CLINICAL SYNTHESIS

Psychosocial Approaches to the Treatment

of Bipolar Disorder
David J. Miklowitz, Ph.D., and Michael J. Gitlin, M.D.

Even when treated with best-practice pharmacotherapy, many patients with bipolar disorder have slow recoveries from
illness episodes, high rates of recurrence, and considerable functional impairment. This article reviews randomized trials of
psychotherapy as adjunctive to pharmacotherapy. There is evidence for the efficacy of family-focused interventions, group
psychoeducation, interpersonal and social rhythm therapy, and cognitive-behavioral therapy in delaying or preventing
relapses and stabilizing illness episodes. Although these treatments share many common strategies (e.g., psychoeducation),
little is known about how they work, when in the illness progression they should be administered for maximal effect, and how
to efficiently train large numbers of community clinicians. Online versions of psychoeducational care are being developed,
with promising early results. Studies that identify changes in neural circuitry that mediate the effects of psychosocial in-
tervention may be especially informative in clarifying targets of evidence-based psychosocial care.
Focus 2015; 13:37–46; doi: 10.1176/appi.focus.130106

CLINICAL CONTEXT
Bipolar Disorder: Prevalence, Course, and Disability
Bipolar disorder is a highly disabling illness, with average
onset at 18 years, low academic and social achievement in
childhood, high rates of drug or alcohol abuse in adolescence
and adulthood, and high rates of suicide and cognitive dys-
function throughout the lifespan. The lifetime prevalence in
the United States is 1.0% for bipolar I disorder, 1.1% for bi-
polar II disorder, and 2.4% for subthreshold bipolar disorder
(1), with lower rates in a cross-national epidemiologic study
(2). Approximately 2% of adolescents have had manic episodes
(3). Across clinical studies conducted in different countries,
lifetime rates of bipolar disorder in childhood converge on
1.8% (4), suggesting that rates may be increasing in more re-
cent birth cohorts.
Pharmacological regimens for bipolar disorder include
mood stabilizers (commonly, lithium, valproate, or lamotrigine)
or second-generation antipsychotics (i.e., quetiapine, olanza-
pine, aripiprazole, risperidone, ziprasidone, and lurasidone).
Antidepressants, when given at all, are usually prescribed
adjunctively to mood stabilizers. Even with optimal medica-
tion regimens, however, only 21%–27% of patients with bi-
polar depression recover fully from episodes within 1 year (5)
and 37%–49% have recurrences (6, 7). Five-year relapse rates
in naturalistically treated samples typically range from 60% to
85% (8).
Even when treated with best-practice pharmacotherapy,
many bipolar patients have subthreshold depressive symptoms
that persist after acute episodes of mania or depression. Sub-
threshold symptoms have considerable prognostic significance:
even mild levels of residual depression are associated with
low levels of psychosocial functioning and high risk for
recurrences (9, 10). Lack of full remission—indicating that the
illness is still active—is associated with a shorter time to
recurrences of depression or mania (11). Moreover, many
patients have residual psychosocial impairments following
episodes that are not targeted by medications (9, 10). For
example, lack of social support following acute mood epi-
sodes was associated with more severe depressive symp-
toms at 1-year follow-up, especially among patients who did
not fully recover from the their acute episodes (12). Corre-
spondingly, treatments that bring the patient to a full and
durable remission and enhance social support during the
postepisode period are most likely to prevent or delay
recurrences.
Psychosocial Treatments as Adjunctive
to Pharmacotherapy
When evaluated against the backdrop of the growing num-
ber of pharmacological options for bipolar disorder, prog-
ress in psychological interventions has been relatively slow.
Yet, adding psychotherapy to pharmacotherapy has been
found to reduce rates of recurrence by 50% or more com-
pared with usual care (13). Additionally, 31 of 35 controlled
studies examining the efficacy of psychosocial interventions
have shown efficacy when compared with control conditions

Focus Vol. 13, No. 1, Winter 2015 focus.psychiatryonline.org 37

PSYCHOSOCIAL APPROACHES TO THE TREATMENT OF BIPOLAR DISORDER
(typically, nonspecific treatments or usual care) (14). Most
treatment guidelines for bipolar disorder recommend add-
ing psychotherapy (at minimum, psychoeducation sessions
focused on illness management) to medications to speed
recovery from mood episodes, delay or minimize recur-
rences, and enhance psychosocial functioning (e.g., refer-
ence 15, 16.).
Therapy modalities with evidence of efficacy in bipolar
disorder include cognitive-behavioral therapy (CBT), group
psychoeducation, family-focused therapy (FFT), and in-
terpersonal and social rhythm therapy (IPSRT). This article
reviews recent randomized trials of psychosocial inter-
ventions, emphasizing major strategies, putative therapeutic
ingredients, and limitations. We conclude with clinical and
research recommendations, with particular emphasis on
community implementation studies.
