Psychiatric Annals

CME Article 

Beyond Pharmacotherapy for Bipolar Disorder: The Role of Adjunctive Psychological Treatments

Kathryn Fletcher, PhD, MClinPsychol, BSc (Hons); Greg Murray, PhD, MClinPsychol, BA (Hons), BSc (Hons)

Abstract

Recent years have seen increased research attention to psychological interventions as adjuncts to medication treatment of bipolar disorder (BD). Adjunctive psychological treatments are recommended in all major clinical guidelines for BD, and we now know that evidence-based treatment involves both pharmacotherapy and psychological therapy. We provide an overview of what is known about psychological interventions for BD, including the existing evidence base, core content elements of therapy, and emerging innovations. An overarching theme is the patient as a motivated agent in his or her own well-being; we emphasize recovery-oriented treatment goals, self-management approaches, and digital platforms to improve access to these empowering activities. Mental health professionals are encouraged to support their patients' participation in evidence-based psychological therapies as part of a holistic approach to managing BD. [Psychiatr Ann. 2019;49(9):399–404.]

Abstract

Recent years have seen increased research attention to psychological interventions as adjuncts to medication treatment of bipolar disorder (BD). Adjunctive psychological treatments are recommended in all major clinical guidelines for BD, and we now know that evidence-based treatment involves both pharmacotherapy and psychological therapy. We provide an overview of what is known about psychological interventions for BD, including the existing evidence base, core content elements of therapy, and emerging innovations. An overarching theme is the patient as a motivated agent in his or her own well-being; we emphasize recovery-oriented treatment goals, self-management approaches, and digital platforms to improve access to these empowering activities. Mental health professionals are encouraged to support their patients' participation in evidence-based psychological therapies as part of a holistic approach to managing BD. [Psychiatr Ann. 2019;49(9):399–404.]

The role of psychological therapy as an adjunct to pharmacotherapy for bipolar disorder (BD) is now widely recognized. Clinical guidelines recommend several evidence-based psychological treatments for BD, each sharing common features but with unique treatment priorities. These treatments can hasten time to recovery, reduce the risk of relapse, and improve functioning. There is, however, also room for innovation in these interventions to optimize patient outcomes. The aim of this review is to encourage wide adoption of a holistic treatment approach by (1) introducing the recognized psychological interventions for BD and their evidence base, (2) characterizing the targets of psychological treatment of BD, and (3) highlighting emerging innovations (self-management approaches, digital delivery, and quality of life [QoL] as a primary treatment target). We commence by briefly providing an overview of treatment approaches to BD, and conclude that psychological interventions can readily and effectively be integrated with pharmacotherapy for BD.

Symptoms, Impacts, and Treatment Approaches

BD is a life-long relapsing condition characterized by recurrent episodes of depression, mania, and hypomania, with chronic inter-episode mood symptoms. Psychosis and highly distressing mixed-mood episodes are common, and comorbidity is the rule rather than the exception, with anxiety and substance use commonly present and contributing to worsening illness course.1,2 Suicide risk is a particular concern, with mortality studies indicating that BD may be associated with the highest suicide risk relative to other psychiatric conditions.3 Two key downstream impacts of this symptom profile have been well characterized: BD is associated with poor functional outcomes (particularly in work and relationship domains) and impaired QoL. It should also be remembered that BD is associated with significant strengths including creativity and openness.4

Therefore, BD is a complex condition from the clinician's viewpoint. At different times for a given patient, a variety of outcomes might be prioritized, including maintenance of mood stability, prevention of future episodes, and monitoring risk. Holistic treatment attends not just to the disorder but also to the person with the disorder, and patients can also expect assistance with optimizing functioning, maximizing strengths, and improving QoL.

The first-line treatment for BD is medication (including mood stabilizers and antipsychotics), with the average patient being prescribed more than three psychotropic medications.5 Outcomes are far from ideal—even with best-practice management, nearly one-half of patients experience recurrence within 2 years.6 Poor outcomes are at least partly due to medication nonadherence (around 50% in large studies), explained largely by undesirable side effects (sedation, weight gain).

