Bipolar Disorder

2nd edition

Robert P. Reiser
University of California, San Francisco, CA
Larry W. Thompson
Stanford University, Stanford, CA
Sheri L. Johnson
University of California, Berkeley, CA
Trisha Suppes
Stanford University, Stanford, CA
About the Authors
Robert P. Reiser, PhD, is a cognitive behavioral therapist
in private practice focusing on treatment of individuals and
families with serious mental illness and a Fellow of the
Academy of Cognitive Therapy. He supervises graduate
clinicians in training and provides workshops, consultation,
and technical assistance with a goal of improving treatment
of bipolar disorder and schizophrenia in community mental
health settings. Dr. Reiser currently works as a consultant
with the Felton Institute in San Francisco providing
supervision and training for clinicians and case managers
using cognitive behavioural therapy for psychosis (CBT-P),
and supervises medical residents at the University of
California, San Francisco in the Department of Psychiatry.

Larry W. Thompson, PhD, received his doctorate from Florida

State University in 1961. Since then he has held the rank of
Professor at three universities, Duke University, University
of Southern California, and Stanford University. Dr.
Thompson’s recent interests have focused on the problems and
issues involved in transporting evidenced-based
psychotherapeutic interventions from the research laboratory
into community settings.
Sheri L. Johnson, PhD, is Professor of Psychology at the
University of California Berkeley, and the Director of the
Cal Mania (CALM) team. She has published over 200 manuscripts
and five books. Her research has focused on psychological
aspects of bipolar disorder for the past twenty years, with
funding from the National Alliance for Research in
Schizophrenia and Depression (NARSAD) and from the National
Institute of Mental Health.

Trisha Suppes, MD, PhD, is Professor at Stanford University

in the School of Medicine Department of Psychiatry and
Behavioral Sciences and Director of the Bipolar and
Depression Research Program at Palo Alto Veterans Affairs.
Her research focuses on improving diagnoses, treatment, and
best care practices for patients with bipolar disorder and
depression. Recent work includes exploring the biological
basis of mood disorders and personalized approaches to
treatment.
Advances in Psychotherapy – Evidence-Based Practice
Series Editor
Danny Wedding, PhD, MPH, School of Medicine, American
University of Antigua, St. Georges, Antigua

Associate Editors
Larry Beutler, PhD, Professor, Palo Alto University /
Pacific Graduate School of Psychology, Palo Alto, CA
Kenneth E. Freedland, PhD, Professor of Psychiatry and
Psychology, Washington University School of Medicine, St.
Louis, MO
Linda C. Sobell , PhD, ABPP, Professor, Center for
Psychological Studies, Nova Southeastern University, Ft.
Lauderdale, FL
David A. Wolfe , PhD, RBC Chair in Children’s Mental Health,
Centre for Addiction and Mental Health, University of
Toronto, ON

The basic objective of this series is to provide therapists

with practical, evidence-based treatment guidance for the
most common disorders seen in clinical practice – and to do
so in a reader-friendly manner. Each book in the series is
both a compact “how-to” reference on a particular disorder
for use by professional clinicians in their daily work and an
ideal educational resource for students as well as for
practice-oriented continuing education.

The most important feature of the books is that they are

practical and easy to use: All are structured similarly and
all provide a compact and easy-to-follow guide to all aspects
that are relevant in real-life practice. Tables, boxed
clinical “pearls,” marginal notes, and summary boxes assist
orientation, while checklists provide tools for use in daily
practice.
Library of Congress Cataloging in Publication information
for the print version of this book is available via the
Library of Congress Marc Database under the Library of
Congress Control Number 2016956063
Library and Archives Canada Cataloguing in Publication
Reiser, Robert P., author
Bipolar disorder / Robert P. Reiser (University of
California, San Francisco, CA), Larry W. Thompson (Stanford
University, Stanford, CA), Sheri L. Johnson (University of
California, Berkeley, CA), Trisha Suppes (Stanford
University, Stanford, CA). -- 2nd edition.
(Advances in psychotherapy--evidence-based practice ; v. 1)
Includes bibliographical references.
Issued in print and electronic formats.
ISBN 978-0-88937-410-2 (paperback).--ISBN 978-1-61676-410-4
(pdf).-- ISBN 978-1-61334-410-1 (epub)
1. Manic-depressive illness. I. Thompson, Larry W., author
II. Johnson, Sheri L., author III. Suppes, Trisha, author IV.
Title. V. Series: Advances in psychotherapy--evidence-based
practice ; v. 1

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|v| Preface
In the 10 years since our first edition, interest has
continued to grow in the psychosocial treatment of bipolar
disorder. A number of new randomized clinical trials have
been completed. In the preface of our first edition we noted
that, despite the substantial evidence supporting several
psychological treatment approaches for bipolar disorder,
these treatments were often not used by practitioners.
Unfortunately, even with better treatment resources
available, a wide gap remains between effective evidence-
based treatments and the actual standard of care delivered in
the community. The present state of affairs remains
consistent with the picture presented in the National
Institute of Mental Health (NIMH) white paper on research in
mood disorders more than 10 years ago, which summarized that
only about 10% of the treatments for depression (a far more
common mood disorder) meet the standard guidelines for
evidence-based care. This need not be the case. There is a
wealth of research and treatment information available, and
we aim to make this readily accessible to the individual
practitioner. We seek to provide updated practical guidance
for an evidence-based treatment of bipolar disorder while
trying to avoid an overly narrow or complex approach. We have
also attempted to address important problems likely to be
encountered with the more challenging patients often seen in
treatment settings such as community mental health clinics.
We aim to provide the practitioner with an evidence-based,
comprehensive, integrated approach to the treatment of
bipolar disorder that is practical, easily accessible, and
can be readily applied in clinical practice.

Assumptions for Use of this Book

This book presents a psychosocial treatment approach that
does not substitute for standard psychiatric care. The
treatment program presented here is designed to provide
supplemental treatment for individuals who are receiving
standard psychiatric care and medication management. Medical
treatment should be a requirement of participation in any
psychosocial treatment program, and, in most cases, patients
with bipolar disorder will need to be on medication.
Providing psychotherapy to patients with bipolar disorder
without psychiatric care presents a serious risk and is
contraindicated in most cases.

This guide assumes that the reader has some knowledge of

treating individuals with more serious mental disorders. As
these individuals are often seen in community settings, we
discuss adapting treatment strategies to minimize attrition,
address motivational issues, and maximize gains for complex
multi-disordered patients in diverse, multi-disciplinary,
community-based settings. This guide is not intended to
substitute for the clinical supervision and requisite
training required to treat patients with bipolar disorder,
nor is it intended as a substitute for seeking professional
medical and psychiatric advice about treatments or medication
for each patient.
|vi| Acknowledgments
The first two authors wish to thank The Health Trust, a
nonprofit foundation in San Jose, California, that generously
supported their work with bipolar disorder for two years.
Robert Reiser dedicates this book to honor and keep alive the
memory of Tony Masini, a young psychologist who cared for
people with serious emotional disorders and was a passionate
advocate and spokesperson. All book royalties from the first
author will be donated to NAMI. He also wishes to acknowledge
the generous contributions of ongoing supervision,
assistance, and mentorship of Monica Basco and the initial
project support from Ellen Frank. Larry Thompson wishes to
acknowledge the value of his wife’s ongoing love and
support. We are also indebted to our patients and our
students who have been our best teachers. Sheri Johnson
dedicates this book to her partner, Daniel Rose. Trisha
Suppes dedicates this book to her two daughters Rebecca Ann
and Kaegan Lee, and to the many wonderful teachers and
mentors that have made her journey possible.

Robert P. Reiser

Larry W. Thompson

Sheri L. Johnson

Trisha Suppes
Contents
Preface
Assumptions for Use of this Book

Acknowledgments

1 Description
1.1 Terminology

1.2 Definition
1.2.1 Additional Considerations in the Classification and Diagnosis of
Bipolar Disorders

1.3 Epidemiology

1.4 Course and Prognosis

1.5 Differential Diagnosis

1.5.1 Major Depressive Disorders
1.5.2 Substance-Induced/Medication-Induced Bipolar and Related Disorder
1.5.3 Disruptive Mood Dysregulation Disorder
1.5.4 Psychotic Disorders
1.5.5 Attention-Deficit/Hyperactivity Disorder
1.5.6 Personality Disorders
1.5.7 Medical Illness

1.6 Co-Occurring Psychiatric and Medical Disorders

1.7 Diagnostic Procedures and Assessment Tools

1.7.1 Assessment of Mania
1.7.2 Assessment of Bipolar Depression
 1.8 Implications for Clinical Practice

2 Theories and Models of Bipolar Disorder

2.1 Biologically Based Disease Models

2.2 Psychoeducation

2.3 Interpersonal and Social Rhythm Therapy

2.4 Family-Based Treatment

2.5 Cognitive-Behavioral Treatment

3 Diagnosis and Treatment Indications

3.1 Decision Tree for Determining Optimal Treatments
3.1.1 Treatment Options for Young Adults
3.1.2 Treatment Options for Potentially Self-Damaging Behaviors
3.1.3 Treatment Options for Repeated Episodes of Mania/Hypomania Despite
Medication Adherence
3.1.4 Treatment Options for Poor Recognition of Symptoms
3.1.5 Treatment Options for Persistent Subsyndromal Depression

4 Treatment
4.1 Biological Approaches to Treatment

4.2 Psychosocial Approaches to Treatment

4.2.1 Structure and Course of Psychosocial Treatment
4.2.2 The Initial Phase of Treatment: Orientation and Engagement
4.2.3 The Middle Phase of Treatment: Skill Building – Filling the Tool
Box
4.2.4 The Final Phase: Maintaining Treatment Gains

4.3 Family-Focused Treatment

4.4 Self-Help Approaches and the Recovery Model

4.4.1 Combating Social Stigma
 4.4.2 The Role of Self-Help and Support Groups

4.5 Mechanisms of Action of Psychosocial Approaches

4.6 Efficacy and Prognosis of Psychosocial Approaches

4.7 Problems in Carrying Out Treatment

4.7.1 Addressing Manic Symptoms in Session
4.7.2 Suicide Risk Assessment and Management
4.7.3 Improving Treatment Adherence
4.7.4 Treatment of Co-Occurring Substance Use Disorders

4.8 Summary

5 Further Reading

6 References

7 Appendix: Tools and Resources

Treatment Agreement

Checklist for Session Agenda

Activity Schedule

Activity Log – Daily List of Healthy Behaviors

Mood Chart Adapted From Basco and Rush (2007)

Identifying Signs of Depression or Mania

Identifying Early, Middle, and Late Signs of Depression or Mania

“Unhelpful Thought Record” – Weighing the Evidence

Coping and Wellness Plan

Self-Help Resources
Books
Websites
Self-Help Organizations With Local Chapters
 1
Description
|1|

Many people who are diagnosed with bipolar disorder are

initially referred for medication treatment, with little
consideration of psychosocial treatments. Many therapists
worry about their capacity to treat bipolar disorder, as they
are keenly aware of potential risks and (correctly) accept
that medications are the first line of treatment. Reluctance
to treat this disorder has increased therapists’ doubts
about treating bipolar disorder in private practice settings.
When you consider how many facets of life and well-being are
influenced by bipolar disorder, though, this would seem to be
the perfect disorder to target for psychosocial treatment.
Indeed, our own personal experiences suggest that, armed with
some humility and some appreciation for the severity of the
challenges, along with a well-stocked toolkit, helping people
with bipolar disorder gain back a sense of control, promoting
understanding of the disorder and its triggers, and
considering ways to rebuild life domains damaged by episodes,
is an incredibly rewarding endeavor. This book attempts to
give the practitioner a firm foundation and background to
undertake this work.

Because accurate diagnosis is a foundation for successful

treatment, we begin by considering the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5;
APA, 2013), with fine-grained attention to differential
diagnosis and the implications for clinical practice. Based
on growing evidence of partial genetic overlap between
schizophrenia and bipolar disorder, “Bipolar and related
disorders” is now a separate chapter in the DSM-5. Some
additional small changes were made in the criteria set,
discussed below and throughout the book, based upon the best
available evidence.

1.1 Terminology
Bipolar disorder (BD), previously known as manic depressive
illness, is a mood disorder defined by manic symptoms of
varying severity. Most people with BD will also experience
depressive symptoms. Manic symptoms may involve changes in
energy, impulsivity, behavior, and cognition. BD is usually
characterized by an episodic course throughout the lifetime,
resulting in significant impairment in social, interpersonal,
and occupational functioning.

Emil Kraepelin compiled an enduring set of observations

regarding the presentation and course of illness for patients
with manic-depressive illness (Kraepelin, 1921), and many of
the manic symptoms he observed continue to be featured in
diagnosis. The DSM-5 (APA, 2013) and the International
Classification of Diseases of the World Health Organization
( |2| Maier & Sandmann, 1993) are the major systems in use
internationally (see online materials for comparison). In the
DSM-5, bipolar disorders (BDs) are grouped into the following
mutually exclusive categories depending upon the severity and
duration of symptoms during the lifetime.

Bipolar I disorder (BD I) is characterized by at least

one manic episode during the lifetime. Manic episodes,
in turn, are defined by manic symptoms of sufficient
severity to cause marked impairment in social and
occupational functioning, to result in a psychiatric
hospitalization, or to involve psychosis.
Bipolar II disorder (BD II ) is characterized by at
least one hypomanic episode, as well as one or more
major depressive episodes, during the lifetime.
Hypomanic episodes are defined by manic-type symptoms in
which symptoms are not long in duration nor as severe to
cause marked impairment in social or occupational
functioning, to warrant psychiatric hospitalization, or
to involve psychosis. Depression episodes may be
associated with psychotic symptoms, though this is seen
less frequently then in patients with BD I depression.
Cyclothymic disorder is characterized by mood
instability over a 2-year period (or one year in
children and adolescents) with hypomanic and depressed
symptoms that do not meet full criteria for a manic
episode or a major depressive episode.
Substance/medication-induced bipolar and related
disorder is defined by mood symptoms that have been
triggered by use of or withdrawal from substances.
Bipolar and related disorder due to another medical
condition is defined by manic type symptoms that appear
to be consequent to a medical condition.
 Other specified bipolar and related disorders has
replaced the Diagnostic and Statistical Manual of Mental
Disorders: DSM-IV-TR (4th ed.) (DSM-IV-TR; APA, 2000)
category of “Not otherwise specified.” This category
is now used to note four subcategories that do not meet
full criteria for one of the above listed disorders:
Short-duration hypomanic episodes (2–3 days) and major
depressive episodes; hypomanic episodes with
insufficient symptom count and major depressive
episodes; hypomanic episode without a history of major
depression episodes; and short-duration cyclothymia
(less than 24 months).
Unspecified bipolar and related disorders is intended
for temporary use when insufficient information is
available but it appears likely the person has some
manic symptom history.

