European Psychiatry 20 (2005) 359–364

http://france.elsevier.com/direct/EURPSY/

Original article

Psychoeducation: improving outcomes in bipolar disorder

Francesc Colom a,*, Dominic Lam b,*
a
Bipolar Disorders Program, IDIBAPS, Barcelona Stanley Medical Research Center, Barcelona, Spain
b
Henry Wellcome Building (PO77), Psychology Department, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK
Available online 19 August 2005

Abstract

Background. – A relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of
psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierar-
chical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between
theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance
treatment of bipolar patients.
Methods. – A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases.
“Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords.
Results. – Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction
with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment,
and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and
reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance
enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients’ health
beliefs and illness-awareness.
Conclusions. – The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays
unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer
the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological
agents.
© 2005 Published by Elsevier SAS.

Keywords: Bipolar disorder; Psychoeducation; Cognition; Psychotherapy

1. Introduction: why psychoeducation?
Bipolar illness is a severe, chronic and recurrent condition
that represents a major health problem resulting in economic
burden and high mortality rates [2,15,28,40]. The efficacy of
some psychological treatments in preventing relapses has lead
to a relevant paradigm shift in the treatment of bipolar disor-
der, switching from an exclusively pharmacological therapeu-
tic approach, to a combined yet hierarchical model in which
pharmacotherapy plays a central role, and psychological inter-
ventions help cover the gap that exists between theoretical
efficacy and “real world” effectiveness. Most of the psycho-
therapy studies recently published report positive results on
* Corresponding authors. Tel.: +34 93 227 5401; fax: +34 93 207 5678
(F. Colomb); tel.: +44 20 7848 0885; fax: +44 20 7848 5006 (D. Lam).
E-mail address: fcolom@clinic.ub.es (F. Colom).
0924-9338/$ - see front matter © 2005 Published by Elsevier SAS.
doi:10.1016/j.eurpsy.2005.06.002
maintenance when used as an adjuvant treatment, and effi-
cacy
in the treatment of depressive episodes. Interestingly, several
groups from all over the world reported similar positive results
and reached very similar conclusions; almost every interven-
tion tested contained important psychoeducative elements
including both compliance enhancement and early identifi-
cation of prodromal signs — stressing the importance of life-
style regularity — and exploring patients’ health beliefs and
illness-awareness.
Psychoeducation also seems to be a key intervention in
the enhancement of treatment adherence and improvement
of long-term outcome in several medical conditions such as
cardiac illness [27], diabetes [33] and asthma [14]. Psycho-
education is simply a key element of a good medical practice
and covers a fundamental right of our patients: the right to be
informed about their illness. But psychiatric disorders—
especially those that may lead to a lack of insight or illness-
360 F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
awareness—are, due to their intimate nature where behavior
and decision-making are often altered, the field that may ben-
efit more from this intervention.
2. Psychoeducation: an evidence-based approach
Despite the considerable variability of proposed ap-
proaches and paradigms to psychological treatments—from
psychoanalysis and humanist approaches to behavioral
therapy—many of the therapeutic proposals have not been
tested, and therefore, should not be considered for routine
treatment unless further supportive evidence has been estab-
lished [8]. Fortunately, in the last few years, we have moved
to a phase of consolidation of well-tested approaches, with
most studies indicating a high efficacy of psychoeducation-
based programs in the prevention of relapses [10,35]. The
pioneering studies in the field, carried out by Peet and Har-
vey, reported some changes in patients’ attitudes towards
lithium [17,34]. Unfortunately, little attention was paid to
major outcome measures such as relapses. In Europe, the stud-
ies of Eduard van Gent showed a significant decrease of non-
compliant behavior and hospitalizations amongst psychoedu-
cated patients [41].
The Barcelona Bipolar Disorders Program has shown the
efficacy of group psychoeducation in preventing all types of