There is a long history of interest in the potential of psychological therapies to improve outcomes in BD, particularly by targeting the cognitive, behavioral, and social challenges of people with BD. More recently, this interest has been pursued in treatment outcome research largely using randomized controlled trial (RCT) methodology. Research to date has focused almost entirely on psychological therapies as adjunctive to, rather than stand-alone, interventions for BD (for an exception in relation to bipolar II depression, see Swartz et al.7).

Evidence-Based Psychological Practice: What the Guidelines Tell Us

Current clinical guidelines worldwide recommend adjunctive psychological treatment as part of a comprehensive management plan for those with BD.8 Strongest evidence is for the utility of psychological interventions for the management of bipolar depression9,10 and during the maintenance phase to prevent relapse.11 There is no evidence to date for specific psychological interventions for acute mania;12 however, psychological support and stimulus control for this phase are encouraged by the National Institute for Health and Care Excellence13 and the Royal Australian and New Zealand College of Psychiatrists.9

Psychological Therapy Description

Psychoeducation. Psychoeducation focuses on information about BD, emphasizes adherence to medication, and stabilizing moods. It aims to help the patient become an expert on managing BD through acceptance of the condition, understanding their symptoms and treatment options, and taking a proactive approach in managing the condition.

Cognitive-behavioral therapy. Cognitive-behavioral therapy (CBT) focuses on the relationship between thoughts, feelings, and behaviors to reduce symptoms and risk of relapse. CBT aims to help patients manage symptoms by increasing awareness of and challenging unhelpful thought patterns that influence behaviors.

Interpersonal and social rhythm therapy. Interpersonal and social rhythm therapy (IPSRT) focuses on addressing interpersonal problem areas (eg, loss, transitions, conflicts with others) impacting on mood, in combination with behavior modification to stabilize circadian rhythms. IPSRT aims to help patients establish and maintain regular rhythms of activity and social interactions.

Family focused therapy. Family focused therapy (FFT) concentrates on family dynamics that exacerbate symptoms. FFT aims to help identify and resolve difficulties and conflicts within the family (eg, reducing “expressed emotion” that is critical, hostile, or over-involved) by supporting improved communication and problem-solving skills.

Evidence-Informed Psychological Practice

Current evidence-based psychological treatments for BD include psychoeducation (group and individual), CBT, IPSRT, and FFT. No studies have directly compared these therapies, and the strongest evidence for efficacy is for psychological interventions as a set.9 These treatments are associated with more rapid time to recovery, reduced relapse risk, improved functioning, and treatment adherence. Importantly, the therapeutic “brands” are not as distinct as their names might imply, and their shared content elements are well-recognized (Table 1), so they can be considered key ingredients found to be useful for BD.14 Interestingly, these content elements overlap substantially with self-management strategies spontaneously identified as important by people who cope well with their BD.15

Commonalities of Psychological Treatments for Bipolar Disorder

Table 1:

Commonalities of Psychological Treatments for Bipolar Disorder

As reviewed by Murray8 and Mulder et al.,16 evidence-based psychological treatment guideline development continues to be hamstrung by limitations associated with RCT methodology, including inappropriate treatment controls, allegiance bias, and the impossibility of blinding. It is increasingly recognized that RCTs may not be the “gold standard” evaluation of such treatments, with process-based research (identifying how these therapies work, for whom, and under what circumstances) paving the way forward. There is strong clinical consensus that, to ensure all key content elements are covered, psychosocial treatment should be guided by one of the evidence-based treatment manuals.17 Irrespective of the particular psychotherapy chosen, a highly collaborative therapeutic relationship with commitment to seeing a patient long-term is central to optimal ongoing management.18 It is important to note that longer treatments (or at least booster sessions) may result in optimized outcomes, as the evidence suggests that benefits of psychosocial treatments for BD decrease over years. In practice, access to in-person psychological treatments varies widely across health systems, a problem that digital health interventions are moving to address.

How Does Evidence-Based Psychological Intervention for BD Work in Practice?