Specifiers, which have changed significantly in DSM-5,

are used to denote important elements about the presentation
or course of illness. Most specifiers are used for BD I and
BD II illnesses, with some applicable to the other bipolar
diagnoses. Current specifiers include:

With anxious distress (new to DSM-5)

With mixed features (new to DSM-5, applies to
manic/hypomanic or depressive episodes)
With rapid cycling
With melancholic features
|3| With atypical features
With psychotic features, which can be mood-congruent or
mood-incongruent
 With catatonia
With peripartum onset, which now includes peripartum as
well as postpartum within 4 weeks of delivery
With seasonal pattern (applies to depressive, hypomanic,
and manic symptoms now)
Further course specifiers:
In partial remission or full remission
Mild, moderate, or severe severity

The specifiers have significantly changed in DSM-5 compared

to DSM-IV-TR. The new mixed features specifier is an
important change in DSM-5. In an improvement over DSM-IV-TR,
symptoms like irritability, distractibility, and agitation
that are common to mania and depression, are not used in the
mixed feature specifier criteria. Mixed states are important
to detect, as they are related to the higher likelihood of
suicidal behavior. Increased energy during depressive periods
could also foster impulsive behaviors.

1.2 Definition
Table 1 presents the criteria for a manic episode or a
hypomanic episode as described in the DSM-5. Increased
activity or energy was added as a cardinal symptom in DSM-5,
in part because this may be more reliably reported than mood
states.

BD II criteria require the presence of at least one episode

of major depression. Table 2 presents the criteria for a DSM-
5 diagnosis of a major depressive episode . Although the
diagnosis of BD I does not require the presence of an episode
of major depression, the majority of people who experience
manic episodes will experience at least one or more episodes
of depression during their lifetime. Depressive and manic
episodes can and do co-occur, and the mixed feature specifier
is used when at least three symptoms of the opposite pole are
present (see Table 3).

Over time, the DSM has given increasing attention to

bipolar spectrum disorders. Cyclothymic disorder was
introduced in DSM-III, and BD II was introduced in DSM-IV. As
with BD I, both are considered long-term conditions. Accurate
detection of bipolar spectrum disorders may require observing
fluctuations over time. BD II is not just a subthreshold or a
“light” version of BD I. This condition is stable over
time, and involves significant depressive episodes, levels of
functional impairment, and suicidality that are similar to
those observed in BD I (Merikangas et al., 2011). As we will
discuss, there is relatively little evidence concerning
treatments for BD II.

As with other forms of BD, cyclothymic disorder is tied to

poor outcomes. Youth with cyclothymic disorder have been
found to have lower quality of life and fewer days of good
quality of life than youth with serious medical illnesses
(Freeman et al., 2009). Findings of two studies suggest that
cognitive |4| behavioral treatment has promise for improving
prognosis and quality of life (Van Meter & Youngstrom, 2012).

Table 1 DSM-5 Criteria for Manic and Hypomanic Episodes (Adapted from
APA, 2013)
A. Abnormally and persistently elevated, expansive, or irritable mood and
increased activity or energy
B. During this period, three or more (four if mood is only irritable) of the
following changes from usual behavior are present to a significant degree and
persistent:
1. Increased self-esteem
2. Little need for sleep (e.g., feels rested after 3 hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience of racing thoughts
5. Distractibility (attention overly drawn to irrelevant stimuli)
6. Increased goal-directed activity (either socially, at work or
school, or sexually) or psychomotor agitation
7. Excessive involvement in activities with potential painful
consequences (e.g., reckless spending, sexual indiscretions, or
unwise investments)
C. The episode is not caused by the direct effects of a substance (e.g., drug of
abuse, an antidepressant medication, or other treatment) or medical condition
(e.g., hyperthyroidism), unless symptoms persist after the effects of the
somatic agent are no longer present
D. Symptoms are present most of the day, nearly every day

For a Manic Episode

Symptoms are present ≥ 1 week (or less if hospitalization is needed)
The symptoms cause marked occupational or social impairment, require
hospitalization, or include psychotic features
For a Hypomanic Episode
Symptoms are present for ≥ 4 consecutive days
Unequivocal change in functioning, but not marked impairment or need for
hospitalization
Psychotic symptoms are not present

Table 2 DSM-5 Criteria for a Major Depressive Episode (Adapted from APA,
2013)

A. Depressed mood or loss of interest or pleasure in almost all activities.

B. At least four of the following are present during the period of depressed mood
or low interest:
1. Significant weight loss or gain
2. Sleeping too much or too little
3. Psychomotor agitation or retardation that is observable by others
4. Fatigue or low energy
5. Worthlessness or excessive guilt
6. Difficulty concentrating, making decisions, or thinking clearly
7. Recurrent thoughts of death or suicide, or a suicide plan or attempt
C. Significant distress or impairment
D. Not due to a substance or medical condition
E. Symptoms are present nearly every day, most of the day, over a two week period
 |5| Table 3 DSM-5 Criteria for Mixed Features Specifier (Adapted from APA,
2013)

Manic or hypomanic episode with mixed features

At least three of the following are present most days during the episode:

1. Sad or depressed
2. Decreased interest or pleasure
3. Psychomotor slowing
4. Fatigue or decreased energy
5. Feelings of extreme worthlessness or guilt
6. Recurrent thoughts of death or suicidal ideation, plan, or attempt

Depressive episode with mixed features

At least three of the following are present most days during the episode:

1. Expansive or euphoric mood

2. Increased self-esteem or grandiosity
3. Hypertalkativeness or pressured speech
4. Flight of ideas or racing thoughts
5. Increased goal-directed activity or psychomotor agitation
6. Excessive involvement in pleasurable activities with likely painful
consequences
7. Decreased need for sleep

1.2.1 Additional Considerations in the

Classification and Diagnosis of Bipolar
Disorders
The DSM-5 approach has been criticized because the diagnostic
thresholds for the number of symptoms and duration was set in
a relatively arbitrary fashion. Recent studies provide
support for some of the thresholds defined, such as the four-
day threshold for diagnosing hypomanic episodes (Miller et
al., 2016).
 Individuals whose symptoms do not surpass diagnostic
thresholds for hypomania but whose symptoms still cause
significant distress or impairment can be diagnosed with
“Other specified bipolar and related disorder.”
Subthreshold variants such as this may be somewhat common in
patients with depression. Up to 40% of patients presenting
with a major depressive episode were found to have
experienced at least one hypomanic symptom, with 20%
experiencing at least 2 symptoms (Zimmerman et al., 2009).
Detection of such symptoms can be improved by giving
dimensional assessments of the relative severity of manic
symptoms (as well as depressive symptoms), which we will
discuss below.

Although there has been concern for some time that

practitioners might be missing these important subsyndromal
symptoms, there has also been a massive rise in the rate of
diagnosis of BD. This increase in diagnosis has been
particularly notable in youth in the US, with a 40-fold
increase in rates of BD diagnosis observed between 1994 and
2003 among those younger than age of 18 years (Moreno et al.,
2007). Two studies have now found that one-third to one-half
of individuals who receive a clinical diagnosis of BD do not
meet criteria when a more careful, structured diagnostic
interview is used (Zimmerman et al., 2010). Once a patient is
labeled with BD, the diagnosis typically remains |6| in the
records for a long time. An inaccurate diagnosis could lead
to inappropriate use of medication, stigma, and
inappropriately targeted treatment such as diminished
accessibility of antidepressant medication. Hence, one of our
goals in this volume is to provide careful guidelines for
accurate diagnosis. Clinicians will want to attend to
hypomanic symptoms that lead to distress or impairment
without surpassing the threshold for hypomania, but it is
equally important to avoid over diagnosing BD. Efforts were
made in the DSM-5 to increase diagnostic specificity without
loss of sensitivity, for example, by adding increased
activity to the criteria A for mania and hypomania. It was
hoped that including a fuller range of symptoms as captured
by the mixed features specifier would improve diagnostic
reliability.

1.3 Epidemiology
As noted above, bipolar spectrum disorders are more common
than BD I. The World Health Organization World Mental Health
Survey Initiative is the largest available study on the
prevalence of BD. In this representative sample of 61,392
adults in 11 countries, the lifetime prevalence was estimated
to be 0.6% for BD I, 0.4% for BD II, and 1.4% for
subthreshold BD. There is debate about how common these
subthreshold variants are, with some arguing that variants of
BD other than BD I and II may affect 2–4% or more of people
depending on definitions and sample (Regeer et al., 2004). In
the US, higher prevalence estimates have been observed: 1.0%
for BD I, 1.1% for BD II, and 2.4% for subthreshold BD
(Merikangas et al., 2007). Relatively little is known about
whether these cross-national differences are genuine. It is
important to consider that culture influences stigma,
acceptance of mental health problems, and comfort discussing
symptoms. Cross-national variation in the prevalence of
bipolar disorder has also been tied to fish oil consumption
(Noaghiul & Hibbeln, 2003), as well as cultural emphasis on
individualistic striving (Johnson & Johnson, 2014a). In
contrast to unipolar depression, which affects nearly twice
as many women as men, men and women are equally likely to
suffer from BD I, though the ratios suggest more women than
men are diagnosed with BD II. Among those diagnosed with BD,
however, overall women experience more episodes of depression
than do men and so may be more likely to seek treatment.

The onset of BD tends to occur around age 18–20, with

about 50% of patients having their first episode before this
age. Initial onset in older individuals above 50 years of age
is seldom seen, though when this is observed a thorough
assessment for physical causes such as metabolic or
neurologic issues is warranted. Prepubertal and early
adolescent onsets are observed, and are more common among
those with a family history of mood disorders (Rihmer &
Angst, 2005). Early onset is associated with more difficulty
completing education, and so may set the stage for lower
occupational attainment throughout the life course. Early
onset is also related to higher rates of recurrence, co-
occurring psychiatric disorders, and suicidality (Perlis et
al., 2004).

Cultural differences have not been fully examined for BD.

Although the prevalence of BD does not appear to differ by
race or ethnicity, there are pro |7| found concerns about the
misdiagnosis and under treatment of minorities. A large body
of research suggests that African-Americans with BD are
highly likely to be misdiagnosed with schizophrenia (Snowden,
2001). In a nationally representative sample, not a single
black person diagnosed with BD I was receiving adequate care
(Johnson & Johnson, 2014b), and non-white Hispanic patients
were also unlikely to receive adequate care (Salcedo,
McMaster, & Johnson, in press). Poor treatment of minorities
does not appear to be just an artifact of patient
characteristics such as insurance status or treatment-
seeking, suggesting that systematic provider biases in making
diagnoses and selecting treatment options may be involved.
Tendencies to misdiagnose minority individuals can be
combated by using systematic, rigorous assessment tools.
Given that culture influences emotion labeling and
regulation, sleep patterns, individualistic striving,
willingness to seek treatment, and expectations about
treatment, this would appear to be an important area for
ongoing research.

BD is a major source of disability (Thomas, 2004). As might

be expected, the economic burden for families, health care
programs, and industry is immense. Some authors have argued
that BD may be the most costly psychiatric disorder in the US
(Peele, Xu, & Kupfer, 2003). Although family members of those
with BD often achieve above average levels of success and
creative accomplishment (Johnson, Edge, Holmes, & Carver,
2012; Kyaga, Lichtenstein, Boman, & Landen, 2015), the
effects of the recurrent episodes take their toll on careers
and employment. More than two-thirds of individuals fail to
return to work in the year after a hospitalization for mania
(Harrow, Goldberg, Grossman, & Meltzer, 1990), and, on
average, those with BD (I or II) are unable to work for more
than 2 months per year (Kessler et al., 2006). Accordingly,
BD is related to higher risks of unemployment, poverty, and
homelessness. These risks may be particularly high for those
with BD I (Rihmer & Angst, 2005). Nonetheless, for both BD I
and BD II disorder, severity of depression is a major
predictor of difficulty in functioning (Judd et al., 2005;
Kessler et al., 2006). The psychological toll on families and
friends of bipolar patients is also of major importance.
Often the economic and emotional stresses of coping with
these symptoms eventually become so great that family members
and other loved ones become overwhelmed. Addressing these
social and occupational costs of BD is a core goal of
psychotherapy for BD.

1.4 Course and Prognosis

The course of BD varies across individuals and across time,
and also by subtype of disorder. Episodes can vary in
duration from days to months, and in frequency, ranging from
a single lifetime manic episode to rapid cycling of mania to
depression within a single 24-hour period. The severity of
depressive and manic symptoms can also range from minor
perturbations in functioning to marked functional impairment
with psychotic features. Bipolar spectrum conditions may
differ in consisting predominantly of depression or mania.

BD I and II show a number of similarities as well as

differences. For example, in one prospective longitudinal
multisite study over a 10-year period (Judd et al., 2003), BD
I and II were characterized by similar demographic
|8| characteristics, high rates of substance use disorders
and anxiety disorders, and persistent subsyndromal depressive
symptoms that were a dominant concern. On the other hand, a
number of differences between the two subtypes were observed.
Substance use disorder was somewhat more common in BD I than
BD II. Contrary to what one might think, BD II was related to
slightly longer and more frequent mood episodes, including
more subsyndromal depression than was BD I, leading to fewer
weeks well (46% vs. 53%). These findings underline the need
to aggressively treat both BD II and BD I.