bipolar episodes—manic or hypomanic, mixed and
depressive—and increasing time to relapse at the 2-year
follow-up [11]. Depressed patients may tend to only get nega-
tive aspects of psychoeducational information and may have
serious cognitive difficulties that may hinder the learning pro-
cesses needed in psychoeducation. Manic patients can be dis-
ruptive and do not absorb the information because of distract-
ibility and other cognitive disturbances. Hence,
psychoeducation should be always performed during eu-
thymia; in this study, patients were required to have main-
tained an euthymic state (Young Mania Rating Scale
[YMRS] < 6, Hamilton Rating Scale for Depression [HAM-
D] < 8) for at least 6 months prior to entering the study. The
study had a reasonably large sample size (n = 120) and a ran-
dom allocation of subjects to either a treatment condition (psy-
choeducation plus standard pharmacological treatment) or
non-intervention (non-structured meetings plus standard phar-
macological treatment) [10]. The psychoeducational group
consisted of 8–12 patients, twenty 90-min sessions under the
direction of two trained psychologists. The content, which
followed a medical model with a directive style, encouraged
participation and focused on the illness rather than on psy-
chodynamic issues. At the end of the 2 year follow-up, the
number of hospitalizations per patient was lower for the psy-
choeducation group, although the number of patients who
required hospitalization did not change significantly. This can
be interpreted as psychoeducation having good attributes for
avoiding the impact of the “revolving door” phenomena in
the bipolar population.
Interestingly, a recent sub analysis of the study data shows
that psychoeducation may even be useful in those complex
patients fulfilling criteria for a comorbid personality disorder
[12]. This might be particularly interesting if we consider on
the one hand the poor outcome of comorbid bipolar patients
[4,13,26,42] and on the other hand the complexity of its treat-
ment [5,9]. Thus, psychoeducation may be especially useful
for the more difficult-to-treat bipolar patients.
The Barcelona Bipolar Disorders Program group tried to
replicate the Archives’ study, paying attention to the specific
role of psychoeducative elements beyond the simple — but
indispensable — enhancement of treatment adherence [11].
This was a randomized clinical trial using the same 21-session
program, but included only 50 bipolar I patients who fulfilled
criteria for being considered as treatment compliant (elicited
by compliance-focused interviews with the patients and
his/her first-degree relatives or partner, and plasma concen-
trations of mood stabilizers) [11]. The trial was designed to
clarify whether the influence of psychoeducation goes beyond
the improvement of treatment adherence, and positive results
were seen: the effect size was similar to the Archives’ study,
as were the results. Time to relapse was longer for psycho-
educated patients and, at the end of the 2 year follow-up, 92%
of subjects in the control group fulfilled criteria for recur-
rence, versus 60% in the psychoeducation group (P < 0.01).
The number of total recurrences and the number of depres-
sive episodes were significantly lower in psychoeducated
patients.
There is also good evidence for the efficacy of a
psychoeducation-focused family intervention from the stud-
ies performed by the Colorado group guided by David Mik-
lowitz. Miklowitz et al. carried out a randomized study among
101 bipolar patients who were stabilized on maintenance drug
therapy and were randomized to receive either 21 sessions of
family-focused psychoeducational treatment (n = 31) or two
family education sessions and follow-up crisis management
(n = 70), both treatments delivered over a 9 month period [30].
After a 2 year follow-up, patients assigned to the longer psy-
chosocial treatment had fewer relapses, longer times to
relapse, significantly lower non-adherence rates than patients
assigned to the shorter intervention and even some improve-
ment in certain mood symptoms. Thus, professionals may
expect to see great treatment benefits from use of this integral
approach, especially when combined with other individual
therapies [29].
3. Topics to be addressed in a psychoeducational
program
Psychoeducation of bipolar patients should include infor-
mation about the high recurrence rates associated with the
illness, drugs and their potential side-effects, early detection
of prodromal symptoms and symptoms management, the
importance of avoiding illicit substances and alcohol, the
importance of maintaining routines, stress management and
some concrete information about issues such as pregnancy
and bipolar disorder, suicide risk, stigma, social problems
related to the illness, etc. (Table 1).
 F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364 361