The Role of Stress in Bipolar Disorder
What psychological characteristics of individuals with bi-
polar disorder—or their life contexts—would one seek to
modify in psychotherapy? When evaluated in remission,
bipolar patients do not appear to have consistent personality
types or patterns of dysfunctional thinking that distinguish
them from individuals with other disorders. There is evi-
dence, however, that many bipolar patients are highly stress-
sensitive (i.e., prone to rapid recurrences following life
stressors; 17, 18) and that childhood adversity (i.e., sexual,
physical, or emotional abuse) potentiates this stress sensi-
tivity (19, 20). Life events that cause changes in sleep/wake
rhythms (21) or increases in goal-directedness (22) may
precipitate manic symptoms in otherwise stable patients.
Negative life events, such as the loss of a significant other, are
more closely associated with depressive episodes, especially
in the absence of adequate social supports (18).
Much like patients with other psychiatric disorders, bi-
polar patients are quite sensitive to family conflict and dis-
tress. Bipolar patients who have caregivers who are high
in “expressed emotion” when discussing the patient with
a clinician (i.e., express highly critical, hostile, or overpro-
tective attitudes or beliefs) or when interacting directly
with the patient are more likely to relapse over 9 months
than those in less affectively charged (low expressed emo-
tion) caregiver/patient relationships (23). Most recently, the
role of childhood adversity has been highlighted as a pre-
dictor of initial and recurrent mood episodes (20). In the
Stanley Foundation multisite study of bipolar disorder, sex-
ual and physical abuse were associated with earlier age at
onset, more medically serious suicide attempts, more illness
episodes, and substance abuse comorbidity (24, 25).
Thus, stress plays an important role in the onset of mania
and depression among individuals with bipolar disorder,
through both genetic and environmental risk pathways.
Conversely, teaching patients strategies for coping with
stressful events, even if they do not directly address child-
hood contexts, may reduce the impact of such stressors on
relapse and psychosocial impairment.
38 focus.psychiatryonline.org
TREATMENT STRATEGIES AND EVIDENCE
Common Elements of Psychotherapy
Psychosocial treatments are intended as adjuncts to phar-
macotherapy and are typically offered during the post-
episode “continuation” phase or the maintenance phase of
treatment. They are present-focused and emphasize learn-
ing skills for managing the disorder (psychoeducation). Al-
though the modalities have common objectives (Table 1),
there are distinct elements as well: format (e.g., whether
treatment is given individually, in groups, or in family units),
length (minimum 3–6 sessions and up to 30 or more), and
whether treatment is intended for patients in remission,
those recovering from an acute episode, or both.
In the following sections, we review randomized trials of
psychotherapy. Further details of these trials, and coverage
of psychotherapy methods that have only been tested in
uncontrolled trials, are available elsewhere (26, 27).
Cognitive-Behavioral Therapy (CBT)
CBT approaches to bipolar disorder consist of three core
strategies: behavioral activation (i.e., helping patients to in-
crease activity levels when depressed and “dial it down” when
their moods escalate), relapse prevention (identifying pro-
dromal symptoms of new episodes and implementing pre-
emptive plans), and cognitive restructuring (modifying
automatic negative thoughts and core dysfunctional beliefs).
Behavioral activation may include reducing daily activities to
avoid overstimulation, even if these events are pleasurable.
Cognitive restructuring may involve challenging “hyperposi-
tive” thinking (e.g., “I cannot lose…I’m in complete control of
my fate”) as well as overly pessimistic thinking.
Cognitive-behavior therapy has the most extensive re-
cord of randomized trials in bipolar disorder, although CBT
protocols vary from study to study. In the U.K. study of Lam
et al. (28), 103 euthymic patients with bipolar disorder were
randomly allocated to CBT (12–18 sessions) plus pharma-
cotherapy or usual care (pharmacotherapy alone). CBT
emphasized psychoeducation, challenging dysfunctional
cognitions, and medication adherence monitoring. At 1 year,
44% of the patients in CBT had relapsed versus 75% of those
in usual care. At 30 months, patients in CBT no longer dif-
fered from patients in usual care on time to overall relapse,
but they did have fewer depressive relapses and days in mood
episodes.
Scott and associates (29) examined 22 sessions of CBT
compared with treatment as usual (TAU) among 253 bipo-
lar patients treated in five U.K. mental health centers. Un-
like the Lam et al. (28) study, patients began in a variety of
symptom states. No differences were found between CBT
and TAU on time to recurrence over 18 months. However,
a post hoc analysis revealed that patients who had fewer
prior episodes were more likely to have recurrences in TAU
(55%) than in CBT (41%), whereas recurrences were more
likely among those who had many prior episodes in CBT (81%)
than TAU (66%). These results suggest two possibilities: CBT
Focus Vol. 13, No. 1, Winter 2015

is best suited to the earliest phases of the disorder, or CBT
may be unsettling and agitating to patients who are unstable,
have a more refractory illness, or have more cognitive
impairment.
