of the samples. Follow-up lasted between 1 and 8 years. Three studies reported results by bipolar disorder subtype (Colom et al. 2003; Kallestad et al. 2016; Parikh et al. 2015) and are summarized below.

Colom and colleagues (2003) conducted a trial of group PE compared with an unstructured support group among participants with BD I and BD II, all of whom were receiving pharmacotherapy and usual outpatient psychiatric care as well. Group PE was a manualized, structured program of 21 sessions developed by the study authors. Colom and Vieta’s (2006) program targeted treatment compliance, illness awareness, early detection of prodromal symptoms, and lifestyle regularity. At 2- and 5-year follow-up, assignment to group PE was associated with significantly lower relapse rates (Colom et al. 2003, 2009a). In a follow-up report analyzing data from the BD II subset only, at 5-year follow-up, group PE was associated with significant advantages over the support group (Colom et al. 2009b): fewer participants with one or more episode recurrence (62.5% vs. 100%), fewer days with symptoms of hypomania or depression (10.5% vs. 47%), and higher levels of functioning. Colom and colleagues suggested that PE derives its effect from improved functioning, possibly attributable to the power of PE to reduce time depressed (versus hypomanic). Accordingly, they proposed that group PE may be improved for BD II if modified to place more emphasis on depression, including subsyndromal and atypical symptoms, comorbid anxiety, and physical health care.

Parikh and colleagues (2015) randomly assigned individuals to receive either 6 weeks of group PE or 20 weeks of individual CBT as an adjunct to naturalistic pharmacotherapy. Group PE was a manualized, structured program of six sessions designed to teach illness recognition and coping strategies and assist with creation of an explicit care plan to address triggers for mania and depression. Individual CBT included traditional CBT techniques in addition to an emphasis on understanding the diagnosis and course of BD, personal warning signs, and a “relapse drill” of actions to reduce relapse. After 72 weeks, there were no treatment group effects for the primary outcome, mood burden over time, suggesting that brief group PE may be as effective as a full course of individual CBT. Among those with BD II, only one participant spent more than 50% of the time ill. Almost 18% spent no time ill, and most (76%) spent less than 25% of the time ill. Subsyndromal symptoms, particularly of a depressive type, accounted for as much as 23% of the mood symptoms experienced by the BD II cases, compared with only 17% in BD I cases. Investigators concluded that combination pharmacotherapy and psychosocial interventions, whether individual or group, results in favorable outcomes for both BD I and II.

In the third study, Kallestad and colleagues (2016) compared the effectiveness of individual and group PE. Individual PE was a three-session intervention based on a PE workbook from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The workbook included information about bipolar disorder, importance of medication adherence, schedule management, dysfunctional cognitions, communication skills, and preventing episodes. Group PE was a 10-session manualized treatment based on model. Although there were no significant group differences, there was a significant interaction between group and diagnosis. Compared with individuals with BD I, individuals with BD II benefited less from either intervention, and individuals with BD II receiving individual PE fared significantly worse than those receiving group PE. BD II individuals had significantly earlier admissions to the hospital and higher rates of comorbid substance use, another factor that was significantly and independently associated with earlier hospital admission. Kallestad and colleagues (2016) hypothesize that the poor outcomes associated with BD II may be related to the high frequency of substance use, treatment-refractory depressive symptoms, and overall illness instability in the BD II population. They concluded that PE might need to be adapted specifically to meet the needs of those with BD II.

In aggregate, it appears that PE is a helpful treatment to prevent recurrence of mood episodes for individuals with BD II in the maintenance phase. There is no information about this treatment as an acute intervention for BD II. For this population, PE may be most potent in group format and when administered early in the course of illness (Morriss et al. 2016). Given its prominent focus on disease recognition and management, PE may benefit from modification to increase its salience for those with BD II. For instance, BD I and II differ in presentation (e.g., mania, psychotic features), course (Judd et al. 2003), and illness management (Yatham et al. 2018). It may be particularly helpful to emphasize the recognition and management of subthreshold symptoms, especially those depressive in nature; unstable course of illness; and comorbid substance use.