Table 1
Sessions of the psychoeducation program [10,11]
Contents of the Barcelona Psychoeducative Program
1. Introduction
2. What is bipolar illness?
3. Causal and triggering factors
4. Symptoms (I): mania and hypomania
5. Symptoms (II): depression and mixed episodes
6. Course and outcome
7. Treatment (I): mood stabilizers
8. Treatment (II): antimanic agents
9. Treatment (III): antidepressants
10. Serum levels: lithium, carbamazepine and valproate
11. Pregnancy and genetic counseling Fig. 1. Concerns about medication, following the BEAM survey [32].
12. Psychopharmacology vs. alternative therapies side effects, and “feeling ashamed”. It is noticeable that all
13. Risks associated with treatment withdrawal these reasons are related to a lack of information, whilst other
14. Alcohol and street drugs: risks in bipolar illness
reasons traditionally considered by psychiatrists, such as side
15. Early detection of manic and hypomanic episodes
effects, were cited by less than 5% of patients. Thus, infor-
16. Early detection of depressive and mixed episodes
17. What to do when a new phase is detected?
mation is never enough to improve treatment compliance [7].
18. Life-style regularity Other specific interventions for compliance, such as the Con-
19. Stress management techniques cordance model by Scott, are also useful for improving com-
20. Problem-solving techniques pliance [38]. Although it cannot be assured that every single
21. Final session factor is indispensable for the success of psychoeducation,
the combination of them all has shown good prophylactic
Psychoeducation is aimed at providing bipolar patients with results.
a theoretical and practical approach towards understanding
and coping with the consequences of illness in the context of 4. Early detection and relapse prevention
a medical model, turning “the” illness into “their” illness,
thereby attempting to make the patient understand the com- Despite the use of mood stabilizers, a significant propor-
plex relationship amongst symptoms, personality, interper- tion of bipolar patients suffer from frequent relapses [25];
sonal environment, medication side-effects, and becoming some continue to be re-hospitalized [3]. Non-adherence to
responsible (but never guilty) when faced with the illness. medication is part of the reasons for the failure of drugs to
protect bipolar patients. However, some patients reported to
This allows them to actively collaborate with the physician in
have adhered consistently to prophylactic medication, still
some aspects of the treatment.
experienced relapses. In view of these findings, the National
De-stigmatization and improvement of illness-awareness
Institute of Mental Health Workshop on the Treatment of
plays a crucial role in the beginning of the bipolar psycho-
Bipolar Disorders concluded that there was an urgent need to
education, as patients may have pre-existing ideas about their
develop new pharmacological and psychological treatments
illness that may be pushing them to denial. Understanding
for bipolar patients [36].
denial and learning the biological causes of the illness con-
Clinically it is observed that mania can fuel itself and
stitute an essential part of the first sessions. Another impor-
depression can spiral down. During an early stage of mania,
tant issue is the distinction between causes (biological) and
patients may not be totally aware that increased sociability,
triggering factors. This issue will be crucial for establishing a reemergence of feelings of sociability and confidence, and
good treatment adherence later on in the course of the illness. decreased need for sleep may be part of prodromal symp-
One of the main targets of psychoeducation concerns the toms of mania. Likewise, during the prodromal stage of
enhancement of treatment adherence, which is usually very depression, patients may not know what the prodromal symp-
poor in bipolar patients, even when euthymic [9]. This may toms of depression are. In either case, even when patients are
be viewed negatively, by some professionals of other fields aware of these prodromal symptoms, they may not have any
of psychiatry. Nevertheless, the truth is that poor compliance skills to cope with them. It is hoped that a combined approach
has often a lot to do with misinformation or ignorance amongst of prophylactic medication plus an early intervention approach
relatives and the public, as shown by the results of the BEAM of helping bipolar patients to recognize and curb prodromal
survey by Paolo Morselli et al. [32]. This survey completed symptoms may prevent full-blown bipolar episodes.
by the GAMIAN advocacy forum questioned the patients’
main concerns about how bipolar disorder affected their lives
5. Inherent problems in defining prodromes in mental
and the issues regarding taking their prescribed drugs (Fig. 1).
health
The most frequently cited reasons for non-compliance of treat-
ment were “feeling dependent”, “feeling that taking medica- In medicine, prodromes are defined as the early signs and
tions is slavery”, “feeling afraid”, concern about long-term symptoms that herald a full episode. However, the presenta-
362 F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
tion of such first symptoms can be more idiosyncratic and is
probably the result of a complex mixture of biology, psycho-
logical make-up and past experiences. Prodromal symptoms
can also be strikingly different, or similar to the full-blown
episode but of less intense quality. Furthermore, the concept