In a well-designed Canadian trial of 204 patients in full or
partial remission, participants were randomly assigned to 20
sessions of individual CBT or 6 sessions of group psycho-
education (30). No differences emerged over 1.5 years in
symptom severity or recurrence rates. Given that group psy-
choeducation cost an average of $180 per participant whereas
CBT cost $1,200 per participant, group psychoeducation
would appear to be the more cost-effective alternative.
Finally, investigators at the University of Tubingen, Ger-
many randomized 76 patients to 20 sessions of CBT or 20
sessions of individual supportive therapy, both with phar-
macotherapy (31). The patients had subthreshold manic or
depressive symptoms, but none were in an acute episode. No
differences were observed in relapse rates over 33 months
(overall rate, 64.5%). The authors point to the common ele-
ments of the two approaches (i.e., provision of information,
systematic mood monitoring) in explaining the lack of dif-
ferences on relapse. Additionally, the length of the two treat-
ments proved informative: risk for relapse decreased by 10%
with each therapy session that patients attended, regardless of
the treatment condition.
Group Psychoeducation
Several research teams have evaluated group treatment in
conjunction with pharmacotherapy for relapse prevention.
Group treatments take advantage of the social support pro-
vided by other patients, who may enliven psychoeducation
with real-life examples. Colom and associates (32) at the
University of Barcelona tested a 21-session group treatment
that included exercises to promote greater awareness of
illness states, early detection and intervention with pro-
dromal symptoms, the importance of medication adherence,
and enhancing stability through lifestyle (e.g., sleep/wake
cycle) regularity. Although this group treatment had ele-
ments in common with CBT, it made minimal use of cog-
nitive restructuring or behavioral activation (pleasant
events) schedules (33). Colom et al. found that, over 2 years
a 21-session structured psychoeducation group was associated
with fewer recurrences (67% versus 90%) and better psy-
chosocial functioning than a 21-session support group (32).
Over 5 years, patients who had received the structured
groups had far fewer days of acute illness (mean 154 days)
compared with those who received the unstructured group
(586 days) (34).
Two randomized trials examined the effectiveness of
group psychoeducation within the context of multicom-
ponent care plans. In 11 Department of Veterans Affairs
sites (35), 306 patients received mood monitoring from
a nurse care coordinator and group psychoeducation (5
weekly followed by twice monthly groups for up to 3 years)
to improve relapse prevention skills. Over a 3-year period,
patients in the multicomponent program spent fewer weeks
Focus Vol. 13, No. 1, Winter 2015
MIKLOWITZ AND GITLIN
TABLE 1. Objectives of Adjunctive Psychotherapy for Bipolar
Disorder
Improve ability to identify and intervene early with incipient signs
of relapse
Enhance emotion-regulation skills
Improve family relationships (i.e., enhance interpersonal
communication and problem-solving)
Increase acceptance of the disorder and its treatments
Enhance adherence with medication regimens
Stabilize sleep/wake cycles and other daily or nightly routines
Reduce drug and alcohol abuse
in manic episodes than patients who received usual care.
Patients in multicomponent care also had significant im-
provements in social functioning and quality of life.
The largest randomized trial in bipolar disorder (N=441)
tested a similar 2-year multicomponent care intervention—
with group psychoeducation at the same frequency—within
the Kaiser Permanente health network (36). Patients in the
multicomponent intervention had lower mania scores and
spent less time in manic or hypomanic episodes than pa-
tients in a usual care condition. Neither this study nor the
Bauer et al. study found effects of the multicare program
on depressive symptoms. “Dismantling” design studies, in
which modules of multicomponent treatments are tested
with and without each other, will provide one avenue for
determining the unique contribution of group psycho-
education to symptom outcomes.
An adaptation of structured psychoeducation groups
called “functional remediation treatment” emphasizes
patients’ cognitive functioning, with exercises designed to
improve memory, attention, problem solving, and organiza-
tional skills. In a 10-site randomized trial in Spain, 268 patients
were assigned to 21 weekly group sessions of functional re-
mediation, 21 sessions of standard group psychoeducation,
or TAU (37). Patients in the functional remediation groups
showed greater improvements in psychosocial functioning
than those in TAU, but fared only slightly better than patients
in the standard psychoeducation groups.