As a first step, psychological interventions typically educate the patient and their family about BD and emphasize the need for adherence to medication as prescribed. Collaborative discussions considering patient concerns can improve medication adherence, including motivational interviewing focused on the pros and cons of medication and psychoeducation regarding the impact of substance use on the efficacy of prescribed medications. Patients are encouraged to commence daily mood monitoring to improve recognition of idiosyncratic patterns, triggers, and early warning signs as part of relapse identification and prevention. Suicide risk requires careful evaluation and monitoring in an ongoing way throughout the course of treatment, addressed through safety planning (including the development of an individualized crisis plan, ideally involving family and other support people where feasible), and increased frequency of therapeutic contact as needed. Risk issues highlight the critical importance of team communication when pharmacotherapy and psychological treatments are offered by different people.

Other aspects of treatment include discussions regarding personal and lifestyle factors that may precipitate episodes (eg, substance use); engaging or maintaining social, familial and occupational roles; coping and stress management; emotion regulation skills; effective interpersonal communication; and identifying and challenging unhelpful thoughts and beliefs.19 Treatment should be tailored to the individual patient, with appropriate attention to the therapeutic relationship.16

Although some writers assume BD treatments can be separated in dualistic silos, “medications target biology”, “psychological interventions target the person,” current psychological therapies for BD are characterized by a significant biobehavioral focus. For example, stabilization of social rhythms to help scaffold circadian function is a central focus of IPSRT, but is also present in the other evidence-based treatments.20 Attention to abnormal reward sensitivity in BD is highlighted in contemporary psychological approaches to manic ascent and depressive spirals. The targets of psychotherapies for BD, therefore, extend beyond psychological change alone to also include behaviorally mediated attention to the biological vulnerabilities of BD. These goals are achieved through specialized psychoeducation and specific behavioral exercises. Building on earlier work,17,21 we have proposed an integrative biopsychosocial framework for psychosocial intervention. This generic model (see Murray22) captures key targets for psychological intervention in BD, which would then be individually tailored based on patient needs and priorities.

There is growing research into a personalized medicine approach, with some evidence that stage of illness may be an important parameter around which to tailor intervention.23 There is consensus that psychological interventions generally are most efficacious earlier in the course of illness.18 At a more granular level, there is interest in the hypothesis that those early in their illness trajectory may benefit from psychoeducation to facilitate acceptance of the diagnosis and treatment adherence; conversely, those with a longer-established condition may benefit more from insight-oriented approaches (eg, encouraging acceptance and values-driven action, redressing earlier traumas and maladaptive schemas that contribute to ongoing mood instability). Clinicians should be mindful of the interaction between symptom state and psychological intervention. For example, trauma-focused work would best be undertaken once stability is achieved.

Newer psychotherapeutic approaches being tested in this population include cognitive and functional remediation, mindfulness-based cognitive therapy (MBCT), and dialectical-behavioral therapy, all of which have shown promise in terms of improving psychosocial functioning, reducing symptoms of depression and anxiety, and improving emotion regulation. Mindfulness-based interventions (sometimes referred to as “third wave” psychotherapies) hold particular promise for BD. As overviewed by Murray et al.,23 alterations in mechanisms associated with the therapeutic benefits of mindfulness (attention regulation, body awareness, emotion regulation, change in self-perspective) may be specifically effective in reducing vulnerability to core symptoms of BD (including emotional reactivity), addressing common comorbidities, and improving cognitive function, while facilitating psychosocial recovery with improvements in QoL. Indeed, a recent systematic review reported preliminary evidence of benefits of MBCT for depression, anxiety, and mood regulation in BD.24 Although the evidence base is growing, further testing of these treatments is required.

Ideally, psychological treatment will be delivered by clinicians with experience in BD specifically. Selection of an evidence-based treatment should consider patient's strengths and preferences12 and be offered in a patient-centered manner. Assessment and targeted treatment of comorbidities (anxiety and substance use in particular) forms an essential aspect of psychological intervention. Attention must also be paid to supporting the careers of people with BD.25 Importantly, where possible, a team-based approach to treatment is optimal; ongoing communication between the treating psychiatrist, psychologist, and other inter-disciplinary team members (eg, social worker, nursing staff, dietician) will ensure that the patient receives integrative, holistic care.

