Bipolar disorder is a chronic psychiatric illness that can have devastating effects on afflicted individuals and their families. It is the sixth leading cause of disability worldwide, and prevalence is estimated to be around 1% in the general adult population. The age of onset of bipolar disorder typically occurs during late adolescence or early adulthood, although onset can occur in childhood. Early-onset bipolar disorder is commonly associated with impairment in multiple domains, including increased risk of psychiatric hospitalisation, antisocial behaviour, addictions and suicidal behaviour. The need to optimise treatments for for these patients for whom medication could be long-term and associated with adverse side effects, has increased the interest in the role of psychological treatments.

What is the evidence for psychosocial treatments for childhood bipolar disorder?

Moderate to low quality evidence suggests cognitive behavioural therapy, education, and family therapies may improve mood symptoms and increase knowledge about the disorder in children or youth with bipolar disorder. More research is needed to assess Interpersonal Social Rhythms Therapy and Dialectical Behavioural Therapy.

November 2021

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Cognitive impairment is an affliction for many people with bipolar disorder, and affects domains including executive function, attention, memory (particularly verbal memory), and social cognition. These deficits interfere considerably with day-to-day function.

Cognitive remediation (or rehabilitation) interventions usually take the form of repetitive exercises with or without computers and sometimes augmented by group sessions, strategy coaching and homework exercises, which serve as training for cognitive processes such as memory or attention, as well as social skills and communication. Strategy learning focuses on providing alternative strategies to compensate for the observed difficulties with cognition; in contrast, rehearsal learning is aimed at restitution of lost skills. This type of intervention is specifically targeted to particular cognitive domains which are known to be deficient in people with bipolar disorder, with the intention of compensating or improving functional outcome.

What is the evidence for cognitive remediation?

Low quality evidence is unable to determine any benefits of cognitive rehabilitation for people with bipolar disorder. Review authors report that findings were not robust due to the variety of intervention designs, the methodological limitations of the studies, and the lack of studies in the field.

November 2021

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Dual diagnosis is a term that refers to having both a mental illness such as bipolar disorder and a substance use problem. Studies of dual diagnosis investigate the effectiveness and availability of treatments for improving outcomes relating to either diagnosis, such as symptoms, functioning, quality of life, substance use, or cognitive problems.

What is the evidence for treatments for dual diagnosis?

Moderate to low quality evidence finds some improvement in symptoms and substance use with cognitive behavioural therapy plus medication. However, these results were not consistently found using different measures of substance use and symptoms.

November 2021

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The course of bipolar disorder and its treatment response tends to worsen over time, highlighting the importance of early intervention. As bipolar disorder cannot be diagnosed on the basis of depression alone, the onset of a manic episode may indicate an underlying bipolar disorder. Interventions for first-episode psychosis or depression have begun to be extended to those with bipolar disorder, however such interventions need to be tailored to suit people with first-episode bipolar disorder, and research is sparse for these patients.

What is the evidence for psychosocial treatments for first-episode bipolar disorder?

Low quality evidence is unable to determine the benefits of interventions for people with first-episode bipolar disorder. More research is needed.

November 2021

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People deemed at high risk for bipolar disorder can be identified by having a family history of a mood disorder and/or having subclinical symptoms that are not severe enough for a diagnosis. Subclinical symptoms include depression, difficulty with concentration, episodic mood swings, anxiety, sleep disturbances, and sensitivity to stress. Familial risk accompanied by mood dysregulation or other mood symptomatology could help define the population at high risk of bipolar disorder. Early intervention involves identifying and treating these high-risk individuals as repeated mood episodes put people at risk of poor symptomatic and functional recovery.

What is the evidence for psychosocial treatments for people at high risk for bipolar disorder?

Moderate quality evidence finds benefits of early interventions, particularly family-orientated therapies, for improving mood and functioning in people aged between 9 and 30 years who are at risk of bipolar disorder.