Hence, group psychoeducation has been shown to be
an effective and, in all probability, cost-effective adjunct
to pharmacotherapy for patients with bipolar disorder. Its
role in treating and preventing manic symptoms is more con-
sistent than for depressive symptoms. Research on the pro-
cesses that mediate the effects of group psychoeducation—for
example, whether being treated alongside of others leads
to decreased stigmatization and a greater willingness to
adopt illness management strategies—may lead to the de-
velopment of even more powerful group approaches. Group
treatments may be more difficult to implement in public or
private settings where treatment is dispersed across dif-
ferent providers and locations, but the availability of Skype
and other online communication tools may minimize these
limitations.
focus.psychiatryonline.org 39
PSYCHOSOCIAL APPROACHES TO THE TREATMENT OF BIPOLAR DISORDER
Family-Focused Treatment (FFT)
Given in up to 21 weekly followed by biweekly sessions
during the postacute (continuation) period, FFT aims to
hasten stabilization and reduce the likelihood of recurrences
of bipolar disorder (38). In the initial treatment phases,
patients and family caregivers (usually spouse or parents)
are instructed in how to recognize early warning signs of
mania or depression and develop prevention strategies (e.g.,
how best to alert the patient to changes in his or her moods
or behavior, rehearsing what to say to the attending psy-
chiatrist). Assisting patients in stabilizing their sleep/wake
cycles and staying adherent to medications are also key
strategies of family psychoeducation; however, clinicians
encourage family members to recognize their roles in these
problems (e.g., a parent who sets no limits on a 15-year old
who stays up all night playing video games, a spouse who
supports the patient in believing that marijuana is a good
substitute for mood stabilizers). In later stages of FFT (6–9
months), clinicians assist families in skills training for en-
hancing communication (i.e., learning to listen actively, re-
quest changes in each other’s behavior, offer both positive
and constructive negative feedback) and problem-solving. At
this point, patients are often able to return to tasks that were
on hold during and following acute episodes (e.g., parenting
of young children).
Unlike CBT or group psychoeducation, FFT sessions always
involve family members, and skills training focuses on im-
proving family relationships. Cognitive restructuring is not
a key component of treatment except in cases where, for ex-
ample, patients’ or caregivers’ attitudes are based on mis-
information about the illness (e.g., “lithium destroys brain
cells”; “bipolar disorder is no different than just being moody”).
Table 2 summarizes the randomized trials of FFT in
adults and adolescents with bipolar disorder. Overall, FFT
and pharmacotherapy have been associated with a 35%–40%
reduction over 2 years in recurrence rates compared with
brief psychoeducation and pharmacotherapy, with numbers
needed to treat (NNTs) ranging from 5 to 10 (39–48). In several
trials, effect sizes for FFT (compared with brief treatment) have
been stronger in patients from families with high expressed
emotion than from families with low expressed emotion, sug-
gesting that patients in high-intensity/high-conflict families
may benefit most from FFT (40, 41, 47).
Family Interventions for Pediatric Bipolar Spectrum
and High-Risk Conditions
Despite the greater uncertainty about the diagnostic
boundaries of pediatric bipolar conditions, there is a more
extensive empirical basis for family interventions in this
age group. Fristad and colleagues (49) examined 8-session
multifamily psychoeducational groups in which parents of
bipolar children had the opportunity to interact with one
another. The psychoeducational material included infor-
mation about mood management, communication skills,
and coping strategies to avert mood escalation. In the largest
pediatric study to date, 165 bipolar (70%) and depressed
40 focus.psychiatryonline.org
(30%) children (ages 8–12 years) were randomly assigned to
immediate 6-month group treatment or a delayed group
treatment in which treatments were given from study
months 12–18. Over 1 year, children whose families partici-
pated in the immediate groups showed greater improvement
in affective symptoms than children whose families were
waitlisted (49). The clinical benefits of psychoeducation
were mediated by improvements in parents’ ability to ad-
vocate for their child’s mental health care and the higher
quality of services utilized. In turn, quality of services was
associated with improved mood symptoms in children over
1 year (50).
The 12-session child and family-focused cognitive be-
havioral therapy program (also known by the acronym
“RAINBOW”) incorporates single-family psychoeducation
sessions with individual parent psychoeducation and CBT
for the child (cognitive restructuring, behavioral activation
[pleasurable events scheduling], and mindfulness meditation)
(51). In a randomized trial with 69 children and adolescents
(ages 7–13, mean 9 years) who also received medication
management, greater improvements were observed over 6
months for mania symptoms, depressive symptoms, and
global functioning scores compared with an equally in-
tensive psychosocial TAU condition (51).