Cognitive-Behavioral Therapy

CBT, administered individually or in a group format, focuses on identifying and changing maladaptive thoughts, beliefs, and behaviors that contribute to psychiatric symptoms (Chiang et al. 2017). When tailored for bipolar disorder, CBT typically incorporates strategies such as management of sleep and routines, attention to medication adherence, and PE about bipolar disorder (Lam et al. 2003). This section includes variants of CBT such as cognitive therapy and mindfulness-based cognitive therapy (MBCT).

We identified three studies with face-to-face individual (Meyer and Hautzinger 2012; Miklowitz et al. 2007; Parikh et al. 2015) and three studies with group (Gomes et al. 2011; Jones et al. 2015; Perich et al. 2013) CBT as the active intervention. Individuals with BD II comprised between 21% and 37% of the samples. Follow-up lasted between 1 and 2 years. Three studies reported results by bipolar disorder subtype (Meyer and Hautzinger 2012; Miklowitz et al. 2007; Parikh et al. 2015). One study was described in the PE section and is not repeated here (Parikh et al. 2015).

Miklowitz and colleagues (2007) reported BD II outcomes from STEP-BD, a multisite project that compared the efficacy of three individual psychotherapies—CBT, family-focused therapy (FFT), and interpersonal and social rhythm therapy (IPSRT)—with that of a three-session PE control intervention as treatments for acute BD depression. All participants were receiving pharmacotherapy. For the control condition, participants received a STEP-BD PE videotape and workbook, and sessions focused on a review of these materials (content previously described in the PE section). CBT sessions included PE, life events scheduling, cognitive restructuring, problem-solving training, relapse prevention, and interventions for comorbidities, if applicable. FFT sessions included PE, strategies to foster the development of a common understanding between patients and relatives about the index episode, medication adherence, and role of stress, relapse prevention, communication enhancement, and problem solving. IPSRT is discussed in detail in the next section. Briefly, IPSRT sessions included PE and a focus on interpersonal relationships with behavioral interventions to modify social rhythms. After the study authors controlled for site, family involvement, and BD subtype, assignment to any one of the three intensive psychotherapies was associated with significantly higher rates of recovery (64% vs. 52%), shorter time to recovery (median=113 days±78.2 vs. 146 days±80.0), and greater improvement in functioning. Bipolar disorder subtype did not alter the effect of interventions on these outcomes, and this suggests that all three psychotherapies—CBT, FFT, and IPSRT—were comparably efficacious in BD I and BD II.

Meyer and Hautzinger (2012) compared CBT with supportive therapy (ST). In the ST condition, therapists provided emotional support and general advice. CBT included PE, relapse prevention, cognitive and behavioral strategies for depression and mania, and training in communication skills and/or problem solving. There were no significant differences between groups in relapse rates or mood symptoms, although assignment to CBT was associated with a trend for preventing any mood episode. Bipolar disorder subtype was a nonspecific predictor of outcomes: those with BD II had a higher risk of recurrence and increased risk for depressive relapse. That is, CBT and ST were both less effective for the management of BD II than for the management of BD I.

On the basis of these RCTs, CBT and its variants appear to be efficacious for acute BD II depression and may also prevent recurrence—although one study suggested that those with BD II had worse outcomes relative to BD I. It seems likely that CBT may need some subtype-specific modifications. Like PE, CBT may benefit from greater emphasis on the recognition and management of subthreshold symptoms. It may also be important to add additional focus on dysfunctional thoughts, beliefs, and behaviors acquired during years of living with an untreated and unrecognized illness.

Interpersonal and Social Rhythm Therapy

IPSRT is a manualized treatment that addresses interpersonal problems and disrupted social rhythms (Frank 2005). Social rhythms are those daily activities—such as time of out of bed, first contact with another person, start of daily activity, dinner, and time to bed—that are thought to exert an effect on underlying biological rhythms. IPSRT rests on an “instability model” that defines three interconnected pathways to bipolar recurrences: stressful life events, medication nonadherence, and social rhythm disruption. IPSRT helps individuals identify and manage symptoms, link mood to life events, mourn the loss of the healthy self, resolve a primary interpersonal problem area (role transitions, role disputes, interpersonal deficits, or grief), maintain a regular daily rhythm, and predict and problem-solve potential precipitants of rhythm dysregulation. IPSRT typically is administered individually but can be provided in a group format.