New Developments in Psychological Intervention for BD

Given that treatment outcomes remain poor for people with BD, innovation is urgently required in the psychological intervention space. Here, we briefly introduce three emerging initiatives: a focus on recovery and QoL goals, self-management approaches, and the accelerating role of digital interventions. These innovations share a core assumption of the patient as a motivated agent in his or her own wellbeing.

New Goals for Treatment: Recovery and QoL

Moving beyond relapse prevention, personal recovery outcomes are increasingly recognized as an important focus of treatment. Within the mental health context, the self-management approach aligns with the recovery-oriented framework, a consumer-led movement that encourages personal agency. Rather than solely focusing on symptomatic improvement, QoL is the central goal. RCT evaluations are slowly shifting their focus to functioning and QoL as primary outcome measures alongside traditional symptomatic improvements, but further investigations with this focus are needed. The concept of recovery is both meaningful and measurable in BD, with interventions now shifting their focus to enhance recovery outcomes. One such outcome that is prioritized by those with BD is QoL, with patients reporting that improvements in this area are of equal importance to symptom remission.23

Self-Management Approaches to BD

There is a growing movement toward self-management approaches to BD. Self-management approaches have long been successfully applied to chronic medical conditions such as diabetes and asthma, and they are rapidly expanding into the domain of persistent mental disorders.

Self-management approaches to mental health empower the individual to take control of his or her own recovery and live successfully with the impact (physical, social, and emotional) of a chronic condition. For BD, elements of self-management include psychoeducation about BD and its treatment, behavioral tailoring to facilitate medication adherence, teaching coping strategies for persistent symptoms, and development of relapse prevention plans along with personal recovery-focused goals.26 A recent systematic review and meta-analysis26 of self-management interventions for adults with severe mental illness (schizophrenia spectrum disorders, BD, and major depression) alongside standard care reported a range of improved outcomes including symptom reduction, reduced length of hospital admission, improved functioning and QoL, and subjective measures of recovery (hope, empowerment, and self-efficacy). The authors concluded that self-management interventions should form part of the standard package of care to those with severe mental illness. As for psychological treatment, these are best considered as adjuncts to first-line intervention with medication.

Self-management is effective in BD27 and recommended by clinical guidelines;13 however, these interventions are not routinely implemented at a service level.26 Digital interventions are rapidly addressing this gap.

Digital Mental Health Care Innovations

Digital mental health care solutions that incorporate self-management can overcome barriers to treatment, including costs of face-to-face treatment, accessibility, and heavy caseloads of time-poor clinicians. Technology allows highly interactive and engaging programs to be offered on a variety of platforms (eg, web-based, smartphone apps, wireless devices), empowering people with treatment choice and control.28 Web-based psychological interventions are acceptable to those with BD29–31 and have a growing evidence base, with a recent RCT of a web-based self-management program showing benefits in reducing bipolar depression.32

Web-based self-management programs ( www.bdwellness.com) can be offered as an adjunct to usual clinical care or as part of a blended-therapy approach for clinicians seeking to integrate digital mental health care into their practice.33 Patients with severe mental health problems support the blended-care approach, viewing digital interventions (web-based, smartphone apps) as working in conjunction with existing supports (rather than as an alternative).34 For example, patients on waiting lists could be provided with digital intervention to receive psychoeducation, self-management strategies, and assistance in identifying needs and goals prior to therapy.35 This approach could potentially reduce the amount of face-to-face sessions required and allows end-users to progress through content at any time at their own pace.