FFT has been examined in two trials with bipolar ado-
lescents (FFT Adolescent version, or FFT-A). In the first,
adolescents with bipolar I, II, or not otherwise specified
disorder who received 21 sessions of FFT and pharmaco-
therapy had more rapid recovery from depressive episodes
at study entry, less time in depressive episodes at follow-up,
and more time well over 2 years compared with adolescents
in brief psychoeducation (“enhanced care”) and pharmaco-
therapy (40). A second trial involving 145 adolescents with
bipolar I or II disorder treated over three sites did not replicate
these results: adolescents in FFT-A and those in enhanced care
(both administered with best practice pharmacotherapy) were
equivalent in time to recovery and time to recurrence. Ado-
lescents in FFT-A, however, had fewer severe manic symptoms
in the second study year than those in enhanced care (39).
Children and teens who are at high risk for bipolar dis-
order, typically defined as those with bipolar disorder not
otherwise specified or major depressive disorder who have
at least one first-degree relative with bipolar I or II disorder,
also have positive responses to FFT. In a 1-year randomized
controlled trial, genetically predisposed children and ado-
lescents (ages 9–17 years) who received 12 sessions of FFT
(high-risk version) with or without pharmacotherapy re-
covered more rapidly from their initial depressive symptoms,
had more weeks in remission, and showed greater improvement
in hypomania symptoms over 1 year than those who received
brief psychoeducation with or without pharmacotherapy (47).
Studies currently underway will examine whether family in-
tervention is effective in delaying or preventing the onset of
bipolar I or II disorder in high-risk children.
A version of dialectical behavior therapy (DBT) has been
developed for adolescents (ages 12–18 years) with bipolar I,
Focus Vol. 13, No. 1, Winter 2015
 MIKLOWITZ AND GITLIN

TABLE 2. Randomized Trials of Family-Focused Treatment (FFT) for Patients with Bipolar Disorder or High-Risk Conditions
FFT versus
Study Sample Type of Trial Clinical State Comparison Group Key Findings
Miklowitz et al. (41) 101 adults with RCT (2 years) Depressed or manic in Crisis Management 54% survival rate in FFT
bipolar I prior 3 months (CM) (2 family versus 17% in CM
psychoeducation
sessions)
Rea et al. (42) 53 adults with RCT (2–3 years) Manic episode in prior Individual therapy 36% rehospitalized in
bipolar I 3 months (21 sessions) FFT, 60% in
individual therapy
Miklowitz et al. (43) 100 adults with Open (1 year) Depressed or manic CM FFT plus interpersonal
bipolar I/II with matched episode in prior 3 therapy associated
controls months with longer time to
relapse and less
depression
Miklowitz et al. (44, 45) 293 adults with RCT (1 year) Current episode of Collaborative care (3 At 1 year, 77%
bipolar I or II depression psychoeducation recovered in FFT;
sessions) or CC 65% in IPSRT; 60% in
CBT; 52% in CC;
better functioning in
FFT, CBT, and IPSRT
versus CC
Miklowitz et al. (40) 58 adolescents RCT (2 years) Mood episode in prior 3 enhanced care (EC) Adolescents in FFT
with bipolar I, 3 months; acutely or education sessions recovered from
II, or NOS subsyndromally ill depression 7 weeks
faster than
adolescents in EC
Perlick et al. (46) Caregivers of 46 RCT (4.7 Various states 8–12 session health Caregivers and patients
BD I adults, 1 months) program in FFT had decreases
year in depression
compared with
health program
Miklowitz et al. (47) 40 children RCT (1 year) Depression or TAU (1––2 sessions of Children in FFT
(ages 9–17 subthreshold manic family education) recovered from
years) symptoms depression 8 weeks
faster and spent
more time in
remission over 1 year
than children in TAU
Miklowitz et al. (39) 145 adolescents RCT (2 years) Mood episode in last 3 Enhanced care (3 No group differences
with bipolar I months; currently sessions of family in recovery or
or II (12–17 symptomatic education) recurrence; FFT
years) associated with less
severe manic
symptoms in year 2
Miklowitz et al. (48) 122 adolescents/ RCT (6 months) Attenuated psychotic Enhanced care (3 Patients in FFT had
young adults symptoms plus sessions of family greater reductions in
deterioration in education) positive symptoms;
functioning Patients over age 19
showed better
functioning in FFT

II, or not otherwise specified disorder (52). DBT was modeled
as a 1-year treatment consisting of 18 family skills training
(conducted with individual family units) and 18 individual
skills sessions. DBT is a cognitive-behavioral therapy that
incorporates components of Eastern philosophy (e.g., mind-
fulness meditation) to enhance emotion regulation, mindful
awareness, distress tolerance, and interpersonal skills. In
a 20-subject trial with a 2:1 randomization ratio, adolescents
were randomly assigned to DBT (N=14) or a less-intensive
psychosocial treatment condition (N=6). All participants re-
ceived medication management as well. Adolescents who
received DBT had less severe depressive symptoms and more
improvement in suicidal ideation over the year; they also
evidenced more weeks in remission (52).