of prodrome can be circular in bipolar disorder: if unusual
experiences lead to an episode, these unusual experiences are
defined as bipolar prodromes but if the same unusual experi-
ences do not lead to an episode, they cannot be defined as
prodromal. With this limitation in mind, the term prodromes
is used pragmatically in this paper, as a shorthand for the
early warnings that patients may be at the early stages of a
bipolar episode.
Several naturalistic studies have found that bipolar patients
were able to report prodromes [1,18,23,31,39]. Across these
studies, there is good agreement about the most common pro-
dromes of mania. These are: decreased need for sleep;
increased activities/energy and sociability; racing thoughts;
increased self worth; sharper senses; increased optimism; and
irritability. However, there is less agreement about the com-
mon prodromes of depression. A significant proportion of
bipolar patients were found to have difficulty in detecting
depression prodromes, particularly those with significant
residual depression symptoms. Patients found it difficult to
determine when residual symptoms might become prodro-
mal symptoms. However, across studies the most common
prodromes for bipolar depression were: loss of interest in
activities or people; not able to put worries or anxieties aside;
interrupted sleep; and, feeling sad or wanting to cry.
Lam, Wong and Sham reported that bipolar patients were
able to report common prodromes reliably over 18 months
[24]. Furthermore, the study found that patients’ coping abili-
ties with manic prodromes at baseline correlated with their
current levels of social functioning at baseline. The study also
predicted patients’ levels of functioning, manic symptoms and
relapses 18 months later. Since mania prodromes may pre-
cede a full bipolar syndrome by weeks [31,39], their early
detection and intervention are particularly important if mild
changes in mood states are not to spiral into more severe and
prolonged conditions. It becomes logical to explore whether
educating patients to detect and cope better with prodromes
may prevent relapses. Two recent randomized controlled stud-
ies of early detection and intervention of bipolar episodes will
be reviewed [22,35].
6. Psychological treatments to improve outcome in
bipolar disorder
Bipolar disorder is a complex illness. The effectiveness of
any treatment program would probably largely depend on its
ability to target selective problems in specific phases of the
illness. Psychotherapy is generally accepted as minimally
effective during an acute phase of the illness [21,22]. Like
other recently published evidence-based psychological treat-
ment for bipolar disorder [10,29], both studies discussed
below are combined treatment of mood stabilizers and psy-
chological therapy.
The two studies described here taught patients to detect
prodromes early and promote good coping. Therapy required
patients to learn to carry out regular and intensive monitoring
of early signs. As discussed above, patients who have residual
symptoms might have particular difficulties in detecting
depression prodromes. They require extra training to discrimi-
nate residual symptoms from prodromal symptoms by learn-
ing to monitor not just prodromes, but the trend in which their
mood is going. Other patients who prefer to be in a state of
high arousal and aspire to being slightly high may choose to
ignore early prodromes [20]. Often close personal knowl-
edge of patients and good therapeutic reports are required in
order to be collaborative and discuss the pros and cons of
being aroused, chaotic behavior and risk of relapses.
6.1. Identifying early symptoms of relapse
The simple intervention study by Perry et al. enrolled
69 patients who had experienced two or more bipolar epi-
sodes, one of which was in the previous 12 months [35]. Sixty-
nine patients were randomized into treatment-as-usual groups
(TAU) of mood stabilizers and outpatient follow-up, or TAU
plus psychological treatment. Psychological treatment con-
sisted of seven to 12 sessions with a psychology assistant.
Patients identified three symptoms at the warning stage when
they would start monitoring their mood closely. They were
also helped to identify three symptoms when they would con-
tact health professionals for treatment. The overall results over
the 18 months of the study period showed that, compared
with TAU alone, psychological treatment reduced manic epi-
sodes by 30% and increased the time to the first manic recur-
rence (log rank = 7.04, df = 1, P < 0.01). However, there was
no effect on depressive recurrence despite increased antide-
pressant use in the treatment group. An improvement in social
functions, particularly social functions at work, was detected.
Lam et al. [22] reported a randomized, controlled study
using a cognitive therapy (CT) to help prevent relapses and
promote social functioning. One hundred and three bipolar I
patients were randomized into a CT group or a control group.
Patients were required to be suffering from frequent relapses
despite the prescription of commonly used mood stabilizers.
Because of the relapse prevention nature of the study, patients
enrolled were not in a severe episode of mania or depression.
Both the control and the CT group received mood stabilizers
and regular psychiatric follow-up. In addition, the CT group
received 12–20 (mean 14) sessions of CT during the first
6 months and two booster sessions in the second 6 months.