Most programs of this type draw from the evidence-based psychological treatments for BD outlined earlier. For example, our group is currently testing a novel mindfulness-based online self-management program to improve QoL in people who have had more than 10 episodes of BD35 based on positive results from an earlier pilot.30 The consumer voice is captured throughout the program, building awareness of common issues faced by others with BD and thus normalizing shared challenges, and it provides a “real-world” feel that is not captured by the usual clinician-client interactions.33

More complex digital health platforms present innovative opportunities for intervention. A multitude of self-help apps are available for BD (see www.psyberguide.org for unbiased reviews), incorporating real-time mood and activity monitoring and other self-management strategies (eg, monitoring sleep, medication adherence, psychoeducation information) on mobile devices. These offer a portable, personalized approach that is feasible and acceptable to patients. Exciting developments in research include investigation of integrated web/smartphone platforms that offer personalized in-the-moment intervention based on current mood state as part of a dynamic, ecologically valid therapeutic system to support self-management of BD.

Conclusions

Adjunctive psychological treatments form part of the cornerstone of best-practice management of BD. These treatments should be implemented early in the course of illness to maximize patient outcomes, and they should be informed by evidence-based approaches. The field is developing rapidly. Emerging research and international practice suggest that recovery-focused outcomes are important treatment goals in addition to symptom reduction. Practicing clinicians would ideally include QoL measures ( www.bdqol.com/questionnaire) to outcome monitoring as part of a patient-centered approach. Encouragement of self-management interventions alongside usual clinical care should be considered. Digital mental health care solutions will shortly be the major modality for delivering self-management interventions for BD. In sum, BD is one of the most complex psychiatric disorders, generating significant treatment challenges. Evidence-informed psychological interventions (whether delivered face-to-face or through digital platforms) emphasize empowered self-management, embrace a broad set of outcome goals, target a range of important mechanisms, and form a key part of the intervention armamentarium.