November 2021

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Internalised stigma occurs within an individual, such that a person’s attitude may reinforce a negative self-perception of mental disorders, resulting in reduced sense of self-worth, anticipation of social rejection, and a desire for social distance. Stigma can be an important barrier for people with bipolar disorder to seek out proper treatment. Also see the related topic on stigma under the course and outcomes category.

What is the evidence for therapies for internalised stigma?

Moderate to high quality evidence suggests a small effect of reduced internalised stigma with targeted interventions comprising psychoeducation and peer-led group discussion.

November 2021

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Parents with a bipolar disorder may face challenges in accessing and maintaining treatment programs. They may be less likely to seek treatments due to problems finding care for their children, particularly when inpatient care is required, and at short notice. Parents may also find it difficult to properly adhere to treatment programs due to the demands of parenthood.

What is the evidence for treatments for parents with bipolar disorder?

Only one trial specifically included parents with bipolar disorder and found unclear, low quality evidence for any benefit of the Positive Parenting Program (Triple P). Review authors conclude that more research is needed and future interventions should combine different intervention strategies to target multiple areas in a flexible manner.

November 2021

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Eye Movement Desensitisation and Reprocessing (EMDR) therapy and other trauma-focussed therapies are generally beneficial for patients with post-traumatic stress disorder (PTSD). They are also currently being investigated in patients with other diagnoses who have had exposure to traumatic events.

EMDR therapy involves identifying past events that are causing dysfunction, identifying current circumstances that elicit distress, and desensitising internal and external triggers. During EMDR therapy, patients attend to the emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus, usually therapist-directed lateral eye movements. The therapist may teach the patient a variety of imagery and stress reduction techniques to use during and between sessions. When patients report no distress related to the targeted memory, they are asked to focus on a preferred positive belief instead. Over the course of treatment, patients gain insight about their stressful situations, and the associated emotional distress reduces. Other trauma-focused therapies include prolonged exposure, which involves cognitive behavioural therapy to teach people to gradually face trauma-related memories, feelings, and situations.

What is the evidence for trauma-focussed therapies?

Only one study was identified assessing people with bipolar disorder, which reported improvements in mood and trauma symptoms following EMDR compared to treatment as usual. However, this evidence is of low quality as the sample is very small (20 people).

November 2021

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Non-adherence to medication is a widespread issue that can make the clinical management of bipolar disorders problematic. Non-adherence to treatment reduces the likelihood of symptom improvement and increases the likelihood of relapse and hospitalisation. Greater treatment adherence generally improves quality of life, fosters positive attitudes towards treatment, and results in greater insight into the disorder. Also see this related topic on treatment non-adherence under the course and outcomes category.

What is the evidence for therapies for treatment non-adherence?

Moderate to low quality evidence suggests a medium-sized effect of improved medication adherence with any psychosocial intervention.

November 2021

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Being overweight is common in people with a serious mental illness, the cause of which may be attributable to lifestyle factors such as poor diet and physical inactivity, and also due to medication side effects. Weight gain is a well-documented side effect of many antipsychotic medications, particularly the newer second-generation medications. This could in part be a result of the wide mode of action of antipsychotic drugs, including disruption of metabolic pathways.

Excessive weight gain is a serious health concern, it is associated not only with reduced quality of life and social stigma, but can affect treatment adherence and increase morbidity (both physical and psychological) and mortality. Obesity is reported to double the risk of all-cause mortality, as well as related diseases such as coronary heart disease, stroke and type-2 diabetes.

Pharmacological strategies are at best only moderately effective for weight management, thus the ideal non-pharmacological strategies for weight management should combine diet, exercise and psychological/behavioural components. Weight management is important to ensure that the benefits of medications are not outweighed by the increased risk of physical disease.

What is the evidence for treatments for weight gain?

Moderate to high quality evidence suggests lifestyle interventions are effective for weight reduction in people with any severe mental illness. Moderate to low quality evidence suggests lifestyle interventions also reduces body mass and improves depressed mood.

November 2021

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