We identified four studies with face-to-face individual IPSRT as the active intervention (Inder et al. 2015, 2017; Miklowitz et al. 2007; Swartz et al. 2012a, 2018). Individuals with BD II made up between 17% and 100% of the sample. Follow-up lasted between 3 months and 3 years. Three studies provided results for BD II participants (Miklowitz et al. 2007; Swartz et al. 2012a, 2018); one was discussed in the CBT section and is not repeated here (Miklowitz et al. 2007). To date, the following two reports are the only RCTs to include samples made up exclusively of participants with BD II.

Swartz and colleagues (2012a) compared IPSRT with quetiapine for BD II depression among unmedicated participants with BD II. Over 12 weeks, both groups experienced improvements in depressive and manic symptoms, and there were no significant differences between groups. In a follow-up study, Swartz and colleagues (2018) compared IPSRT plus placebo with IPSRT plus quetiapine for BD II depression. IPSRT plus quetiapine was associated with significantly faster improvements in depression and manic symptoms, albeit with more side effects than IPSRT alone. Side effects of IPSRT plus quetiapine included significantly higher body mass index over time and dry mouth. Response rates did not differ between groups.

On the basis of three investigations, it appears that IPSRT, as a monotherapy or adjunctive treatment, is an efficacious treatment strategy for acute BD II depression. No data are available about its role in the maintenance phase. IPSRT monotherapy should be considered when individuals prefer, or need, a nonpharmacological modality. IPSRT has been modified for BD II (Swartz et al. 2012b), with changes that include increased attention to the following: providing a rationale for making changes to social rhythms, identifying mood states, regulating levels of stimulation, managing grandiosity, addressing emotional dysregulation, and treating comorbid substance use.

Integrated Care Management

Integrated care management (ICM) is a multicomponent population-based intervention designed to improve clinical care and outcomes (Azrin 2014). ICM is founded on integrated care models for chronic illness care and includes evidence-based strategies for case management and patient- and provider-level interventions. We identified two studies with face-to-face ICM as the active intervention (Bauer et al. 2006; Simon et al. 2006). Individuals with BD II made up 13% and 24% of the samples, and follow-up lasted 3 and 2 years, respectively. Neither report included results by subtype; therefore, the specific utility of ICM for managing BD II is not clear.

Functional Remediation

Functional remediation (FR) is a neurocognitive intervention designed to target attention, memory, and executive functioning deficits associated with bipolar disorder (Torrent et al. 2013). FR includes structured group sessions providing neurocognitive techniques, psychoeducation on cognition-related issues, and problem solving to enhance functioning. We identified one RCT of FR detailed across two reports (Solé et al. 2012; Torrent et al. 2013), plus an additional report that exclusively detailed outcomes in the BD II subgroup (Solé et al. 2015).

Torrent and colleagues (2013) compared FR, PE, and treatment as usual (TAU) as treatments for impaired functioning among participants with BD I and BD II. Compared with TAU, FR was associated with significantly greater improvement in global psychosocial functioning. There were no significant differences between FR and PE. In post hoc analyses of the BD II subset, Solé et al. (2015) assessed treatment effects on global psychosocial functioning. They found a nonsignificant trend favoring FR with a significant treatment×time interaction: BD II participants receiving FR showed significant reduction in subsyndromal depressive symptoms compared with PE.

On the basis of results from one study, FR appears to be a promising strategy to address impairments in psychosocial functioning for euthymic individuals with BD II. No data is available on the effects of this intervention during an acute mood episode. Like other interventions reviewed, FR may confer its advantages by reducing depressive symptoms, which, in turn, leads to improved functioning.

Technology-Assisted Interventions

Despite the strong rationale for psychotherapies in BD II, barriers to their dissemination include limited availability of trained therapists and patient access to specialized mental health services (Stein et al. 2015). Adjunctive psychotherapies that implement modern technologies reduce this pressure. We identified seven studies evaluating technology-assisted interventions. One study compared an online intervention with in-person TAU (Todd et al. 2014). Two studies compared active online to control online interventions (Barnes et al. 2015; Lauder et al. 2015). Three studies utilized a hybrid approach, combining an in-person intervention with an online component (Bilderbeck et al. 2016; Depp et al. 2015; Faurholt-Jepsen et al. 2015), and one study had a within-subject, preversus post online intervention design (Hidalgo-Mazzei et al. 2016, 2017). Three interventions included elements of CBT (Barnes et al. 2015; Lauder et al. 2015; Todd et al. 2014). PE and mood monitoring were central components of all interventions. Individuals with BD II comprised between 12% and 49% of the samples. Follow-up lasted between 3 months and 12 months. There are no studies or subanalyses of outcomes in individuals with BD II. Therefore, the specific utility of technology-assisted interventions for managing BD II is unknown. Of note, because BD II is a depression-predominant illness, Faurholt-Jepsen and colleagues’ (2015) findings (see Table 10–1) of worsening depressive symptoms associated with an in-person intervention with an online component may be particularly important to consider when developing technology-assisted interventions for BD II.