Patients diagnosed with BD typically experience recurring

mood episodes over their lifetime, even with best available
pharmacologic treatment. The recurrent relapses and
persistent subsyndromal symptoms interfere with day-to-day
functioning for many patients. Co-occurring disorders will
make the prognosis even worse. Without treatment this
disorder can be particularly devastating, resulting in major
disruptions in functioning accompanied by substantial losses
of friends, family, and finances. The magnitude of the
problems is illustrated in the findings of the Stanley
Foundation Bipolar Network (Post et al., 2003). This
multisite program implemented aggressive, highly flexible
pharmacotherapy strategies to address mood disorders and
other co-occurring conditions. Using the NIMH-Life Chart
Methodology (Denticoff et al., 2000), these researchers
followed more than 600 patients in treatment for 30 months.
Two-thirds of the bipolar outpatients continued to be
affected by symptoms. Even when researchers have carefully
documented adequate blood serum levels of lithium, rates of
relapse remain high (Keller et al., 1992). Even with the best
available medication treatment, many patients will report
concerns about break-through symptoms, and hospitalizations
are too frequent. While medications are the cornerstone of BD
treatment, additional modalities of treatment are needed.

Suicide is a major concern in BD. People with BD have been

estimated to be 20–30 times as likely to die from suicide as
the general population (Pompili et al., 2013; Schaffer et
al., 2015), and it has been argued that BD is the psychiatric
condition with the highest rates of suicide (Ilgen et al.,
2010; Nordentoft, Mortensen, & Pedersen, 2011). In one
national study that followed people for 36 years after their
first psychiatric treatment, 8% of men and 5% of women
diagnosed with BD died from suicide (Nordentoft et al.,
2011). More than half of those with BD report suicidal
ideation within the past 12 months, and one in four persons
diagnosed with BD I report that they have tried to attempt
suicide (Merikangas et al., 2011).

Findings such as these emphasize that while essential

pharmacotherapy alone is often not sufficient to eliminate
symptoms and restore function completely, many patients want
help coming to terms with their illness and learning
prevention skills. In recent surveys, those with BD reported
prioritizing the restoration of quality of life above symptom
prevention. Psychotherapy is designed to help improve
understanding of the illness and of the need for medications,
to reduce relapse and subsyndromal symptoms, and to restore
domains of life impacted by this illness.

|9| 1.5 Differential Diagnosis

In this section, we aim to give advice on differentiating the
subtypes of BD frommajor depressive disorder, disruptive
mood dysregulation disorder, psychotic disorders,
attention deficit disorder, personality disorders, and
medical illnesses that may trigger manic-type symptoms. For
each, we highlight symptoms and other forms of overlap, and
then consider characteristics that differ between disorders,
such as diagnostic criteria, key signs and symptoms, family
and patient history, and other qualitative factors.

1.5.1 Major Depressive Disorders

Even though major depressive disorder (MDD) might seem easy
to differentiate from BD, differential diagnosis of MDD is
the most common source of misdiagnosis and improper treatment
of BD. BD II by definition involves episodes of depression.
Although not all persons with BD I will experience
depression, people are much more likely to seek treatment for
depression than for mania. About 60% of patients with BD I or
II present in an initial depressive episode (Judd et al.,
2003). Many of these people may not spontaneously describe
their history of manic symptoms, and so it is critical that
therapists ask about experiences of manic symptoms carefully
when patients report depressive symptoms because
antidepressants administered without a mood stabilizer may
induce mania among persons with BD I. Even in patients who
initially deny a history of manic symptoms, it is important
to continue to monitor for onset of manic symptoms. In one
sample of patients followed for 15 years after
hospitalization for a major depressive disorder episode,
about 27% went on to develop hypomania and 17% went on to
develop a manic episode (Goldberg, Harrow, & Whiteside,
2001).

The most common reason for a failure to distinguish BD I is

the failure to ask about mania history when a person presents
with depression (Brickman, LoPiccolo, & Johnson, 2002).
Taking a careful history of previous manic symptoms,
supplemented by reports from family members and significant
others, is key to proper diagnosis, and we will discuss tools
to facilitate this below.

Remember that hypomanic episodes may not entail significant

impairment, and so patients and caregivers may not be
concerned by these episodes or raise them for consideration.
In addition, patients may not correctly label symptoms of
hypomania unless education is provided, especially if the
individual is prone to mixed symtoms or “energized
depression.”

1.5.2 Substance-Induced/Medication-Induced Bipolar

and Related Disorder
As noted in Table 4, many substances can trigger mania-like
symptoms, including antidepressant medications. When a
patient reports changes in substance use before the onset of
mood symptoms, consider the timing of onset and whether
symptoms remitted with discontinuation of substances.
Generally, substance |10| and antidepressant-triggered
episodes are diagnosed as medication-induced mood disorder,
and would not be considered toward a diagnosis of BD I or
II. However, if symptoms persist after the effects of the
physiological substances are not present, this can be
considered evidence for a BD (see DSM-5).

Table 4 Substance/Medication-Induced Mood Disorder

Mood symptoms developed while the patient was exposed to substances. The
symptoms remit when the physiologic effects of the substance(s) are not
present.
The substances are capable of producing mood symptoms. Substances that
commonly trigger mood changes include alcohol, amphetamines, cocaine,
hallucinogens, other psychedelics, inhalants, phencyclidine, sedatives,
hypnotics, anxiolytics, and antidepressants.
Substances and medications may elicit many manic symptoms including elevated,
irritable or expansive mood, altered activity, impulsive decisions, diminished
sleep, or depressive symptoms, including depressed mood, diminished interest
or pleasure in activities, guilt, or suicidal feelings.
Mood symptoms may develop during intoxication, during initiation or
discontinuation of a substance, or within one month of withdrawal from a
substance.

1.5.3 Disruptive Mood Dysregulation Disorder

One of the cardinal symptoms of mania is irritability and
anger, and there is some evidence that BD in children is also
characterized by anger and irritability. Anger and
irritability are also central features of disruptive mood
dysregulation disorder (DMDD), a new diagnosis introduced in
the DSM-5. The diagnostic criteria specify recurrent temper
outbursts that occur an average of three or more times per
week and are present for 12 months or more without remission
of more than 3 months. Between temper outbursts, the child
demonstrates persistent irritability. The diagnosis can be
considered when symptoms develop before age 10.
 DMDD was added to the diagnostic system in part to address
concerns over the growing misdiagnosis of BD in youth, which
we discussed above. When clinicians focus strictly on rages
as a reason for diagnosing BD, highly inaccurate diagnoses
may result. In one study, one-third of youth who were
hospitalized with clinical records of rages had been
diagnosed with BD; with careful interviewing, however, only
9% met diagnostic criteria for BD (Carlson, Potegal,
Margulies, Gutkovich, & Basile, 2009). Chronic irritability,
arguing, and tantrums are predictive of anxious and
depressive disorder onset over time, but do not predict BD
(Stringaris, Cohen, Pine, & Leibenluft, 2009). Hence, when
youth present with irritability and rages, consider whether
those difficulties are associated with other manic symptoms,
such as elevated self-esteem, decreased need for sleep, hyper
talkativeness, goal-directed activity, or reckless behavior.

|11| 1.5.4 Psychotic Disorders

Patients with BD I can experience psychotic symptoms.
Although the rate of hallucinations and delusions in some
community samples diagnosed with BD appears to be less than
30% (Kessler et al. 2005), psychotic symptoms increase the
likelihood of treatment and hospitalization in BD. Psychosis
can also be present during depressive episodes of BD I or BD
II, but are very uncommon in BD II (< 1%) (Judd et al.,
2003). Most commonly, psychotic symptoms during bipolar
episodes are mood-congruent, but they can be mood-
incongruent.
 When psychotic symptoms persist two weeks after all mood
symptoms remit, a diagnosis of schizoaffective disorder is
appropriate. Generally, BD patients rarely show psychotic
symptoms unless mood symptoms are severe. Both BD I and
psychotic disorder (PD) patients can have grandiose or
persecutory delusions, as well as disorganized thinking and
loose associations, suggestive of a thought disorder. Both
are frequently agitated, highly irritable, and may show
catatonic symptoms. However, there are a number of
distinguishing features between BD and PD. Most importantly,
BD I patients by definition have mood-related symptoms,
whereas only some PD patients, such as those with
schizoaffective disorder do (APA, 2013). BD I patients
generally have higher premorbid functioning than do PD
patients, lapse into an episode more precipitously than PD
patients, and are more likely to return to a premorbid level
between episodes. BD I patients are also more likely to have
relatives who suffer from BD I or II.

1.5.5 Attention-Deficit/Hyperactivity Disorder

Symptoms of attention deficit with hyperactivity (ADHD ) and
BD overlap significantly, as both can involve hyperactivity,
distractibility, and impulsivity (Kent & Craddock, 2003). The
mood-related symptoms, such as euphoric mood, inflated self-
esteem, and grandiose ideas, though, are not included in the
ADHD diagnostic criteria and so are helpful for differential
diagnosis. Inattention co-occurring with these mood symptoms
would not be considered evidence of ADHD. When
inattentiveness persists in the absence of mood symptoms,
this is more consistent with an ADHD profile.

1.5.6 Personality Disorders

Mood symptoms may mimic symptoms of personality disorders and
may intensify impulsivity, anger, reactivity, and other
behavioral problems that are often seen as signs of a
personality disorder. During depression, people may also
overestimate the degree of difficulty they have had in their
functioning. Consistent with this potential for over
diagnosis, studies identify a 50% reduction in the rate of
personality disorder diagnoses among remitted samples as
compared to samples assessed during mood episodes (George,
Miklowitz, Richards, Simoneau, & Taylor, 2003). Accordingly,
avoid making firm diagnoses of personality disorders during
acute mood episodes. In considering differential diagnoses,
the most central issue is that BD is typically
character |12| ized by fluctuating symptoms, whereas
personality disorders represent more enduring patterns of
behavior, typically beginning in adolescence or young
adulthood. Gathering data about functioning over time, with
corroboration from relatives and significant others, is
advised in differentiating personality disorders from BD.

Bothborderline personality disorder and BD I or II are

characterized by primary problems with affective instability,
difficulty regulating emotions, impulsivity, and significant
periods of depressive symptoms. In particular, patients with
BD with rapid cycling (more than four mood episodes in a 12-
month period) may be inappropriately overdiagnosed as having
borderline personality disorder. Manic symptoms, but not
borderline personality symptoms, are related to heightened
positive moods and intensive pursuit of goals (Fulford,
Eisner, & Johnson, 2015). Residual mood symptoms related to
BD can appear as a borderline personality disorder. If this
is the case more aggressive medication treatment may address
such residual symptoms. Significant response to medication is
diagnostic for BD.

Manic symptoms also show some overlap with some symptoms of

antisocial personality disorder. During a manic episode,
individuals may become excessively involved in impulsive or
pleasure-seeking behaviors (gambling, sexual indiscretions,
etc.). Antisocial behavior that occurs exclusively during the
course of a manic episode should not be diagnosed as
antisocial personality disorder. The lack of remorse or
indifference that characterizes antisocial personality
disorder can be contrasted with the extreme regret, guilt,
and remorse that individuals with BD I or II typically
experience after a manic or hypomanic episode. Personality
disorders are optimally diagnosed after symptoms remit or as
a differential related to mood disorders.

1.5.7 Medical Illness

Medical illnesses, including neurologic disease, head trauma,
concussion, endocrine disorders, and psychoactive substances,
can cause bipolar-like symptoms. In most patients, BD
symptoms will begin by the early twenties. Although
neurological diseases are rare in this early age group, any
such underlying cause of symptoms would be important to know
as it would influence the course of illness and might suggest
other treatments. There is debate if all BD patients should
consider a brain scan to rule out neurological conditions
such as tumor, because these explanations of symptoms are
rare. For new onset of BD after the age of 50 though,
secondary causes are likely and medical and neurological
examinations are justified.

1.6 Co-Occurring Psychiatric and Medical

Disorders
Co-occurring disorders are more the rule than the exception
in BD; most people with BD will meet criteria for an
additional disorder (Merikangas et al., 2011). About 75% of
bipolar patients meet diagnostic criteria for anxiety
disorders during their lifetime, and 42% meet the diagnostic
criteria for alcohol |13| or drug abuse or dependence
(Merikangas et al., 2007). High rates of childhood behavior
problems and ADHD have also been documented (Merikangas et
al., 2011). Lifetime prevalence of personality disorders for
bipolar patients ranges from 29% to 48%, with lower rates
observed when patients are tested after sustaining recovery
for several months (George et al., 2003). BD appears most
likely to co-occur with obsessive-compulsive, borderline,
narcissistic, and avoidant personality disorders (McIntyre,
Konarski, & Yatham, 2004).

Medical problems such as metabolic disorder (with truncal

obesity as a key symptom), obesity, diabetes, and
cardiovascular disorders are particularly likely in bipolar
patients compared to the general population. Mortality due to
cardiovascular disease is more than twice as likely to occur
in bipolar patients as in the general population. Roughly 10%
of individuals with BD are diabetic, and 25–34% are obese
(McIntyre et al., 2007). These co-occurring medical disorders
are particularly common in US samples (Post et al., 2014).
Tobacco use is more common than in the general population,
which exacerbates the elevated rates of cardiovascular
disease (Waxmonsky et al., 2005). Co-occurring disorders
complicate the course of the disorder and must be one of the
targets in treatment (Post et al., 2015). The
multidimensional nature of this disorder thus emphasizes the
need for close collaboration with individuals in medicine,
psychiatry, and other health-related professions when
implementing treatment.

1.7 Diagnostic Procedures and Assessment

Tools
Table 5 Elements of a Good BD Assessment

Screen for past or current manic and hypomanic symptoms in depressed patients.
Ask about shifts in energy as well as mood.
Carefully assess history of lifetime episodes.
Use multiple interviews and include family members/significant others whenever
possible.
Review family history of mania, hypomania, or mood instability in first degree
relatives.
Review hospitalization history.
Always assess suicidality, given high risks.
Use a Life Chart to review timing of episodes, hospitalizations, major life
events, and medication changes.
Request medical records for hospitalizations and extended outpatient
treatment.
There are several diagnostic procedures that can be used to
assess the diagnosis and severity of BD, setting the stage
for treatment success. There is no definitive laboratory test
to confirm the diagnosis of BD. Rather DSM-5 diagnosis is
based on the presence of hypomanic or manic symptoms. Family
history, as well as previous treatment response, may be
weighted in making a diagnosis (Goodwin & Jamison, 2007).
Given the complexity of mood fluctuations, single interviews
with patients are often not reliable in establishing a
diagnosis, |14| and ideally you will develop a perspective
over several interviews with the patient and other
informants. In the course of therapy, patients can also
complete a daily mood chart. See Appendix 5: Mood Chart
Adapted from Basco and Rush (2007) that tracks mood and
related symptoms to help deepen understanding of mood
fluctuations. We recap goals of a good assessment in Table 5.