References

  1. Farren CK, Hill KP, Weiss RD. Bipolar disorder and alcohol use disorder: a review. Curr Psychiatry Rep. 2012;14(6):659–666. doi:. doi:10.1007/s11920-012-0320-9 [CrossRef]22983943
  2. Pavlova B, Perlis RH, Alda M, Uher R. Lifetime prevalence of anxiety disorders in people with bipolar disorder: a systematic review and meta-analysis. Lancet Psychiatry. 2015;2(8):710–717. doi:. doi:10.1016/S2215-0366(15)00112-1 [CrossRef]26249302
  3. Plans L, Barrot C, Nieto E, et al. Association between completed suicide and bipolar disorder: a systematic review of the literature. J Affect Disord. 2019;242:111–122. doi:. doi:10.1016/j.jad.2018.08.054 [CrossRef]
  4. Murray G, Johnson SL. The clinical significance of creativity in bipolar disorder. Clin Psychol Rev. 2010;30(6):721–732. doi:. doi:10.1016/j.cpr.2010.05.006 [CrossRef]20579791
  5. Weinstock LM, Gaudiano BA, Epstein-Lubow G, Tezanos K, Celis-Dehoyos CE, Miller IW. Medication burden in bipolar disorder: a chart review of patients at psychiatric hospital admission. Psychiatry Res. 2004;216:24–30. doi:. doi:10.1016/j.psychres.2014.01.038 [CrossRef]
  6. Tohen M, Zarate CA Jr., Hennen J, et al. The McLean-Harvard First-Episode Mania Study: prediction of recovery and first recurrence. Am J Psychiatry. 2003;160:2099–2107. doi:. doi:10.1176/appi.ajp.160.12.2099 [CrossRef]14638578
  7. Swartz HA, Rucci P, Thase ME, et al. Psychotherapy alone and combined with medication as treatments for bipolar ii depression: a randomized controlled trial. J Clin Psychiatry. 2018;79(2). doi:. doi:10.4088/JCP.16m11027 [CrossRef]
  8. Murray G. Adjunctive psychosocial interventions for bipolar disorder: some psychotherapeutic context for the Canadian Network for Mood and Anxiety Treatments (CANMAT) & International Society for Bipolar Disorders (ISBD) guidelines. Bipolar Disord. 2018;20(5):494–495. doi:. doi:10.1111/bdi.12655 [CrossRef]
  9. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry. 2015;49(12):1087–1206. doi:. doi:10.1177/0004867415617657 [CrossRef]26643054
  10. Miklowitz DJ, Otto MW, Frank E, et al. Psychosocial treatments for bipolar depression: a 1-year randomized trial from the Systematic Treatment Enhancement Program. Arch Gen Psychiatry. 2007;64(4):419–426. doi:. doi:10.1001/archpsyc.64.4.419 [CrossRef]17404119
  11. Scott J, Colom F, Vieta E. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders. Int J Neuropsychopharmacol. 2007;10(1):123–129. doi:. doi:10.1017/S1461145706006900 [CrossRef]
  12. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018;20(2):97–170. doi:. doi:10.1111/bdi.12609 [CrossRef]29536616
  13. National Collaborating Centre for Mental Health (UK). Bipolar disorder: the NICE guideline on the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. https://www.ncbi.nlm.nih.gov/books/NBK498655/pdf/Bookshelf_NBK498655.pdf. Accessed August 8, 2019.
  14. Miklowitz DJ, Goodwin GM, Bauer MS, Geddes JR. Common and specific elements of psychosocial treatments for bipolar disorder: a survey of clinicians participating in randomized trials. J Psychiatr Pract. 2008;14(2):77–85. doi:. doi:10.1097/01.pra.0000314314.94791.c9 [CrossRef]18360193
  15. Suto M, Murray G, Hale S, Amari E, Michalak EE. What works for people with bipolar disorder? Tips from the experts. J Affect Disord. 2010;124(1–2):76–84. doi:. doi:10.1016/j.jad.2009.11.004 [CrossRef]
  16. Mulder R, Murray G, Rucklidge J. Common versus specific factors in psychotherapy: opening the black box. Lancet Psychiatry. 2017;4(12):953–962. doi:. doi:10.1016/S2215-0366(17)30100-1 [CrossRef]28689019
  17. Lam DH, Jones SH, Hayward P. Cognitive Therapy for Bipolar Disorder: A Therapist's Guide to Concepts, Methods and Practice. 2nd ed. Hoboken, NJ: Wiley-Blackwell; 2010. doi:10.1002/9780470970256 [CrossRef]
  18. Goodwin G, Haddad P, Ferrier I, et al. Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol (Oxf). 2016;30(6):495–553. doi:. doi:10.1177/0269881116636545 [CrossRef]
  19. Geddes JR, Miklowitz D. Treatment of bipolar disorder. Lancet. 2013;381(9878):1672–1682. doi:. doi:10.1016/S0140-6736(13)60857-0 [CrossRef]23663953
  20. Murray G. Circadian science and psychiatry: of planets, proteins and persons. Aust N Z J Psychiatry. 2019;53:597–601. doi:. doi:10.1177/0004867419847279 [CrossRef]31088286
  21. Tyler E, Jones S. Cognitive behavioural case formulation in bipolar disorder. In: Tarrier N, Johnson J, eds. Case Formulation in Cognitive Behaviour Therapy: The Treatment of Challenging and Complex Cases. New York, NY: Taylor and Francis; 2015:188–218.
  22. Murray G. An update on bipolar disorder for psychologists. InPsych. 2012;34(1):11–13.
  23. Murray G, Leitan ND, Thomas N, et al. Towards recovery-oriented psychosocial interventions for bipolar disorder: Quality of life outcomes, stage-sensitive treatments, and mindfulness mechanisms. Clin Psychol Rev. 2017;52:148–163. doi:. doi:10.1016/j.cpr.2017.01.002 [CrossRef]28129636
  24. Lovas DA, Schuman-Olivier Z.Mindfulness-based cognitive therapy for bipolar disorder: a systematic review. J Affect Disord. 2018;240:247–261. doi:. doi:10.1016/j.jad.2018.06.017 [CrossRef]
  25. Jonsson PD, Wijk H, Danielson E, Skarsater I. Outcomes of an educational intervention for the family of a person with bipolar disorder: a 2-year follow-up study. J Psychiatr Ment Health Nurs. 2011;18(4):333–341. doi:. doi:10.1111/j.1365-2850.2010.01671.x [CrossRef]21418433
  26. Lean M, Fornells-Ambrojo M, Milton A, et al. Self-management interventions for people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry. 2019;214(5):260–268. doi:. doi:10.1192/bjp.2019.54 [CrossRef]30898177
  27. Leitan ND, Michalak EE, Berk L, Berk M, Murray G. Optimizing delivery of recovery-oriented online self-management strategies for bipolar disorder: a review. Bipolar Disord. 2015;17(2):115–127. doi:. doi:10.1111/bdi.12258 [CrossRef]
  28. Hollis C, Morriss R, Martin J, et al. Technological innovations in mental healthcare: harnessing the digital revolution. Br J Psychiatry. 2015;206(4):263–265. doi:. doi:10.1192/bjp.bp.113.142612 [CrossRef]25833865
  29. Todd NJ, Jones SH, Hart A, Lobban FA. A web-based self-management intervention for bipolar disorder ‘living with bipolar’: a feasibility randomized controlled trial. J Affect Disord. 2014;169:21–29. doi:. doi:10.1016/j.jad.2014.07.027 [CrossRef]25129531
  30. Murray G, Leitan ND, Berk M, et al. Online mindfulness-based intervention for late-stage bipolar disorder: pilot evidence for feasibility and effectiveness. J Affect Disord. 2015;178:46–51. doi:. doi:10.1016/j.jad.2015.02.024 [CrossRef]25795535
  31. Lobban F, Dodd AL, Sawczuk AP, et al. Assessing feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline): a randomized controlled trial. J Med Internet Res. 2017;19(3):e85. doi:. doi:10.2196/jmir.7008 [CrossRef]28341619
  32. Gliddon E, Cosgrove V, Berk L, et al. A randomized controlled trial of MoodSwings 2.0: an internet-based self-management program for bipolar disorder. Bipolar Disord. 2019;21(1):28–39. doi:. doi:10.1111/bdi.12669 [CrossRef]
  33. Fletcher K, Foley F, Murray G. Web-based self-management programs for bipolar disorder: insights from the online, recovery-oriented bipolar individualised tool project. J Med Internet Res. 2018;20(10):e11160. doi:. doi:10.2196/11160 [CrossRef]
  34. Berry N, Lobban F, Bucci S. A qualitative exploration of service user views about using digital health interventions for self-management in severe mental health problems. BMC Psychiatry. 2019;19(1):35. doi:. doi:10.1186/s12888-018-1979-1 [CrossRef]30665384
  35. Fletcher K, Foley F, Thomas N, et al. Web-based intervention to improve quality of life in late stage bipolar disorder (ORBIT): randomized controlled trial protocol. BMC Psychiatry. 2018;18. doi:. doi:10.1186/s12888-018-1805-9 [CrossRef]