Other Individual and Group Interventions

We identified one study with a face-to-face individual intervention not categorized elsewhere (Fagiolini et al. 2009) and three studies with face-to-face group interventions not categorized elsewhere (Castle et al. 2010; Van Dijk et al. 2013; Weiss et al. 2007). Individuals with BD II made up between 16% and 58% of the samples, and follow-up lasted 3 months to 2 years. No report included results by subtype, and therefore the potential role of these interventions in the management of BD II is unclear.

Case Example

Justin is a 21-year-old college student with BD II. Over the past year, he experienced a protracted depressive episode that resulted in his dropping out of school and returning home to live with his parents. Despite medication, he remained depressed. Although Justin was initially reluctant, his psychiatrist convinced Justin to consider an adjunctive trial of psychotherapy. Because of the evidence supporting its efficacy, Justin was referred for IPSRT.

In weekly sessions of IPSRT, Justin learned to recognize features of BD II. He was surprised to learn that a 2-week period of decreased need for sleep, increased energy, elevated mood, and increased libido last spring would be characterized as a hypomanic episode. His cousin Kevin had been hospitalized for mania after getting several speeding tickets and almost setting his house on fire. His parents told him that this was a manic episode. But he knew that his experiences were not like Kevin’s. Last spring, he didn’t get into any trouble and was having a “great time.” How could that be a problem?

It took Justin several sessions to recognize symptoms of hypomania. For instance, last spring he had had multiple sexual liaisons in a short period of time, which he admitted was atypical for him. He also agreed that his mood was “better than good” during this time period. He grudgingly acknowledged that even if the hypomania was “fun,” the depression that followed was not. If, as his therapist suggested, the hypomania may put him at risk for subsequent depressive episodes (especially because he stopped his medications during that time), he wanted no part of it! Because IPSRT focuses on links between routines and mood, he was even more surprised to learn that there was probably a connection between his spring break trip to Mexico and the hypomanic episode that followed. His therapist helped him see that his disrupted routines while in Mexico—including decreased sleep, lack of daytime structure, and loss of regular mealtimes—likely put him at risk for a hypomanic episode.

The therapist conceptualized the IPSRT problem area as a role transition, focused on Justin’s interrupted transition from adolescence to adulthood caused by his having to drop out of school. Being back in his parents’ home contributed to Justin feeling trapped and infantilized. It also resulted in conflict with his parents about expectations for his responsibilities and chores around the house. Sessions were devoted to helping Justin address and better manage the interpersonal difficulties associated with this role transition.

Because BD II is characterized by unstable circadian rhythms (or, as his therapist explained, a “sensitive body clock”), Justin was encouraged to develop more regular routines to help entrain his underlying biologic rhythms. His therapist taught him to use the social rhythm metric (Monk et al. 2002) to monitor his daily routines, mood, and energy, as well as to better understand the connections among them. Living at home with his parents, Justin had a very irregular schedule. He had few daily obligations (“anchors,” in the language of IPSRT), and his sleep schedule was erratic. Both Justin and his therapist believed that these variable routines contributed to the maintenance of his mood symptoms. With the help of the social rhythm metric, his therapist helped Justin establish a more consistent set of routines. They focused initially on regularizing his wake-up time, to reset his circadian clock. He also added regular daily activities into his schedule, including dog walking and a class at the community college. He asked his parents to help schedule regular mealtimes. As Justin’s routines became more regular, his mood improved. As his mood improved, he found it easier to maintain regular routines. After 20 sessions of IPSRT, Justin’s therapist reduced the frequency of visits to monthly with a plan to terminate therapy when he returned to school in the fall.

Only gold members can continue reading. Log In or Register to continue