1.7.1 Assessment of Mania

Most structured interviews, including the Structured Clinical
Interview (SCID) for adults (First et al., 2015) or the
Washington University Kiddie Schedule for Affective Disorders
and Schizophrenia for youth (Gellert et al., 2001), are too
lengthy to be used in routine outpatient practice.
Nonetheless, because many patients and caregivers find DSM
terms confusing (e.g., “pressured speech”) or negative
(e.g., “grandiosity”), SCID probes for mania can help
provide clearer language (e.g., talking too much, feeling
more confident) when inquiring about symptoms. Some
researchers use the Mini-International Neuropsychiatric
Interview (MINI, Sheehan et al., 1998), which uses a simple
“yes” or “no” format for questions about symptoms.
Validity studies for this scale have been favorable with a
slight bias towards false negative responses often seen in a
yes/no format. Version 7.0.1 has incorporated changes
consistent with DSM-5, and covers developmental and severity
features reasonably well. A self-report MINI module is
available to assess mixed features (Hergueta & Weiller,
2013). The MINI has shown sensitivity of 0.91 and specificity
of 0.70 with a kappa coefficient of 0.60 compared to
psychiatric interviews. For youth assessment, parent report
is generally more reliable than child report (Youngstrom,
Findling, & Calabrese, 2004). We focus on screening
instruments and checklists for both depression and mania,
and, in Clinical Vignette 1, we illustrate the identification
of periods of manic symptoms in a dialog between therapist
and patient.

Clinical Vignette 1
Identifying Periods of Manic Symptoms
Therapist: Have you ever had any periods where you have needed
considerably less sleep than usual for days in a row?
Patient: Needed or wanted?
Therapist: No, it’s more like you haven’t felt tired and you didn’t
feel you needed the sleep.
Patient: Not recently, but within the last several months – yes.
Therapist: For more than a week at a stretch?
Patient: It was about a week. I just wasn’t sleeping very much.
Therapist: Did you feel rested?
Patient: No, I was having a lot of trouble sleeping at that time.
[Not consistent with mania]
 Therapist: OK. Have there been times when you were very energetic or
active or were taking on lots of new goals?
Patient: No.
Therapist: Have you had times when your mood was higher or more
irritable than normal for 4 days at a time?
Patient: No.

This appears to rule out key symptoms of hypomanic episodes.

|15| Life Chart

The NIMH Life Chart Method (Denticoff et al. 2000; Leverich &
Post, 1997) is a tool that helps patients and therapists
develop a graph of the course of illness, including episodes,
hospitalizations, significant life events, and medication
responses. Because the Life Chart captures history in a
simplified graphic form that is accessible to both patient
and therapist, it often provides insight into the role of
medication, medication response, and treatment adherence in
past episodes. Typically, the Life Chart will include all
episodes of mania and depression rated on a three point scale
– mild (no functional impairment), moderate (distinct
functional impairment), and severe (functionally
incapacitated – hospitalized), although covering only more
recent time periods is warranted for a person with a lengthy
history. Simplified or online versions (available at
http://www.bipolarnews.org) of this tool can be provided to
patients as a part of the assessment process and the
clinician can help the patient review relevant history. Many
clinicians use this routinely as an assessment and treatment
tool with the rationale that it promotes active patient
participation, and a collaborative, problem-solving approach
for the patient and therapist (Post, Roy-Byrne, & Uhde,
1988).

Young Mania Rating Scale

For assessing the severity of mania, the Young Mania Rating
Scale (YMRS; Young, Biggs, & Ziegler, 1978), a clinician-
rated assessment instrument, has good reliability and
validity and is a sensitive measure of change in symptoms of
mania with treatment. The YMRS may not always be feasible, as
it requires significant training to develop sufficient
interrater reliability and takes up to 30 minutes to
administer.

Clinical Global Impressions Scale – Bipolar Version

(CGI-BP)
The Clinical Global Impressions (CGI)-Bipolar Version
(Spearing, Post, & Leverich, 1997) is a version of the CGI
Scale that was developed for BD. It is very brief, and it is
widely used in clinical trials to assess global severity of
bipolar symptoms.

Self-Report Instruments for Manic Symptom Severity

Self-report tools do not yet accurately screen for BD. After
a diagnosis has been made, though, self-report tools can help
detect changes in mania over time. The Hypomanic Checklist
(HCL-32, Angst et al., 2005) and the Altman Self-Rating Mania
Scale (Altman et al., 1997) are both useful and show moderate
correspondence with interviewer reports. Both tools can help
patients to learn to self-monitor for manic symptoms.

1.7.2 Assessment of Bipolar Depression

Because depression is a key treatment target in BD, we will
review instruments to assess depression severity. There are a
number of self-report and clinician-administered assessments
that can help screen for depression and measure depression
severity at baseline and after treatment.

|16| Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 (Kroenke & Spitzer, 2002; Kroenke, Spitzer, &
Williams, 2001) is a widely used, easily administered and
well-validated screen for depression that is sensitive to
clinical change and can be used to detect changes with
treatment. It requires only 3–5 minutes to administer.
Because scoring is straightforward, the results can be
immediately tallied and discussed with the patient.

PROMIS Emotional Distress-Depression-Short-Form

This 8-item scale is appropriate for assessing depression in
adults (Cella et al., 2010). Items cover negative mood,
negative affect, and negative views of self and others.

Inventory of Depressive Symptomatology Self Report

Version (IDS-SR)
The 30-item Inventory of Depressive Symptomatology (IDS;
Rush, Giles, & Schlesser, 1986; Rush, Gullion, & Basco 1996)
and the 16-Item Quick Inventory of Depressive Symptomatology
(QIDS; Rush et al. 2003) are well validated, brief, public
domain self-report multiple-choice questionnaires designed to
measure depressive symptoms in outpatient and inpatient
populations. Both versions have demonstrated high
reliability, internal consistency, and strong correlations
with other measures of depression (Reilly, MacGillivray,
Reid, & Cameron, 2015; Rush et al., 1996; Trivedi et al.
2004).

Beck Depression Inventory, Second Edition (BDI-II)

For assessing the severity of depression in BD, the BDI-II
(Beck, Steer, & Garbin, 1988) is a widely used and simple
paper-and-pencil self-report checklist that can be completed
in the waiting room in 5–7 minutes. The BDI-II is a reliable
indicator of depression severity and is clinically sensitive
to change. The BDI-II also contains specific items that cover
hopelessness and suicide ideation/plans. Pessimism and
suicidal ideation items are useful indicators of suicide
risk: a “3” or “4” rating on either item should prompt
immediate investigation of current suicidality and
documentation of a management plan.

Hamilton Rating Scale for Depression (HAM-D)

The HAM-D (Williams, 1988) is a clinician-rated scale that is
recognized as a standard for measuring the severity of
depression. The HAM-D scale contains items that assess key
symptoms of depression, including overall mood, somatic
symptoms, insomnia, loss of interest and pleasure, guilt,
psychomotor retardation, agitation, and anxiety. The HAM-D
offers high validity and is sensitive to clinical changes in
terms of response to treatment. A major drawback of the HAM-D
Scale for clinical practice is that it requires training. A
modified version of the HAM-D was developed to provide more
structured interview probes and clearer descriptions of scale
points, and reliability can be established more easily
(Miller, Bishop, Norman, Maddever, 1985). Both versions of
the Ham-D, though, require about 30 minutes to administer
when depression is present.

|17| 1.8 Implications for Clinical Practice

In this chapter, we’ve outlined the high prevalence rates,
difficulties with functioning, family burden, poor quality of
life, high risk for suicide, co-occuring substance abuse, and
high rates of other forms of co-occurring psychiatric
disorders, such as anxiety and eating disorders, in BD. More
sensitive screening and diagnostic procedures can lead to:

1. Improved quality of lives for patients and families.

2. Reduced risk of suicide.
3. Reduced risk of co-occurring substance abuse.
4. Identification of other frequently co-occurring
illnesses that may require targeted treatment.
5. Better recognition of mixed symptoms, preventing their
negative outcomes.
 2
Theories and Models of Bipolar
|18|

Disorder
Here we focus on the background for effectively explaining BD
within a therapeutic framework, using models that have
received strong research support. We begin with a discussion
of the biological basis of BD. We then provide an overview of
the model and rationale for the following treatment
approaches:

Psychoeducation
Interpersonal and social rhythm treatment
Family-based treatment
Cognitive-behavioral treatment

Theories and strategies of psychological treatments of BD

overlap considerably. For example, psychoeducation can be
found in every treatment approach (Miklowitz, Goodwin, Bauer,
& Geddes, 2008). Although BD has a strong genetic basis, the
course of the disorder across individuals and over time is
highly varied. This suggests that variables above and beyond
the innate vulnerability are contributing to fluctuations in
symptoms. Drawing on this, most psychosocial treatment models
of BD emphasize a combined diathesis (vulnerability) plus
stress (environmental) approach. That is, in the context of
biological vulnerability, people with BD may be particularly
vulnerable to environmental and psychological factors as
symptom triggers. As with other recurrent episodic disorders,
such as depression, it is important to identify risk factors
that may trigger new episodes, as well as protective factors.
The treatments described here provide a toolkit for
understanding and addressing how various risk factors can be
addressed, including interpersonal, social rhythm, family,
behavioral, and cognitive factors. At this stage, there is
limited evidence that allows the practitioner to select the
optimal treatment approach from these various models on a
purely empirical basis. We encourage practitioners to
consider the personal relevance of these treatment approaches
for each individual.

2.1 Biologically Based Disease Models

An abundance of clinical research over the past four decades
provides compelling evidence for biological mechanisms in BD.
Twin studies indicate that about 80% of the risk for the
onset of BD is explained by heritability (genes), as compared
to 37% for those with unipolar depression (McGuffin et al.,
2003). Nonetheless, no genetic polymorphisms have been
identified that account for more than 2% of the variance in
whether BD develops. A growing consensus has emerged that no
single genetic polymorphism is likely to |19| be identified
that will fully explain this disorder. Genetic vulnerability
may interact with environmental stressors to precipitate the
onset of mood episodes.
 Many of the brain regions involved in BD overlap
considerably with those that are involved in other emotion-
relevant disorders, such as depression and anxiety disorders.
One model identifies reward pathways in the brain that may
become more active when there is an opportunity to earn
rewards, and promote increased energy and goal-driven
behavior (Depue & Iacono, 1989; Fowles, 1988). Some
neuroimaging studies provide support for this idea, in that
people with BD show greater activation of reward pathways
when given an opportunity to earn rewards (Dutra, Cunningham,
Kober, & Gruber, 2015; Nusslock et al., 2012). Behavioral
research also supports this model. In some studies, people
with BD I and BD spectrum disorders report that they are more
motivated by opportunities to earn rewards even during
periods of remission. People who describe themselves as
highly responsive to rewards on a self-report measure are at
higher risk for the onset of bipolar spectrum disorder, the
conversion from bipolar spectrum disorder to more severe
forms of BD, and a more severe course of mania over time
after diagnosis with BD I (see Johnson et al., 2012, for a
review). This reward sensitivity may shape tendencies to
become more activated after life events involving success, to
think in an overly positive manner after small successes, and
to become more mobilized than do others after making goal
progress in day to day life (Fulford, Johnson, Llabre, &
Carver, 2010). In turn, those who become particularly
immersed in pursuit of new goals are at increased risk of
manic symptoms emerging over time. This cycle of reward and
increased pursuit of reward appears to be specific to mania;
in contrast to mania, negative life events and losses appear
to predict depression (Johnson et al., 2012). However, this
important model is still undergoing testing and the concept
of “reward” may be still too simply stated, especially
given that the majority of manic and hypomanic symptoms and
episodes are mixed and not euphoric for most people with BD
(Miller et al., 2016; Suppes et al., 2005).

A number of important approaches to understanding the

biology of BD are under study. Dysregulation of circadian
rhythms may trigger BD symptoms and episodes (Cosgrove et
al., 2016; Gonzalez, 2014; McClung, 2013). Counseling
patients to maintain regular sleep patterns and to avoid jet
lag, shift work, or late weekend bedtimes is an important
part of helping them manage their illness. The first symptom
of an impending episode is likely to be dysregulation of
circadian rhythms. Exciting new, although early, work
explores the role that the immune system and inflammation may
play in the development and course of BD (Padmos et al. 2009;
Rosenblat & McIntyre, 2016). Inflammation may be important in
many psychiatric illnesses, and is being considered as a
potential treatment target (Sekar et al., 2016). As well,
exploration of cellular dysfunction contributing to the
symptoms observed in BD suggest dysfunction in cellular
function. Findings from a number of studies implicate
mitochondrial dysfunction as one such element (Morris & Berk,
2015; Yoshimi et al., 2016). Parallel animal research is
underway to consider these topics.

The individual’s response to medications is variable and

may depend on individual differences that are not yet well
understood. Some pharmacological agents that influence
different neurochemical systems seem to have similar
|20| effects (e.g., lithium and anitpsychotics). This points
to the fact that there is no single class of medication that
is effective in all cases. Even lithium – the first
medication approved specifically for BD – is efficacious
long term in less than 50% of patients who initially
responded. While past research and clinical experiments were
focused on monoamines, most neurotransimiters act broadly. A
more recent focus is on pathways or connectivity between
brain areas (Gyurak et al., 2016; Williams et al., 2015). A
simple example of this might be more recent work examining
reward pathways and how down regulation (less activity) vs.
up regulation (greater connectivity and activity) could be
related to different clinical states and symptoms. Since it
is known that the reward pathways appear to involve
substantial dopaminergic neurotransmitters, as well as
glutamate and other neurotransmitters, future research may
have us more directly targeting dysfunctional systems of
connected brain areas with medications and other targeted
treatments. Nonetheless, given the wide-ranging mechanisms
driving these symptoms, one might argue that the cluster(s)
of symptoms categorized as BD are likely to be caused by more
than one brain dysfunction. It is likely that as we
understand more about the underlying biological mechanisms,
pharmacological, brain stimulation, and nonpharmacological
treatments for BD will improve.