There are some clues as to what variables are associated
with a positive response to family interventions versus usual

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PSYCHOSOCIAL APPROACHES TO THE TREATMENT OF BIPOLAR DISORDER
care in pediatric bipolar patients, including family expressed
emotion (53), more severe parental depression (51), and greater
child impairment at baseline (54). Currently, we do not know
what patient or family attributes predict a stronger response
to family versus individual CBT or group psychoeducation,
a fertile area for future research.
Interpersonal and Social Rhythm Therapy (IPSRT)
The interpersonal psychotherapy of depression, originally
developed as a comparison to CBT in the Treatments for
Depression Collaborative Research Program (55) has been
adapted for bipolar disorder. In both traditional IPT and
IPSRT, clinicians assist patients in resolving issues related to
grief, role transitions (e.g., divorce or separation), role dis-
putes (e.g., marital or family conflict), or interpersonal deficits
(e.g., repetitive, self-defeating behavior patterns in relation-
ships). In IPSRT, strategies to enhance social and circadian
rhythm regularity are integrated into interpersonal problem-
solving (56). Indeed, psychosocial events that disrupt daily or
nightly routines such as when a person sleeps, wakes, eats, or
exercises have repeatedly been found to precipitate episodes
of mood disorder (21, 57).
In the largest trial of IPSRT (58), 175 patients were ran-
domly assigned during an acute episode of mania, de-
pression, or mixed illness to IPSRT or intensive clinical
management (ICM, a psychoeducational control therapy),
both with protocol-based pharmacotherapy. Once patients
had stabilized (minimum 4 weeks of stability) from their acute
episode, they were rerandomized to IPSRT or ICM, with bi-
weekly and then monthly sessions for up to 2 years. Thus, four
treatment strategies were formed. The 2-year recurrence
rates were: 41% for IPSRT followed by IPSRT, 41% for IPSRT
followed by ICM, 28% for ICM followed by ICM, and 63% for
ICM followed by IPSRT. IPSRT in the acute phase was as-
sociated with a longer time to recurrence in the maintenance
phase than ICM (58). Moreover, patients in IPSRT showed
better occupational functioning during acute treatment than
those in ICM (59).
Interestingly, patients who received IPSRT acutely were
more able to stabilize their social routines and sleep/wake
cycles during acute treatment than those in ICM. Thus,
acute stabilization of sleep/wake rhythms may have down-
stream effects on the prevention of future mood instability
(60). It is less clear why rates of recurrence were highest in
those patients who switched from ICM to IPSRT for the
maintenance phase.
IPSRT may have “stand-alone” effects for patients with
bipolar II disorder. In a small trial for acute bipolar II de-
pression (60), 25 patients were randomly assigned to que-
tiapine monotherapy (beginning at 25 mg and increasing to
300 mg) or IPSRT monotherapy. Over 12 weeks, both groups
improved equally in depression scores, although absolute
response rates were low (27%–29%). Future studies should
examine whether there is an additive effect of combining
IPSRT with a second-generation antipsychotic or mood sta-
bilizer in the acute treatment of bipolar depression.
42 focus.psychiatryonline.org
A Comparison of Therapy Approaches: the
STEP-BD Study
A significant limitation of the bipolar psychotherapy litera-
ture is the lack of controlled comparisons of one specialty
treatment to another. The Systematic Treatment Enhance-
ment Program for Bipolar Disorder (STEP-BD) recruited
293 patients in a depressed phase of bipolar I or II disorder
from 15 sites, and randomly assigned these patients to 1) one
of three intensive psychosocial treatments (up to 30 sessions
of FFT, IPSRT, or CBT over 9 months) or 2) a 3-session
control treatment called collaborative care (CC). All patients
received protocol pharmacotherapy (mood stabilizers or
antipsychotics with or without an SSRI or buproprion). Over
1 year, being in any of the intensive psychotherapies was
associated with more frequent (and more rapid) recovery
from depression and better psychosocial functioning than
being in the CC treatment, but there were no statistical
differences among the intensive treatments (see Table 2 for
recovery rates) (44, 45). Patients in the intensive treatment
were 1.6 times more likely than patients in CC to be clinically
well in any given month of the study.