CT programs in this study are more complex than the schemes
used in the study by Perry et al. In addition to traditional CT
for unipolar depression, the CT in this study consisted of psy-
choeducation using a diathesis-stress model of the illness in
order to enhance medication compliance. Furthermore,
patients were taught the cognitive model of how thinking and
behavior can affect mood. Hence, patients were taught that
 F. Colom, D. Lam / European Psychiatry 20 (2005) 359–364
behavior such as sensation seeking and taking on more tasks
can fuel the mania, whilst ruminating with negative thoughts
and inactivity can worsen the depression.
Cognitive behavioral skills were used to help patients to
monitor mood and prodromes, and to modify behavior in order
to prevent the progression from the prodromal phase into a
full-blown episode. Some bipolar patients have very extreme
goal-attainment attitudes [20]. Examples are: “If I try hard
enough I should be able to excel in anything I attempt,” and
“A person should do well in everything he attempts.” As a
result of these attitudes they are often behaviorally engaged
in achievement activities at the expense of a good routine of
regular meals, adequate sleep and exercise. As a way of cop-
ing, they often engage in very driven behavior of over-
working to “make up for lost time.” Hence, therapists use
traditional CT techniques to target these dysfunctional atti-
tudes in order to promote less driven behavior and a good
daily routine. Results of the study showed that over the
12-month period, significantly fewer patients in the CT group
had bipolar episodes (Wald X2 = 9.0, P < 0.01) or bipolar
admissions (Wald X2 = 6.7, P < 0.03) after controlling for
number of previous episodes. Furthermore, patients in the CT
group also had significantly fewer days in a bipolar episode
(t = 3.56, P < 0.01). The CT group also showed less mood
symptoms on the monthly mood questionnaires (P = 0.04).
The CT group also reported better medication compliance
after covarying for baseline medication compliance (Wald
X2 = 4.3, P < 0.02).
7. Discussion
The findings of these two studies support the conclusion
that psychological treatments specifically designed for relapse
prevention in bipolar affective disorder are useful tools in con-
junction with mood stabilizers. The intervention program in
the study by Perry et al. [35] was simpler and consisted of
purely identifying early warnings and seeking early medical
help. However, it achieved a significant effect in preventing
manic episodes. Lam et al. used a more complex intervention
[22]. It was not easy to identify the active ingredients in that
study. Therapists were also highly trained clinical psycholo-
gists and hence the effect may have been more beneficial; as
one patient wrote: “...realizing that I have a serious mental
illness and that I need to take medication is a first step. The
discrete surveillance of mood and efforts to deal with early
prodromes allows me to assume a measure of control and
hence develop a sense of security against the possible social
and professional consequences of undetected illness.” Medi-
cation helped to stabilize the patient but the early detection
of prodromes and effective coping can add to the treatment
regimen to increase its efficacy.
As clinicians, it is our major duty, to offer the best treat-
ment available to our patients and this includes both evidence-
based psychoeducation programs and newer pharmacologi-
cal agents. Recently, the use of psychoeducation as an
363
adjuvant prophylactic tool has been acknowledged by sev-
eral prestigious treatment guidelines broadening and updat-
ing the treatment paradigms of bipolar disorder [6,16]. We
should keep this in mind in our everyday clinical practice
with bipolar patients especially because the benefits — in
terms of fewer relapses and hospitalizations — are very clear
and the costs very low. Undoubtedly, the usefulness of psy-
choeducation for improving treatment adherence and clinical
outcome of bipolar patients is nowadays unquestionable, and
it provides us with information, a strong tool to manage
despair and fear. Unfortunately, many professionals fail to
use psychoeducation to theirs and their patient’s advantage.
Further research is needed in order to ascertain the role of
other psychological interventions in the treatment of acute
phases — especially bipolar depression — but it is already
known that psychological treatments are efficacious in the
prevention of suicide [37], which, by itself may justify the
inclusion of some cognitive, supportive and/or interpersonal
therapies during the acute depressive phases. To the best of
our knowledge, no evidence-based information on the use of
psychological approaches in (hypo)mania is available. Ela-
tion may not be a good target for psychotherapy, especially
as drugs work well and rapidly, so no complementary therapy
is required. Psychoeducation does not work as a mono-
therapy, but it is, to date, one of the few treatments guaran-
teeing class “A” and “B” effect as an adjuvant mood-stabilizer,
according to the nomenclature of Ketter and Calabrese [19].
We are, therefore, obliged not to withhold this excellent treat-
ment from our patients.
Acknowledgements
Dr. Colom’s work was supported in part by unrestricted
grants from the Stanley Medical Research Institute (Bethesda,
USA), Fundacio Marato TV3 and Red CIEN IDIBAPS-
ISCIII RTIC C03/06.
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