While it is clear that a biological approach to the

treatment of BD is essential, there are limits to our current
understanding. This presents challenges for the clinician
attempting to identify the best combination of medications
for a given clinical presentation. In line with this,
psychosocial therapies are critical additions to medication
treatment to maximize quality of life and general wellness of
patients.

2.2 Psychoeducation
Psychoeducation encompasses many strategies with a goal of
illness management. Psychoeducation is designed to provide
information about the nature and causes of psychiatric
disorders, and to give a clear rationale for seeking and
remaining in treatment (including medication). Most
psychoeducation approaches begin by promoting an
understanding of BD as a recurrent illness that will require
ongoing treatment. Helping clients understand medication side
effects, and ways to reduce these, can be extremely helpful.
The main rationale is that improving adherence with
treatment, especially medication, and assisting patients in
the management of potentially stressful situations can
ameliorate the course of future episodes by helping the
patient identify protective strategies and reduce high-risk
behaviors.

As shown in Table 6, psychoeducation often encompasses

broader illness management strategies. These may include
developing more effective self-management skills, including
managing stressors effectively and developing coping skills.
Psychoeducation programs often help people understand more
about how to recognize prodromal symptoms of mania and seek
rapid treatment when those are noticed. Many programs foster
a better understanding of triggers for the illness
(medication nonadherence, substance use, excessive
interpersonal or family conflict, life stress, sleep loss,
and, in the case |21| of mania, major exciting new goal
attainments). Some programs teach coping skills for reducing
the severity and effects of emergent symptoms. Many include
formulating a relapse prevention and wellness plan.

In a review of 40 randomized controlled trials of

psychoeducation in severe psychopathology, Mueser and
colleagues (2002) concluded that providing information alone
did not necessarily improve medication adherence or broader
treatment outcomes. Rather, effective strategies for
improving medication adherence involved two key components:
(1) providing the patient with concrete strategies for
incorporating medication into his or her daily routine; and
(2) motivational interviewing which focused on addressing a
patient’s concerns about medication. Psychoeducational
programs focusing on coping skills training and relapse
prevention were effective. A recent review of psychosocial
interventions for BD concluded that psychoeducation was one
of the most effective psychotherapies (Miziou et al., 2015).

Table 6 Elements of Psychoeducation

Modify your approach to the “readiness” of the patient/family to accept

treatment.
Tailor your goals to the patient’s and family’s concerns.
Emphasize a collaborative approach, helping patients and family members become
actively engaged in treatment.
Enhance medication adherence by identifying specific beliefs and concerns that
interfere with treatment and developing specific behavioral strategies for
daily adherence.
Help patients monitor their activity, sleep, and warning signs of new
episodes.
 Encourage a regular schedule.
Help patients develop effective self-management skills to manage stressors and
promote coping.
Formulate a relapse plan.

2.3 Interpersonal and Social Rhythm

Therapy
Interpersonal and social rhythm therapy (IPSRT) was adapted
by Frank, Swartz, and Kupfer (2000) based on interpersonal
psychotherapy for depression. IPSRT expands on traditional
IPT by addressing findings that BD is tied to circadian
(daily) rhythm disturbances (Wehr, 1990). Several researchers
have shown that people with BD are more active at night and
less active by day than others are, even during remission
(Gonzalez, Tamminga, Tohen, & Suppes, 2014). These circadian
disruptions have been hypothesized to be a major mechanism
driving symptoms of BD (Wehr, 1990). Consistent with this
idea, life events that involved social rhythm disruptions
were found to be commonly reported before the onset of manic
episodes (Malkoff-Schwartz, Frank, & Anderson, 1998). Ehlers,
Frank and Kupfer (1988) hypothesized that social activities,
such as routine times for meals, work, and social
interactions, regulate circadian rhythms. The goal of IPSRT
is to assist patients in stabilizing their social routines.
Table 7 lists other objectives of this therapy.

|22|Although IPSRT emphasizes profiles of activity across

day and night, a growing body of research suggests that sleep
patterns are particularly important in BD (Murray & Harvey,
2010). Sleep loss can trigger the onset of manic symptoms,
sleep disruptions are common during mania, and diminished
sleep is one of the most common prodromal signs of
encroaching mania. In Europe it is common to treat depression
with sleep deprivation, a strategy that could trigger mania
in a patient with BD. Given the powerful evidence for the
role of sleep, clinicians should consider intervention
strategies that aim to improve sleep (Kaplan & Harvey, 2013;
Manber et al. 2011).

Table 7 Objectives of Interpersonal and Social Rhythm Therapy (Based on

Frank et al., 1999)

Help patients recognize the relationship between mood and life events.
Help patients manage stressful life events.
Stabilize social rhythms.
Address medication nonadherence.
Provide an opportunity for the patient to grieve over losses due to the
illness.
Address interpersonal difficulties, role transitions, and deficits in social
skills.

2.4 Family-Based Treatment

Table 8 Principles for Working With Families of Individuals With Serious
Mental Illness (Based on Dixon et al., 2001)

Coordinate all elements of treatment and rehabilitation to ensure that

everyone is working towards the same goals in a collaborative, supportive
relationship.
Pay attention to the social as well as the clinical needs of the consumer.
Provide optimum medication management.
Listen to families’ concerns and involve them as equal partners in the
planning and delivery of treatment.
Assess strengths and weaknesses in the family ability to support the consumer.
Address feelings of loss.
Provide relevant information for the consumer and his or her family at
appropriate times.
 Provide an explicit crisis plan and response.
Help improve communication among family members.
Provide training for the family in structured problem-solving techniques.
Encourage family members to expand their social support networks, for example,
to participate in family support organizations such as NAMI.
Be flexible in meeting the needs of the family.
Provide the family with easy access to another professional in the event that
the current work with the family ceases.

Most hospitalized psychiatric patients are discharged to

return home to live with family members. In many cases,
family members are the ones that help address day to day
challenges presented by serious symptoms. Given this,
|23| family-based approaches may be the most underused
evidence-based interventions in the treatment of BD and other
serious psychopathology.

One goal of family-based treatment is to provide

psychoeducation about BD. Some of the critical elements of
family intervention as applied to schizophrenia are listed in
Table 8 (Dixon, McFarlane, & Lefley, 2001). While these
principles were developed primarily for work with
schizophrenia, many of the same intervention strategies
appear relevant for BD.

In one review, Dixon et al. (2001) conclude: “Studies have

shown markedly higher reductions in relapse and
rehospitalizations rates among consumers whose families
received psychoeducation than among those who received
individual services.” (p. 904). Furthermore, reductions in
relapse rates were higher for programs lasting more than 3
months, and to be effective these programs needed to include
“skills training, ongoing guidance about management of
mental illness, and emotional support for family members”
(Dixon et al., 2001, p. 905).

A more intensive family-focused treatment for BD evolved

from the findings on the role of expressed emotion, defined
as overly critical or intrusive family interaction styles, in
triggering relapse in schizophrenia and BD (Miklowitz, 2008).
The main assumption of this approach is that reducing stress
in the family environment can reduce or prevent relapse.
Family-based treatment of BD emphasizes psychoeducation, and
training in communication skills and problem-solving skills
among family members to reduce family conflict and distress.
The key objectives of family-focused treatment are summarized
in Table 9.

Table 9 Objectives of Family-Focused Treatment (Based on Miklowitz, 2008)

Help patient and family members integrate experiences with BD.

Assist patient and family members in accepting vulnerability to future
episodes and the ongoing need for medication.
Help patient and family members differentiate BD from personality.
Assist patient and family members in recognizing and coping with stressful
events.
Help family improve relationships.

2.5 Cognitive-Behavioral Treatment

Cognitive-behavioral therapy (CBT) for BD has evolved from
the well-supported CBT approaches for depression (Beck, Rush,
Shaw, & Emery, 1979). CBT targets the negative belief systems
regarding self, world, and others that make the patient
vulnerable to depression (Beck et al., 1979). The assumption
is that bias in information processing causes patients to
misconstrue or misinterpret events in a negative direction,
which then increases the risk of depression. Thoughts,
feeling, and behavior are viewed as reciprocally related such
that, negative thinking (e.g., “I’m incompetent – I won’t
be able to do this”) might lead to changes in behavior
(giving up, not trying, avoiding tasks, |24| isolating,
withdrawing) which can then increase depression. This might
intensify self-critical thoughts (“What a loser I am, I
couldn’t even do this simple task”), increasing immobility
and a lowered mood. To address this spiral, CBT for
depression includes strategies for increasing pleasant and
meaningful activities (to combat withdrawal), identifying
negative thought patterns, and learning to challenge these
negative thoughts. These techniques can be applied to BD
depression.

CBT targets distorted thinking and high-risk behaviors

relevant to manic symptoms. Hypomanic thinking often involves
grandiose beliefs that underestimate risks and overestimate
potential rewards. In the behavioral realm, hypomanic
individuals are predisposed to action and have difficulty
accepting delay. CBT strategies target these behaviors
(“I’m going to tell the boss that he’s a bastard – he’s
had it coming for a long time”) and associated high-risk
cognitions (“It’s going to work out great”). In addition,
this treatment approach uses a range of behavioral
interventions to help delay impulsive actions in the manic
and hypomanic phases. The assumption is that helping the
patient challenge high-risk impulsive actions and distorted
beliefs will improve patient’s ability to counter impulsive
risk-taking behavior and reduce the likelihood of serious
harm.

As with other approaches, CBT addresses medication

adherence. Many of the suggested interventions focus on
addressing distorted beliefs about medication (“I’ll become
dependent,” “I’ll lose my ability to be creative,”
“Taking medication means I’m sick”).

CBT is based on the assumption that modification of

cognitive vulnerabilities can reduce the vicious cycle of
manic and depressive episodes, reduce treatment nonadherence,
and help patients develop more effective coping abilities
that will reduce vulnerability to stress. There are several
different approaches to CBT for BD with published manuals,
and these tend to differ in the emphasis on cognition and
behavior.

Basco and Rush (1996, 2007) developed one of the first

comprehensive CBT manuals for BD. The authors focus on
medication nonadherence and the presence of subsyndromal
symptoms, even when patients are fully adherent. They argue
that psychosocial treatment can enhance medication adherence
and assist patients in identifying psychosocial stressors
that could trigger episodes.

The treatment model is based on the idea that there is a

reciprocal relationship between thoughts, feelings, and
behaviors that can contribute to the acceleration of
prodromal symptoms into full episodes of illness. This
downward spiral is produced by the interaction of early
changes in mood, thinking (reckless optimism, grandiosity,
poor judgment), and behavior (risk-taking behaviors,
activity) that can further impair functioning, resulting in a
worsening slide into depression and mania. We can readily see
how impaired functioning affects support systems and leads to
additional stress.

Basco and Rush identify several primary treatment targets.

Beyond medication adherence, the techniques foster skills in
mood monitoring, identifying early warning signs, considering
stressors, and developing problem solving and coping skills
(see Table 10).

Another CBT model for BD highlights the importance of

identifying prodromes (or early warning signs and symptoms of
an incipient episode) and the development of coping
strategies (Lam, Jones, Hayward, & Bright, 2010).

|25|This treatment supplements psychoeducation and

training on early identification of symptoms with training
patients to identify prodromes of illness and to develop
coping strategies for emergent symptoms (see Figure 1 and
Table 10).

Table 10 Objectives of Cognitive-Behavioral Treatment of Bipolar Disorder

Based on Basco & Rush, 2007:

Educate patients about the disorder, treatment approaches, and common problems
associated with BD.
Teach patients to monitor mood and associated symptoms methodically.
Promote medication adherence.
Develop cognitive and behavioral skills for ameliorating the cognitive,
affective, and behavioral changes associated with manic and depressive
episodes.
 Help patients develop more effective coping and problem solving strategies to
reduce stress.

Based on Lam et al., 2010:

Develop a collaborative working relationship.
Psychoeducation on the diathesis-stress model.
Help patients learn problem-solving skills to manage stress.
Developing specific cognitive-behavioral skills for monitoring and coping with
prodromes.
Assisting patients in maintaining stable routines and getting adequate amounts
of sleep.
Helping patients address long-term vulnerabilities (such as excessive goal-
driven behavior) to reduce future episodes.

Based on Newman et al., 2002:

Modify maladaptive beliefs or cognitive vulnerabilities that predispose
patients to severe episodes of depression and mania.
For mania/hypomania:
1. Address maladaptive perceptions, judgment, and behaviors.
2. Moderate hypomanic/manic thinking by counterbalancing overly positive
thoughts and beliefs.
3. Moderate impulsivity and recklessness by encouraging delaying
behaviors and tactics.
4. Help the patient modulate affect.
5. Assist patients in reducing disorganization and distractibility.
For depression
1. Address maladaptive perceptions, judgment, and behaviors.
2. Counteract hopelessness and demoralization.
3. Address suicidal beliefs.
4. Increase mastery and pleasure.
5. Teach problem-solving skills.
6. Develop social support systems.

This treatment model assumes: (1) that with training,

patients are able to detect prodromal signs of illness
effectively; (2) that a skills-based approach can help
patients develop better coping strategies; and (3) that these
coping strategies will protect against the development of
symptoms. Many of the key strategies outlined in the Lam
manual (2010) have been incorporated into British national
treatment guidelines for BD (NICE, 2014, see Table 11 for a
|26| summary). Some of the strategies described in the Lam
manual appear particularly relevant for addressing the over-
activation that can occur as people with BD pursue rewards
and goals.

Figure 1 Stress-vulnerability model (Adapted from Lam, Jones, Hayward, &

Bright, 2010)

Table 11 Recommendations for Psychological Therapy for BD (Based on NICE,

2014)

Provide psychoeducation.
Emphasize importance of regular daily routine and sleep-wake cycles.
Help patients learn to identify early warning signs and symptoms (prodromes).
Foster skills for coping with prodromes.
Teach problem-solving skills to manage stress.
Provide 6–9 months of intervention and at least 16 sessions of individual
structured psychotherapy.

