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Better Together: How Nonpharmacological Interventions Can Complement Medications for Bipolar Depression

October 03, 2013

LAS VEGAS—Nonpharmacological treatments for bipolar depression are practical and effective interventions that can work in concert with medications to improve patient outcomes, said Saundra Jain, MA, PsyD, LPC, at the 26th Annual U.S. Psychiatric and Mental Health Congress. Dr. Jain examined the evidence for a number of different psychosocial treatments, mindfulness-based cognitive therapy, and exercise for patients with bipolar depression.

“We’re all familiar with the clinical challenges of bipolar depression. Nonpharmacological strategies offer us as clinicians additional treatment options when taking care of this tough patient population,” said Dr. Jain.

Evidence for Psychosocial Treatments

Cognitive-behavioral therapy (CBT), one of the key types of psychosocial treatments, is modeled on the relationship between thoughts, emotions, and behaviors—correcting inaccurate and distorted thoughts may lead to more productive feelings and behaviors.

Recently, research has identified an objective, prospective biomarker that predicts which patients will respond to medication and CBT, and a clinical study by Lam et al. shows that cognitive therapy can help to prevent relapses in bipolar disorder [1]. Over a 30-month period, patients randomized to cognitive therapy had significantly better outcomes in terms of relapses compared with patients receiving standard treatment.

Involving patients’ families in treatment also has positive effects on relapses and overall outcomes. A study by Miklowitz et al. suggests that Family-Focused Therapy (FFT) is linked with more time before relapse, better medication adherence, and greater improvement in depressive symptoms [2].

“Involving a patient’s family in treatment usually proves quite beneficial. It isn’t always smooth sailing, but it’s typically worth the effort. That’s what I really like about FFT—the need to involve and educate family members and have them become active members in the treatment process,” said Dr. Jain.

FFT is characterized by psychoeduation to help the patient and family better understand the disorder, improve communication skills through communication enhancement training, and problem-solving training to effectively resolve conflicts.

Patients may benefit from Interpersonal and Social Rhythm Therapy (ISRT) as well. This therapy aims to regulate social routines and stabilize interpersonal relationships to improve depression and prevent relapse. For more information, Dr. Jain recommends Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy by Ellen Frank.

Combining Mindfulness With CBT

In addition to these psychosocial treatments, patients with bipolar depression may benefit from Mindfulness-Based Cognitive Therapy (MBCT), which includes elements of CBT and mindfulness meditation. Mindfulness involves paying attention in a particular, nonjudgmental way in the present moment, and research suggests MBCT is associated with lower scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) [3].

“MCBT is a regular part of my private practice,” said Dr. Jain. She added, “I don’t offer the eight-week group sessions due to space limitations; however, I do routinely use many of the meditations and the patient book with many of my patients. Overall, patients are open to beginning a meditative practice and report positive results from their practice.”

Some clinicians also may consider prescribing exercise in light of a recent study that found decreased exercise can be a trigger for bipolar depression.[4] However, although exercise has been shown to regulate mood symptoms and potentially calm hypomania, some patients may tend to overexercise when in a manic state or have elevated mood activation. With bipolar mania there is good evidence that exercise may destabilize patients even further.

“In bipolar depression, at the moment, we just don’t have enough data to make recommendations either way,” said Dr. Jain.

“These psychosocial interventions, meditation, and exercise work in conjunction with pharmacological interventions to help us Tame the Beast of bipolar depression. We need to have access to as many interventions as possible in order to give our patients the best chance at achieving better outcomes,” said Dr. Jain.

—Lauren LeBano

References

1. Lam DH, et al. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. . Am J Psychiatry. 2005;162(2):324-329.

2. Miklowitz DJ, et al. A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Arch Gen Psychiatry . 2003;60(9):904-912.

3. Perich T et al. The association between meditation practice and treatment outcome in Mindfulness-based Cognitive Therapy for bipolar disorder. Behav Res Ther . 2013;51(7):338-343.

4. Proudfoot J et al. Triggers of mania and depression in young adults with bipolar disorder. J Affect Disord. 2012;143:196-202.

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