A reanalysis of STEP-BD data (61) revealed that having
a lifetime history of an anxiety disorder was a significant
predictor of differential response to intensive therapy versus
brief treatment. Among patients with lifetime anxiety dis-
orders (N=177), the number needed to treat to observe
a difference in intensive therapy versus CC was 5.88 (small-
to-medium effect). Among patients without a history of
anxiety disorder (N=92), the NNT to observe a difference in
intensive therapy versus CC was 50.0 (minimal effect). This
is a clinically useful finding in that pharmacotherapy for
comorbid anxiety disorders usually includes SSRIs that
can theoretically increase the risk of affective switches in
bipolar patients. The STEP-BD study suggests that psy-
chotherapy is a vital part of the effort to stabilize episodes of
bipolar depression, particularly among patients with anxiety
comorbidity. Furthermore, patients with acute depression
and anxiety may require more intensive psychotherapy than
is typically offered in community mental health centers.
QUESTIONS AND CONTROVERSIES
Despite the increasing number, variety, and sophistication of
trials of psychotherapy for bipolar disorder over the past
decade, we are left with fairly simple conclusions. First,
psychotherapy is an effective adjunct to pharmacotherapy in
the postepisode or remitted phases of bipolar disorder, with
significant evidence for several forms of family intervention,
group psychoeducation, IPSRT, and CBT. These treatments
focus on illness management (psychoeducation) and, to a
lesser extent, interpersonal skill training. Treatments found
to be more effective than usual care are usually 12 or more
sessions and last at least 4–6 months.
Psychotherapies that have an effect on recurrence rates
also reduce hospitalization days, suggesting economic ben-
efits. For example, one study of FFT found that patients with
Focus Vol. 13, No. 1, Winter 2015

bipolar disorder were less likely to relapse over 2 years than
patients in comparably intensive individual psychoeducation
and were less likely to require hospitalization when they did
relapse (42). In the first Barcelona study (32), structured
psychoeducation groups were associated with a cost savings
of approximately $6,500 per patient over 5 years (62). The
“price point” at which psychotherapies pay for themselves in
terms of illness or treatment cost savings (e.g., reductions in
costs of medications, lost days from work, insurance copays)
will be of interest to patients, clinicians, and health care
administrators, but we are far from determining how this
price point differs across settings, age groups, or clinical
presentations.
We do not know what forms of psychotherapy are the
most effective for different phases of illness. Studies of group
psychoeducation (e.g., 32) or CBT (28) specify up to 6
months of remission as an entry criterion, which would
significantly reduce the number of eligible patients in many
settings. Both FFT and IPSRT include patients who have
subthreshold levels of illness and make use of current
symptoms as a teaching tool for defining prodromal symp-
tom states. Some patients may only need a brief period of
psychoeducation and support to help make sense of their
recent mood episode and do not need longer-term therapy;
patients who respond quickly to medications may be in this
group. The role of comorbid disorders other than anxiety,
including substance abuse or personality disorders, in
specifying the type and frequency of treatment deserves
study.
We know relatively little about “mediating variables” or
change mechanisms responsible for why patients improve in
one treatment versus another. Ideally, a study of mediating
mechanisms would compare two or three forms of intensive
psychotherapy after an acute episode and measure presumed
mediators at baseline, midtreatment, and after treatment to
determine whether changes in the mediator precede changes
in symptoms or functioning. An example in FFT is the study
of Simoneau et al. (63), who measured family interactional
behavior in laboratory problem-solving tasks before and after
FFT or after brief psychoeducation. Adult bipolar patients
showed greater increases in positive verbal and nonverbal
behavior from pretreatment to posttreatment in FFT than in
the brief treatment. Moreover, these changes in interactional
behavior predicted the degree of improvement in mood symp-
toms among patients over a 9-month treatment interval. Be-
cause it only measured family interactions at two time points,
this study falls short of showing that changes in family behavior
are causally related to changes in patients’ symptoms. None-
theless, identifying correlates of symptom change at the cog-
nitive, emotional, or interpersonal levels may give us clues as to
what treatments are the most powerful in bringing about
meaningful clinical change and how to make these treatments
more efficient. In the same vein, the ability of pharmacolog-
ical agents to change specific biological markers (e.g., brain-
derived neurotrophic factor) may eventually guide our choice
of drug treatments.
Focus Vol. 13, No. 1, Winter 2015
MIKLOWITZ AND GITLIN
A related issue is the importance of measuring changes in
neural processes from before to after psychosocial treat-
ments. For example, using a repeated measure neuroim-
aging design, one could examine whether patients with
bipolar disorder show decreases in amygdala activation and
increases in dorsolateral or ventrolateral prefrontal cortical
activation when viewing negative facial stimuli from before
to after psychotherapy. Integrating the study of psycho-
therapy with brain imaging techniques may also help de-
termine what patients are the best candidates for intensive
therapy. A pilot study found that amygdala hyperactivation
when viewing fearful faces predicted the degree of response
to FFT versus TAU in children at high risk for bipolar dis-
order (64).