Newman, Leahy, Beck, Reilly-Harrington, and Gyulai, (2002)

developed a cognitive treatment model for BD that focuses on
the central role of cognition in triggering bipolar episodes
(see Table 10). Newman et al. (2002) propose that, in
addition to biological vulnerabilities, cognitive factors
(e.g., distortions in the patient’s perceptions, information
processing, belief systems, and judgment) contribute to the
recurrence of manic and depressive episodes. Their treatment
approach aims to modify the patient’s beliefs, especially
long-standing fundamental beliefs that shape cognitive
processing of events. For example, a patient with the
longstanding belief that they are unloveable will be prone to
noticing evidence to support that belief, and to remembering
that information selectively. The assumption is that
modification of these cognitive vulnerabilities can fortify
the patient against the continuing vicious cycle of manic and
depressive episodes by developing more effective coping and
problem-solving abilities and reducing vulnerability to
stress. Although there is considerable evidence that negative
thinking styles can predict the course of |27| depression,
negative cognition does not seem to help predict manic
symptoms (Johnson, Cuellar, Peckham, 2014). Rather, after
small successes, people with BD show surges in confidence
(Johnson et al., 2012), and high confidence predicts more
manic symptoms over time (Lam, Wright, & Sham, 2005). The
Newman manual (2002) uses behavioral interventions to help
patients delay impulsive actions based on overly confident
thinking (see Table 20).

Monitoring behaviors and emotional states is a cornerstone

of most cognitive-behavioral therapies. Monitoring helps the
patient be more aware of early signs of a mood shift, which
is the first step in using corrective therapeutic strategies.
We will discuss a number of self-monitoring tools.
 3
Diagnosis and Treatment
|28|

Indications
This chapter provides advice on treatment indications – that
is, how to determine the most appropriate treatment. After
describing basic issues, we include a decision tree for
evaluating the best treatment options/settings, and specific
advice for addressing common presentations.

Even though treating BD can be extremely gratifying, not

every practitioner will want to take on the responsibility of
treating patients with BD in a private practice setting.
Patients with BD provide significant clinical challenges,
with complex problems and co-occurring disorders. Certain
patients cannot be properly treated in a private practice
setting, because their symptoms are too serious to be
appropriately managed without access to partial
hospitalization or inpatient services. How will you decide
whether or not you should consider treating a given
individual with BD? As summarized in Table 12, your decision-
making should consider the stability of the patient, the
presence of high-risk symptoms, their willingness to comply
with psychiatric and psychological treatment regimens, and
the presence of a robust social support system. It is also
extremely helpful to have effective communication with
psychiatric treatment providers if you are not directly
managing medications.

Table 12 Determining if an Outpatient Setting Is Appropriate for the

Patient

Has the patient agreed to take a mood stabilizer, receives current psychiatric
care, and is treatment adherent?
Is there a pattern of recent instability, hospitalizations, or emergency room
visits suggesting that standard outpatient treatment will not be sufficient
for the patient to remain stable?
Does the patient have a stable living situation?
Does the patient have sufficient social support available?
Does the patient present an acute suicide risk that cannot be managed in
outpatient care?
Will the patient be able to comply with the requirements of outpatient
treatment in terms of attending for regularly scheduled appointments?
Is the patient sufficiently motivated to commit to a course of outpatient
treatment?

3.1 Decision Tree for Determining

Optimal Treatments
|29|

Pharmacological intervention should always be a part of the

treatment plan. There are many psychological treatments to
consider, and because these have received equivalent levels
of research support, treatment planning should be
individualized to the patient. In addition to a standard
diagnostic assessment discussed in Chapter 1, treatment
planning should be guided by the items in Table 13, such as
the severity, phase, and course of the illness. Although
psychoeducation may be particularly helpful early in the
course of the disorder, many patients with highly recurrent
illness already have a strong understanding of the nature of
the illness and medication treatments. For those patients,
considering the extent to which cognitive, behavioral,
interpersonal, and family triggers may be relevant should
guide your choice of intervention strategies.

Table 13 Information to Be Reviewed in Initial Interviews

1. Acuity of current presentation

a) Current presenting symptoms
b) Suicidal risk
c) Medication adherence
d) Coping skills
e) Social skills
f) Psychosis or poor reality testing
g) Current substance misuse
h) Hopelessness and demoralization
i) Current functioning
j) Judgment
k) Other high risk factors/behaviors

2. Life history and course of illness

a) Degree of interepisode recovery
b) Highest level of functioning
c) Presence of subsyndromal dysthmia and depression
d) Age of onset
e) Course of the disorder to date

3. Environmental factors
a) Interpersonal, family, and social stressors
b) Interpersonal, family, and social resources
c) Job, career, school-related problems
d) Goals and aspirations

4. Treatment factors
a) Family/significant other engagement
b) Degree of medication adherence
c) Degree of acceptance/denial of illness
d) Degree of overall readiness and engagement in treatment
e) Willingness to accept help in therapeutic relationship
f) Ability to manage without structured, supervised living situation

In a review of psychosocial interventions for BD,

|30|
Zaretsky (2003) concludes:
 Treatment of acute episodes is likely best accomplished by
pharmacotherapy. Psychoeducational interventions appear to improve
medication adherence and should be considered early in the course of
illness. Treatment interventions that focus primarily on helping
patients identify early prodromes of relapse to take proactive steps
have also been shown to be effective. Such interventions should be
considered after medication adherence has been adequately addressed.
(Zaretsky, 2003, p. 85).

3.1.1 Treatment Options for Young Adults

Treatment options for a young adult with a recent
hospitalization for a first episode might focus on helping
the patient understand BD, and working to reduce denial of
illness, medication nonadherence, and family conflict. First-
line treatment options are likely to include psychoeducation,
a focus on engaging the patient in self-care, normalizing
their experiences, motivational interviewing to enhance
medication adherence, and family-focused treatment.

3.1.2 Treatment Options for Potentially Self-

Damaging Behaviors
For individuals with higher-risk presentations, such as a
recent hospitalization, suicidal behavior, high-risk
hypomanic behaviors (risk-taking, poor judgment), or
medication nonadherence, possible interventions might include
developing a safety plan and identifying high-risk behaviors,
addressing the patient’s past behavior, high-risk hypomanic
behaviors, teaching the patient to use “delay tactics,”
behavioral strategies to limit stimulation to contain
impulsive behaviors, and motivational interviewing to enhance
medication adherence.

3.1.3 Treatment Options for Repeated Episodes of

Mania/Hypomania Despite Medication Adherence
For an individual with a repeated history of manic or
hypomanic episodes who is medication compliant (see the
Clinical Vignette 2: Developing Coping Strategies for a
Psychotic Episode and Table 14) possible interventions might
include reconsidering pharmacological interventions, or
implementing symptom monitoring so that the patient can call
the psychiatrist for medication adjustments in the face of
prodromal symptoms. Patients may also want to learn specific
skills for identifying the triggers of manic episodes and for
implementing behaviorally-oriented coping strategies to
prevent the spiral upward into mania and to limit lifestyle
damage from manic symptoms.

|31| Clinical Vignette 2

Developing Coping Strategies for a Psychotic Episode
Bill is a 40-year-old Caucasian male. He lives with his girlfriend of 18
years, who provides financial and emotional support for him. He has had a
sporadic work history and is not currently working. His presenting problems
and concerns focused on feeling anxious and overwhelmed. He presented as
motivated for treatment, pleasant, articulate, bright, and able to be
insightful except during manic episodes. His partner was supportive of
therapy and involved in coping plans developed by Bill. Bill’s treatment
goals are identified in Table 14.
Bill was first diagnosed in 1981, at age 17, with BD, which he attributed to
“high school stress.” The most recent of three psychiatric hospitalizations
in June of 2003 was for a severe manic episode with psychotic features
(including delusions of grandeur). He attributed the episode to changes in
medication and stress.
The therapeutic work with Bill focused on identifying and monitoring early
prodromal signs of mania and becoming aware of how stressful situations
increased his risk of illness. Bill began regularly monitoring his mood on a
daily basis using a mood monitoring graph adapted from Basco and Rush (1996)
over a period of several weeks. He regularly completed his mood monitoring,
where he typically rated himself in the “0” to “+2” range, indicating
normal or slightly elevated mood in the normal range. In addition, Bill
developed a set of early warning indicators that acted as “red flags” for
previous episodes and he identified specific coping strategies that he could
use when he identified the onset of hypomania.
Bill identified the following early warning signs of a hypomanic/manic
episode:

Feeling more “keyed up” and having trouble settling down

Feeling stressed
Starting to lose sleep
Beginning to experience unusual thoughts and feelings
Becoming secretive and hiding these thoughts and feelings from his
partner

Bill developed the following coping plan for hypomania/mania:

Deep breathing and meditation

Talk to significant other
Call doctor
Make medication changes
Prioritize activities
Slow down: don’t drive on freeway; don’t react to other drivers
Avoid overstimulation: avoid arguments; avoid ruminating

Several weeks into the treatment program, Bill began to experience increasing
signs of activation and complained about stressors he associated with selling
his house and feeling pressure from his girlfriend to complete tasks related
to their impending move. After missing group for a week, Bill returned and
reported that he had had a “mixed manic episode” this past week in which he
began to experience unusual thoughts (“My desktop files are organized in an
especially significant way”; “I’m part of a grand plan”; “I have a true
understanding of my life”) and a sense of being very buoyed up and restless.
 His mood graph indicated a sharp spike into the +4 to +5 range, indicating
“very manic” or severe hypomania/mania.
Bill was able to communicate with his girlfriend and call his doctor, with
the result that he received some additional medication and did not cycle into
a full manic episode that required hospitalization. This was the first such
episode that Bill had been able to avoid ending up in the hospital in a
severe psychotic state.
|32| When we reviewed the different outcome for this episode, it appeared
that Bill had implemented a few “small” but highly important changes, as he
noted in his diary: “This time it was different, I didn’t hide the
episode.” He was able to let his girlfriend know about the changes in his
thinking instead of being secretive, and he called his doctor for the first
time before being hospitalized. This case illustrates how careful monitoring
and small, specific behavioral changes that are incorporated into a coping
plan can significantly affect the outcome of a bipolar episode.

Table 14 Bill’s Treatment Goals Developed in Bipolar Disorder Group

Openness of mood/illness with others

Self-awareness of mood swings
Difficulty asking for needs to be met
Problems asserting self with others
Overcome fear of stigma
Address employment problems

3.1.4 Treatment Options for Poor Recognition of

Symptoms
For an individual with denial of illness, or inability to
detect symptoms, possible interventions might include
psychoeducation, consideration of maladaptive beliefs about
the illness or symptoms, collaborative review of previous
symptoms using a Life Chart approach, an enhanced focus on
monitoring prodromes of mania and identifying negative
consequences of manic episodes.
3.1.5 Treatment Options for Persistent Subsyndromal
Depression
For an individual with persistent subsyndromal depression
(see the case of Tanya in Clinical Vignette 11: Combating
Demoralization and Hopelessness) or a higher functioning
patient who accepts chronically low functioning and appears
hopeless and demoralized, possible interventions might
include behavioral interventions to activate the patient,
schema-based work to identify long-term self-concept
distortions, and cognitive interventions to combat
hopelessness.
 4
Treatment
|33|

A few principles must be considered in all BD treatment.

Treatment must be individually tailored; there is no place
for a “one size fits all” approach. Consistent adherence to
medication is the foundation of long-term treatment.
Medications must be optimized to reduce side effects.
Additional fundamental elements include psychoeducation.
Psychosocial therapies should be considered. The patient and
therapist must work collaboratively to develop treatment
plans. If possible, consider including significant others in
the planning and ongoing communication.

4.1 Biological Approaches to Treatment

As early as the 1860s, lithium bromide was recommended for
treatment of manic-depressive symptoms and to prevent
recurrence of melancholia. The use of lithium was based on
theories of brain “gout” or salty deposits as a cause,
which the lithium bromide was theorized to remove. As models
of mental illness moved away from these notions, use of
lithium ceased and was only rediscovered in the late 1940s by
Cade in Australia. More than 90% of patients with BD I will
need medications throughout their lifetime, which makes it
important to balance efficacy with side effects (Suppes,
Baldessarini, Faedda, & Tohen, 1991). Treatment research on
BD II and other related disorders such as Other Specified
Disorders continues to lag behind (Ostacher, Tandon, &
Suppes, 2016; Suppes & Dennehy, 2002).

The classic definition of a mood stabilizer in BD is an

agent that treats both manic and depressive episodes, and is
effective in maintenance to prevent the developments of new
episodes. Treatment is made more complex by the range of
presentations within bipolar and related disorders, even
within a given patient over time, including mania,
depression, mixed features of mania and depression, and the
need to consider maintenance treatments during periods of
euthymia. Few agents meet these stringent criteria. The usual
approach to treatment is to think in terms of resolution of
symptoms and maintenance of stability once achieved.
Treatment guidelines generally recognize the importance of
psychosocial treatments but usually recommendations regarding
these treatments are not well integrated into medication
guidelines.

Due to rapid changes in the research and the development of

new medications, guidelines for best practices must be
continually updated to remain current. The goal of the brief
review presented here on medications used in BD is to provide
an overview and general information for didactic purposes.
This overview should not be relied upon as an adequately
detailed treatment guide |34| or up-to-date treatment
protocol for psychiatric medication management. It is
important to remember that guidelines are intended as both
tools for treatment guidance and as educational tools
describing current thinking on best approaches to medication
treatment for patients with BD. Overall, there are relatively
few updated best practices or treatment guidelines for
medication algorithms for BD. The reader may want to
reference at least the following sets of treatment and
medication guidelines: The VA and DOD Bipolar Guidelines
(Management of Bipolar Disorder Working Group, 2010); Grunze
et al. (2010); CANMAT (Parikh et al., 2012); and the recently
published Florida Guidelines (Ostacher et al., 2016).
Guidelines should be used as a guide, an educational tool,
and a starting point for the consideration of a treatment
approach. However, due to the limited well-controlled Level A
evidence (established efficacy) beyond often the first or
second level of recommendations, clinical judgment and
experience must also play a role in the decision making
process.

A few themes emerge across guidelines. First, little

research is available concerning BD II except for quetiapine,
which has gained FDA approval for BD II depressive symptoms
(Ostacher et al., 2016). While many guidelines advise using
the same treatment strategies for both BD I and BD II, recent
data does not support this as necessarily valid. For example,
there has been a long-running debate about the use of
antidepressants in patients with BD. There is now worldwide
consensus that patients with BD I should not receive
antidepressants without a mood stabilizer (Pacchiarotti et
al., 2013). In patients with BD II, this has been a subject
of some debate. In a recent double-blind, randomized study,
patients with current BD II depression were allocated to 16
weeks of an antidepressant (sertraline), lithium, or the
combination. The three arms were matched in treatment
response, switch rates, and activation symptoms, but side
effects were more severe in the combination group (Altshuler
et al., in press.). These results and others suggest that
patients with BD II may not respond the same as patients with
BD I to unopposed antidepressant treatment. Further work is
needed to help us define best treatment practices for
patients with BD II.