Commonalities of Psychological Treatments for Bipolar Disorder

<list-item>

■ Understanding bipolar disorder and its treatments

</list-item><list-item>

■ Monitoring mood

</list-item><list-item>

■ Identifying early warning signs of relapse and triggers

</list-item><list-item>

■ Stress management and dealing with interpersonal conflicts

</list-item><list-item>

■ Stabilize sleep/wake rhythms and daily routines

</list-item><list-item>

■ Develop crisis plans and relapse prevention plans

</list-item><list-item>

■ Medication adherence

</list-item><list-item>

■ Healthy habits (exercise, nutrition, reduce alcohol or drug use)

</list-item><list-item>

■ Reduce self-stigmatization

</list-item>
Authors

Kathryn Fletcher, PhD, MClinPsychol, BSc (Hons), is a Postdoctoral Research Fellow. Greg Murray, PhD, MClinPsychol, BA (Hons), BSc (Hons), is the Director. Both authors are affiliated with the Centre for Mental Health, Swinburne University of Technology.

Disclosure: The authors have no relevant financial relationships to disclose.

Address correspondence to Greg Murray, PhD, MClinPsychol, BA (Hons), BSc (Hons), Swinburne University of Technology, PO Box 218, John St Hawthorn, Victoria, Australia; email: gwm@swin.edu.au.

10.3928/00485713-20190808-01

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