RECOMMENDATIONS FROM THE AUTHORS
In conducting this review, we have been struck by the lack
of evidence for dissemination of evidence-based psycho-
therapies in clinical practice with bipolar patients. Few of
the available treatments are being implemented at the com-
munity level, in part because of the difficulty in accessing
training and supervision from experts. Treatment manuals
that are easy to obtain and digest, followed by low-cost su-
pervision of training cases, will be needed before treatments
can be disseminated on a larger scale. Computer-assisted
learning methods, such as webinars (instead of weekend
workshops), online methods of supervision (e.g., chat rooms),
and clinician- or patient-administered measures of treatment
fidelity (rather than supervisory tape viewing) will all be
useful in reducing training costs (65). These methods, how-
ever, may be less satisfying to learners and may affect their
motivation.
In some community mental health centers, training one
highly motivated clinician to “champion” the treatment and
train others (the “train the trainer” model) can be of im-
mense help in encouraging the broader adoption of novel
psychotherapy methods (65). In community care, admin-
istrators will have to provide individual clinicians with re-
lease time to obtain this specialized level of training.
Clinicians need to adapt the existing treatment manuals
to their practice settings, taking into account the treatment
framework normally used in that setting. So, for example,
a clinic in which the majority of practitioners are psycho-
analytically trained may more easily adopt IPSRT than CBT
or FFT. Moreover, clinicians may work in settings in which
patients are not fluent in English, structured diagnostic
interviews are not considered cost-effective, psychiatric med-
ications are dispensed by a general practitioner, or therapy
protocols that exceed 6–8 sessions are not economically
feasible. Fortunately, certain treatments, including FFT and
IPSRT, have modules that can be given separately from the
full protocols (e.g., prodromal symptom monitoring, relapse
prevention planning, social rhythm tracking and stabiliza-
tion, family communication training) and implemented as
stand-alone strategies.
focus.psychiatryonline.org 43
PSYCHOSOCIAL APPROACHES TO THE TREATMENT OF BIPOLAR DISORDER
Web-centered treatment, in which all components of an
intervention are delivered through an interactive website,
is becoming increasingly available (65). An online self-care
program, “Living with Bipolar,” successfully engaged patients
and was associated with higher quality of life scores than a
waitlist control (66). Another program, bipolarcaregivers.org,
was useful to caregivers in navigating the complexities of bi-
polar disorder and the mental health system. It was less useful
to caregivers of highly chronic patients or those who had com-
plex family problems (67). Further evaluation of online psycho-
education, either as an adjunct to evidence-based psychosocial
treatments or as a substitute for them, is clearly needed.
Finally, future research must determine the best point in
illness development to begin intervening with psychosocial
therapy, and at what level of intensity. Treatment focused on
the earliest symptom phases may interrupt neurotoxic pro-
cesses of the illness and enhance long-term outcomes (68).
Early intervention may be most effective if it is successful in
modifying biomarkers or psychosocial risk processes that
are dysregulated prior to illness onset.
The timing and duration of early interventions, however,
should not be solely based on their costs or presumed effi-
cacy at the group level. Early interventions must also be
personalized. Children or adolescents with early signs of
bipolar disorder are not always motivated for treatment, nor
are their parents necessarily invested in preventing a disor-
der that may not develop anyway. Targeted interventions
that focus on disorders that herald the development of bi-
polar disorder in genetically susceptible children, such as
anxiety disorders, ADHD, conduct disorder, depression, or
substance/alcohol abuse, may be seen as more relevant and
acceptable to patients and parents. Finally, early interventions
may achieve considerable effects by building on resilience
factors in patients, families, or even communities, such as by
increasing community awareness of treatment options for
depression and bipolar disorder (69).
AUTHOR AND ARTICLE INFORMATION
David J. Miklowitz, Ph.D., Department of Psychiatry, University of Cal-
ifornia, Los Angeles (UCLA) School of Medicine, Los Angeles, CA
Michael J. Gitlin, M.D., Department of Psychiatry, University of California,
Los Angeles (UCLA) School of Medicine, Los Angeles, CA
Address correspondence to David J. Miklowitz, Ph.D., Division of Child
and Adolescent Psychiatry, UCLA Semel Institute Room 58-217, David
Geffen School of Medicine, 760 Westwood Plaza, Los Angeles, CA
90024-1759; e-mail: dmiklowitz@mednet.ucla.edu
Dr. Miklowitz has received research funding from the National Institute
of Mental Health, the National Alliance for Research on Schizophrenia
and Depression, the American Foundation for Suicide Prevention, the
Attias Family Foundation, the Danny Alberts Foundation, the Carl and
Roberta Deutsch Foundation, the Kayne Family Foundation, and the
Knapp Foundation; and book royalties from Guilford Press and John
Wiley and Sons. Dr. Gitlin has received honoraria from Otsuka and
Bristol Myers Squibb.
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