BD medication treatment must address three phases: acute,

continuation, and maintenance. The goal of acute treatment is
to reduce current symptoms. During the continuation phase,
typically lasting 3–6 months, medication changes are usually
minimal except to adjust for side effects. The maintenance
phase occurs after symptoms have been in remission for 3–6
months. During this phase, a key decision is whether to
simplify the medication regimen. Doses of medication needed
to reach stabilization and decrease symptoms of an episode
may be lowered due to increased side effects, e.g., sedation.
For example, the minimum lithium blood level needed to treat
acute symptoms is 1.0 mEq/L vs. 0.6–0.8 mEq/L for recurrence
prevention. In sum, a variety of strategies might be explored
before the best efficacy-to-side-effect profile is found and
a stable maintenance program is established. It is worth
remembering that the essential characteristic of BD is
change, so, even in the face of no other factors, at times
there will need to be modification of medications based on
aging or development of other medical conditions. If there is
difficulty stabilizing or protracted treatment-resistance
continues, it is important to consider other mitigating
factors such as co-occurring psychiatric illness, medical
illness, substance abuse, or incorrect diagnosis that
|35| could be contributing to lack of response to medication.
It is important to remember there are a minority of patients
with BD I or BD II that are markedly treatment-refractory.

Below is a list of some of the more common agents used in

the treatment of BD. Table 15, Table 16, Table 17, and Table
18 provide an overview of one recent evidence-based treatment
guideline for BD, the Florida Medication Guidelines (Ostacher
et al., 2016).

Lithium carbonate has been the mainstay for the treatment

of acute mania and its subsequent prevention. The action of
this drug is slow initially and so, for acute treatment, it
is often combined with a second-generation antipsychotic or a
mood stabilizing anticonvulsant. Lithium seems to work more
effectively with patients who present with euphoria rather
than a more dysphoric manic state.

Divalproex is a mood stabilizer often administered in

addition to lithium carbonate, because time to response is
typically shorter. Divalproex tends to have a higher
frequency of response in patients with typical manic symptoms
rather than schizoaffective symptoms. Many individuals with
rapid cycling or dysphoric mania tend to respond better to
this drug than to lithium.

Carbamazepine ER is a mood stabilizer that is often

considered for patients who do not respond to lithium. The
therapeutic range and side effect profile for this drug are
variable across patients, so dosage must be individualized
carefully.
 Lamotrigine is effective as a prophylactic antidepressant
agent in BD I and approved for prevention of new episodes. In
a meta-analysis of all the acute depression studies,
lamotrigine had a greater effect than placebo, though the
effect size was low. Slow titration and dosing strategies are
critical to avoid a rare but severe life-threatening rash
(Stevens-Johnson syndrome).

Clonazepam and Lorazepam, two high-potency

benzodiazepines, are often used as an adjunctive treatment
for patients with acute manic agitation, insomnia, or
dysphoria. They are considered ideal companion medications
for mood stabilizers, because of relatively few side effects.
Long-term use of this drug class, however, may be
problematic. Clonazepam is particularly difficult to withdraw
from as it has a very long half-life.

Virtually all of theatypical orsecond generation

antipsychotics (SGAs), with the exception of lurasidone,
have proven effective in the treatment of mania, and the
majority are effective in combination with mood stabilizers
as well. The SGAs have a more favorable side effect profile
than the first-generation antipsychotics, which makes them
more attractive as adjunctive medications. However, though
tardive dyskinesia is of somewhat lower risk, there are more
concerns about the metabolic impact associated with some of
these medications. Potential substantial weight gain can
often lead to cardiovascular complications or other medical
problems associated with obesity.
 Aripiprazole is approved for acute treatment of mania,
add-on maintenance treatment, and add-on treatment for
bipolar depression.

Asenapine is approved for treatment of acute mania.

Cariprazine is recently approved for treatment of mania.
Clozapine is reported to be highly effective in patients
characterized by classic mania to depression cycle, treatment
resistant mania, mania with mixed features, and rapid
cycling.

|36| Lurasidone proved effective for BD I depression and

unipolar major depression with mixed features in one
controlled study for unipolar major depression with mixed
features, as seen in a novel study by Suppes et al. (2016).

Olanzapine has proven to be effective with some treatment-

refractory patients. It is well tolerated, except for the
problem of serious weight gain.

Quetiapine is effective as an antimanic – it is also

somewhat unique, with positive results from placebo-
controlled trials in BD I and II depression, bipolar
maintenance, and unipolar depression.

Paliperidone is not approved by the FDA though there have

been placebo-controlled trials, and it has been recently
approved for use in schizophrenia. It is the active
metabolite of risperidone.
 Risperidone has proven to be effective in acute mania. The
long-acting injectable form is also approved for maintenance
treatment.

Zisprasidone is an atypical antipsychotic that results in

less weight gain.

Table 15 Recent Guidelines for Management of Mania in BD I (Adapted from

Ostacher et al., 2016)

Level 1A – Established efficacy:

Mild to moderate severity or not requiring hospitalization:
Lithium monotherapy
Monotherapy with aripiprazole, asenapine, divalproex, quetiapine, risperidone, or
ziprasidone
Severe or requiring hospitalization:
Lithium or divalproex plus aripiprazole, asenapine, quetiapine, or risperidone
Level 1B – Established efficacy, but with safety concerns: (a)
Mild to moderate severity or not requiring hospitalization:
Monotherapy with haloperidol or olanzapine
Severe or requiring hospitalization:
Lithium or divalproex plus haloperidol or olanzapine
Level 2 – If level 1A and 1B are ineffective or not tolerated:
Two-drug combination of lithium + divalproex
Lithium or divalproex plus second generation antipsychotic (non-clozapine)
Paliperidone
Carbamazepine
Level 3 – If levels 1 and 2 are ineffective or not tolerated:
Electroconvulsive therapy (ECT)
Clozapine
Clozapine + lithium or divalproex
Lithium + carbamazepine
Divalproex + carbamazepine
Level 4 – If levels 1, 2, and 3 are ineffective or not tolerated:
A 3-drug combination of level 1, 2, and 3. Drugs may include first-generation
antipsychotic (FSA) or second-generation antipsychotic (SGA) BUT NOT two
antipsychotics. Example: lithium + (divalproex or carbamazepine) + antipsychotic.

Note. (a)
Side effect concerns with these agents include weight gain, metabolic
syndrome, and extra pyramidal symptoms (EPS). Side effects warrant vigilance and
close monitoring on the part of the clinician.
|37| Table 16 Recent Guidelines for Management of Bipolar Depression (Adapted
from Ostacher et al., 2016)

Level 1A – Established efficacy: (a)

Quetiapine monotherapy (BD I & II)
Lurasidone monotherapy (BD I)
Lurasidone or quetiapine adjunctive to lithium or divalproex (BD I)
Level 1B – Established efficacy, but with safety concerns: (a)
Olanzapine + fluoxetine (BD I)
Level 2 – Established tolerability, but limited efficacy: (b)
Consult specialist
Lithium (BD I)
Lamotrigine adjunctive to lithium (BD I)
Lamotrigine (BD I)
2-drug combination of above medications
Level 3 – If levels 1 and 2 are ineffective or treatment not tolerated: (c)
Electroconvulsive therapy (ECT)
Level 4 – If levels 1 - 3 are ineffective or treatment not tolerated:
Transcranial Magnetic Stimulation (TMS)
Antimanic therapy + (FDA approved medication for major depression) (d)
Pramipexole
Adjunctive – modafinil, thyroid, or stimulants or a 3-drug combination

Note. (a)
Tolerability limitations include sedation and weight gain. (b) Efficacy
limitations include negative randomized controlled trials but positive meta-
analyses. (c) Consideration merited due to clinical need, despite even greater
efficacy/tolerability limitations than Level 1 and 2 treatments. (d) There is
inadequate information (including negative trials) to recommend adjunctive
antidepressants, aripiprazole, ziprasidone, and levetiracetam.

Table 17 Recent Guidelines for Maintenance Treatment in Bipolar Disorder

(Adapted from Ostacher et al., 2016)

Level 1A – Established efficacy:

Lithium monotherapy
Quetiapine monotherapy
Aripiprazole or long-acting injectable risperidone monotherapy
Quetiapine or ziprasidone adjunctive to lithium or divalproex
Lamotrigine (evidence strongest for prevention of depression, usually as an
adjunct)
Level 1B Established efficacy, but safety concerns: (a)
Olanzapine monotherapy
Olanzapine adjunctive to lithium or divalproex
Level 2 – If Levels 1A and 1B are ineffective or not tolerated:
Continue effective and well-tolerated acute treatment(s) if not listed in Level
1A or 1B
Lithium and divalproex combination
Lamotrigine monotherapy in patients without manic episode in past year
Follow acute mania/bipolar depression guidelines to achieve remission or partial
remission
Level 3 – If Levels 1 and 2 are ineffective or not tolerated: (b)
Adjunctive clozapine (not added to antipsychotics)

Note. (a)
Side effect concerns with these agents include weight gain, metabolic
syndrome, and extra pyramidal symptoms (EPS). Side effects warrant vigilance and
close monitoring on the part of the clinician. (b) Longer-term efficacy data
limited for divalproex monotherapy, carbamazepine (drug interaction risk),
antidepressants, electroconvulsive therapy (inconvenience/expense).

|38| Table 18 Notes About Use of Mood-Stabilizing Medications

Medication Dosage Comments

Lithium In acute mania: Usual titration for tolerability –
1200–2400 mg/day start at 300–600 mg/day, increase 300
(serum level 0.8–1.2 mg/day every week or so. Consider
mmol/l checking levels 5 days after
initiation/dose change. Recheck levels
frequently if clinical toxicity.
Periodic and at least yearly monitoring
of renal and thyroid functions. Lower
doses/levels may be necessary in
nonmanic compared to manic patients. For
maintenance, some patients require serum
levels of 0.8 to 1.0 mmol/l, others can
be maintained with lower levels, but not
below 0.6 mmol/l. In elderly, start with
lower lithium dose, titrate more slowly,
and seek lower serum lithium levels.

Divalproex In acute mania: In mania, initial high dose loading may

5–60 mg/kg/day; 1000 be tolerated, but some patients need
–2500 mg/ day (serum initial titration for tolerability.
level 85–125 μg/ml) Check levels 48 hours after initiation
and adjust dose accordingly. Side
 effects (especially gastrointestinal)
more evident above 100 μg/ml. More
teratogenic than other mood stabilizers.
Lower doses/levels may be necessary in
nonmanic compared to manic patients.

Carbamazepine ER In acute mania: Consider slower initial titration for

200–1600 mg/day tolerability due to hepatic auto-
(serum level 6–12 induction: Start 200–400 mg/day and
μg/ml) increase 200 mg/day every 3 days. Lower
doses/levels may be necessary in
nonmanic compared to manic patients.
Monitor for blood dsycrasias and serious
rash. Screen Asians for HLA-B*1502
(serious rash risk indicator). Decreases
serum levels of multiple other drugs.
Confirm potential drug interactions
before initiating.

Lamotrigine In maintenance: Very slow initial titration to reduce

100–400 mg/day (200 risk of serious rash (Stevens-Johnson
mg/day was most syndrome). Be sure to follow package
effective) insert. The slower, the better in terms
of tolerability and risk for rash. Start
25 mg/day (12.5 mg/day if taken with
divalproex). Target dose is 200 mg/day,
but final doses may be 100–400 mg/day.

|39| Second In acute mania: Titration may be needed for

Generation Aripiprazole: tolerability. Lower doses may be needed
Antipsychotics 15–30 mg/day in depressed patients (e.g., quetiapine
(SGA) Asenapine:
10–20 mg/day
300 mg/day vs. 600 mg/day in mania).
Ziprasidone should be taken with food.
Cariprazine: Asenapine is sublingual. Monitor for
1.5–6 mg/day side effects, including sedation
Olanzapine: (especially with quetiapine and
6–20 mg/day clozapine), weight gain (especially with
Quetiapine: olanzapine and clozapine), akathisia
400–800 mg/day (especially with aripiprazole and
Risperidone: ziprasidone), and EPS (especially with
2–6 mg/day risperidone). Usual recommendations
Ziprasidone: include monitoring weight and BMI at
80–160 mg/day each visit and laboratory metabolic
In acute bipolar indices at baseline, 3 months, and
depression: yearly thereafter.
Quetiapine:
200–600 mg/day
Olanzapine/Fluoxetine:
3 mg/12.5 mg–
12 mg/50 mg/day
 Lurasidone:
40–120 mg/day
Clozapine:
50–400 mg/day (if
treatment resistant)

Antidepressants In acute bipolar Controlled trials to date have not found

depression: a benefit of antidepressants when added
As dosed for major to mood stabilizers/antimanics for BD I
depression (No depression (other than
specific dosing olanzapine/fluoxetine combination). May
recommendations can be be used in combination with antimanic
given in bipolar drugs in some patients with acute
depression.) bipolar depression, but should not be
prescribed as monotherapy in patients
with BD I due to manic switch risk.
SNRIs and TCAs may have greater manic
switch risk. May be continued in
patients who are on them and have
improved.

Note. SNRI = Serotonin-norepinephrine reuptake inhibitor; TCA = Tricyclic

antidepressant .

4.2 Psychosocial Approaches to

Treatment
|40|

Although the primary treatment for BD is mood-stabilizing

medication, substantial support for adjunctive psychosocial
treatment approaches has accrued over the past 20 years.
While there are variations in different therapy models,
successful treatments integrate an understanding of
biological/genetic factors with the need to manage the
psychosocial triggers of symptoms. For example, patients are
taught about the role of daily routines and regular
sleep/wake cycles, work with the therapist to establish
regular routines, learn to identify prodromal signs and
symptoms by monitoring mood and activity/stimulation levels,
and attempt to resolve stressful events in their lives and
develop specific coping strategies to avert relapse.

There is considerable evidence that bipolar depression is

triggered by the same variables that trigger unipolar
depression, including negative life events, social isolation
and lack of social support, and negative cognitive styles
(Johnson et al., 2014). This provides a foundation for using
the rich set of techniques that have been developed in
unipolar depression for addressing bipolar depression. A
number of evidence-based strategies for coping with
depressive episodes have been outlined in the literature over
the past 30 years. Psychological interventions with the
strongest evidence-based support to date for the treatment of
major depressive episodes include cognitive therapy,
behavioral therapy, and interpersonal therapy. Beck et al.
(1979) developed the initial cognitive behavioral treatment
manual for depression, detailing cognitive and behavioral
techniques for depression. Basic strategies and techniques
have been refined since that time, but many of the evidence-
based strategies detailed in their excellent manual are still
appropriate and have been tested in multiple controlled
clinical trials.

A comprehensive review of the psychological treatment of

depressive episodes is beyond the scope of this book, which
is intended to be a compact guide. Here, we will focus on
strategies that are more novel or require specific skills for
implementation in BD. Many of the specific techniques, such
as the development of thought records, the review of
cognitive errors and cognitive biases, the use of behavioral
interventions such as activity scheduling, and pleasant
events scheduling and the use of home practice, are also
illustrated in Section 4.2.3: Behavioral Strategies –
Monitoring and Regulating Activity by Activity Scheduling.
Readers who require more detailed information are referred to
several easily obtained teaching and instructional resources
listed at the end of the book in Chapter 5: Further Reading.

4.2.1 Structure and Course of Psychosocial

Treatment
Although we will focus on individual therapy, research
findings provide strong support for group psychoeducation in
BD (Colom et al., 2009).Where feasible, groups offer the
benefit of providing social support and adressing
stigmatizing views of bipolar disorder, the chance to learn
from watching others’ experiences of symptoms, rapid
exchange of coping strategies among group members, and,
through the process of watching others progress, a way to
restore hope. Many of the techniques we will describe here
can work quite |41| well in a group setting, and
psychoeducation manuals designed for groups are available
(for example, Colom & Vieta, 2006).

The Use of Active, Directive, Structured Therapy

Every effective treatment protocol presented in the
literature for BD requires a highly organized, directive, and
structured approach. Consistent with the spirit of most
active, directive treatments (including CBT), we present a
series of treatment strategies that are highly structured,
agenda driven, and skill focused. The intent is to teach
patients a core set of skills that have a strong evidence
base in terms of their effectiveness with bipolar depression
and mania. This is consistent with the model of illness
management strategies presented in Mueser et al. (2002). The
primary goals of an integrated, evidence-based treatment
program are presented in Table 19.

Table 19 Elements of Evidence-Based Treatment of Bipolar Disorder

Educate patients and family members about the illness

Where appropriate, treat family members or significant others to reduce
conflict and negative expressed emotion in the family and develop support
systems
Focus on improving treatment/medication adherence
Teach patients to routinely monitor mood and activity state/level of
stimulation
Assist patients in detecting prodromes of illness, including mood and activity
level changes
Modify maladaptive beliefs or cognitive vulnerabilities that predispose
patients to severe episodes of depression and mania
Address maladaptive perceptions, judgment, and behaviors
Assist patients in problem-solving and coping strategies to reduce the impact
of aversive life events that precipitate syndromal or subsyndromal mood swings
Assist patients in stabilizing lifestyle and social routines
Develop coping plans to prevent or minimize relapses
Develop a relapse prevention plan

The course of therapy can be conceptualized in three

distinct phases. The initial phase
involves assessment and
development of treatment goals, and the orientation of the
patient(s) to the unique strategies employed in this
structured treatment program. This usually takes two or three
sessions, but there is overlap with the aims of the middle
phase, which places substantial focus on the development of
skills. The number of sessions can vary as a function of many
factors, such as severity and complexity of the patient’s
problems, institutional policies, the patient’s progress in
therapy, etc. Even when working within the framework of a
time-effective therapy model oriented to skills acquisition,
patients with BD typically require a substantial amount of
clinical contact time. Presently, we recommend that at least
16 weekly sessions be allotted to the skill acquisition phase
(consistent with NICE, 2014, guidelines). This sets the stage
for the final phase, which focuses primarily on maintenance
of gains and relapse prevention. This involves bi-monthly or
monthly sessions |42| to review progress and make any
adjustments required to minimize relapse and recurrence of
episodes. For many lower functioning patients, who are in
residential facilities, this can be a time to explore the
possibility of educational or vocational training, job
acquisition, changes in housing, improved transportation
capabilities, or other adjustments leading towards social
recovery. Positive changes in some of these areas often
alleviate some of the environmental stresses that are likely
to trigger the occurrence of episodes. Findings of one study
suggest that continuing maintenance treatment should be a
first-line choice (Lam, Hayward, Watkins, Wright, & Sham,
2005). This means that rather than terminating treatment,
therapists should offer periodic check-in visits and booster
sessions to help maintain gains and provide support during
difficult periods. For example, one patient returned to
therapy six years after his initial treatment was completed
during a stressful period where he began to experience
symptoms of co-occurring mania and depression, after several
years of good functioning and mood stability.
4.2.2 The Initial Phase of Treatment: Orientation
and Engagement
The Need for a Collaborative Approach
Active engagement and collaboration with the patient are
primary keys to success in treatment. Contrary to a
stereotypical view of cognitive and behavioral approaches,
the heart and soul of CBT is the formation of a collaborative
relationship between the therapist and patient. This
supportive foundation must be in place so that both the
therapist and the patient can take an active role in
understanding the problems that bring the individual to
therapy, in defining the goals of therapy, and in working to
achieve those goals. A collaborative model requires that the
initial phase of treatment be devoted to engaging the patient
and motivating him or her to continue in therapy. The model
is one of active participation and self-management of the
illness.

Promoting Morale and Combating Hopelessness

BD is an unforgiving illness. Repeated episodes of depression
and mania can result in severe demoralization over time.
Patients experience helplessness and hopelessness as their
best efforts to reduce mood swings have often failed.
Continued cycles of mania and depression often have
devastating effects on family members, significant others,
finances, and work. BD patients spend much of their time in a
moderately to significantly depressed state, with significant
impairments in functioning, even if they are not in a severe
episode. Much of the disability associated with this disorder
results from these long periods of subsyndromal depression,
perhaps more so than the effects of acute manic episodes,
however dramatic.

One of the core goals of therapy, then, is to address

hopelessness and demoralization. Often patients are initially
unable to follow through on homework assignments and other
tasks because of a pervasive sense of hopelessness and
demoralization.

A primary and ongoing task of therapy is to instill hope

and to give the patient a realistic sense of confidence that
they can hope to experience bet |43| ter times ahead, although
they may be feeling severely depressed currently. “Tunnel
vision,” specifically an inability to see a more positive
future, a constriction of imagined possibilities, is a
symptom of depression that often interferes with the ability
to accept or benefit from treatment. The case discussed in
Clinical Vignette 6: Hopelessness and Worries About Myself,
My Future, and My Illness illustrates strategies for
addressing hopelessness and demoralization, including the
development of a coping card based upon the patient’s
concerns.

Hopelessness is also a key countertransference issue for

therapists working with severely depressed, demoralized,
hopeless, or suicidal patients. It is important not to become
enmeshed in the patient’s sense of powerlessness and
hopelessness and not to accept their biased view of their
abilities and opportunities for improvement. Ongoing
supervision is essential in helping therapists cope with
patients who have severe episodes of unremitting depression.
This can cause therapists to feel frustrated and impatient,
leading to alliance ruptures or premature efforts to activate
patients without fully understanding the difficulties and
barriers they face. Therapists need to be patient in
understanding that sometimes the work of learning these
skills and rebuilding a life damaged by serious episodes is
slow.

Improving Treatment Adherence

Many the patients with BD, especially lower functioning
patients seen in mental health clinic settings, experience
significant attendance problems, difficulty completing
assigned tasks, and are prone to treatment drop-out. The
biology of this disorder can create difficulties with self-
regulation, and this may be expressed in difficulty
maintaining structure and routines and completing assigned
tasks. When patients struggle in this way, maintaining a
consistent, structured treatment program is likely to require
weekly and periodic extra-treatment patient contacts, at
least in the initial phase and in some instances during the
entire course of therapy, to enhance engagement in treatment
and adherence to the treatment regimen. In the initial weeks
of therapy, patients might receive reminder calls in the 24
hours before scheduled individual or group sessions. Personal
calls greatly enhance a patient’s motivation to continue in
treatment, particularly during episodes of more serious
depression and mania. Patients are usually grateful for these
reminders, which help them maintain structure in their daily
and weekly activities. Patients who miss sessions should
routinely receive follow-up calls to review material
scheduled to be covered in the session and to develop
homework assignments. In most cases, patients appreciate the
effort made by clinic staff to keep them informed and
involved in the treatment program. Patients who miss more
than one consecutive treatment session or those identified as
at high risk for drop should receive calls directly from the
therapist. A personal call to a patient provides reassurance
that treatment is important and that the therapist is
concerned about their absence. In some cases, it may take
initial work over multiple weeks to promote regular
attendance and engagement in therapy. Therapists may need to
work consistently to help clients stay organized and develop
a system for appointment reminders. Timely attendance can be
a primary treatment goal and ability to regularly attend
sessions on time can be viewed as an indicator of ability to
stay organized and responsible despite mood symptoms.

|44|A useful strategy for emphasizing the importance of

attendance from the start is to develop a formal contract
with the patient that highlights his or her responsibility
for attendance (see Appendix 1: Treatment Agreement). When
reviewing the contract, it is useful to discuss what some of
the barriers to attendance might be, and how the patient
might deal with these to maintain a high level of attendance.
Ongoing problems with missing sessions or arriving late to
sessions should be dealt with in a noncritical, matter-of-
fact way that supports the treatment alliance by identifying
barriers to attendance and initiating active problem-solving
with the patient. It is useful to regard these problems as
part of the dysregulation experienced by many patients with
BD rather than as deliberate nonadherence.

Developing an Expectation of Active Participation

Another core goal in the initial phase of treatment is to
foster active participation and the expectation that the
patient will be a problem-solver. This includes following
through on a number of tasks such as: attending treatment
sessions, even though they may be feeling hopeless and
demoralized (or overly optimistic and dismissive of
treatment), ongoing monitoring of symptoms, and completing
homework assignments. This requires highly active patient
participation. The goal is to create a collaborative
environment in which individual patients or group members
participate actively in a variety of exercises to acquire key
skills.

Informing Patients About the Therapy Model

It is important to help patients understand the conceptual
and practical basis for the therapy and how this will be
applied in weekly sessions. Even low functioning patients can
comprehend a straight-forward explanation of a skills-based
treatment program. If at all possible, it is very effective
to use information about problems or complaints the patient
has talked about initially as concrete illustrations of how
the model works. For example, patients can readily grasp the
relationship between lowered mood and lowered levels of
activity, and this can be addressed by illustrating the
interactive relationship between mood and activity on a 3 ×
5 card that can be readily available for frequent reference.
This more personalized approach facilitates understanding of
the model. It is important to be sure that the patient has
some understanding of the basics of the model and how this
type of therapy might be similar to or different from other
therapy experiences they have had. Many patients have
experienced nonspecific “talk therapies” in which specific
problem-solving tools are never developed and the patient is
never asked to experiment with changing specific behaviors or
ways of thinking. The therapist can immediately illustrate
different expectations about therapy by asking the patient to
actively write down or summarize key points in the early
sessions. The patient needs to understand from the outset
that this therapy is highly structured and collaborative in
nature. And so, a detailed explanation of what will transpire
in therapy, accompanied by the rationale for how this will be
helpful, should occur fairly early in the initial phase of
treatment. Patients need to appreciate that they will be
expected to be active participants in the process and that
they will have to complete home practice assignments to help
them learn how to deal with life events and their consequent
mood swings. Most manuals pro |45| vide excellent descriptions
of the stress–vulnerability models in BD. We use a model
adapted from Basco and Rush (1996) that emphasizes the
reciprocal relationship among thoughts, emotions, behaviors,
and physiological processes. Once the patient becomes
familiar with this model, some variation of the following
discussion might be appropriate:

“You mentioned that your main problem is to get control

over these terrible mood swings you’re having. It’s pretty
hard to just change how you’re feeling directly, but we can
work on some of the other things that affect how you’re
feeling. Even though we can’t work on the feelings directly,
we still have these two areas, thoughts and behaviors, that
we can work on to make you feel better. This is good because
we can help you learn to change how you look at things, which
can make you feel better, and we also can help you learn to
do things that will make you feel better.”

Eliciting Target Concerns and Formulating Initial

Treatment Goals
A core goal in the initial phase is to elicit target concerns
from the patient, and then work collaboratively with the
patient to formulate one or more of these complaints into
initial treatment goals. Treatment goals should reflect a
well-defined plan for change, not an ill-defined problem; be
relevant to a particular problem the patient has raised; and
be framed so that it has specific components that are
measurable. Again, asking the patient to write down a list of
treatment goals developed in the session and assigning a
review of these goals as homework emphasizes the active,
collaborative nature of the therapy.

Treatment goals should be personally meaningful to the

patient. Too often, clinicians focus primarily on a reduction
in psychiatric symptoms as a primary goal of treatment. In
our experience, it is important to develop goals that reflect
the patient’s values, interests, and objectives in life and
that reflect their level of functioning. While “becoming
less depressed” is an important symptomatic goal, it is
hardly motivating in terms of a meaningful life goal. It is
useful to take a recovery-based approach in which patients
are encouraged to identify (and eventually pursue) truly
meaningful life goals that will provide sufficient motivation
to endure a difficult course of treatment, often including
unpleasant side effects from medication. Because patients
often begin treatment in a demoralized and hopeless state,
the clinician’s role is to help them develop an expectation
of success in achieving important life goals and ambitions,
despite a history of severe and recurrent episodes of illness
in the past. Many patients prioritize improved quality of
life and restoration of key roles as much more central than a
strict symptom-reduction focus. An example of setting
treatment goals is provided in Clinical Vignette 3.

Clinical Vignette 3
Setting Treatment Goals (Second Session)
Therapist: So today one of my goals is to talk a little more about what
you’d like to get out of this. Last week we talked about a
few goals for you – getting some improvement in your
depressed mood and energy level – and those are really
important goals.
Patient: Yeah, inertia is also a bit of a problem
|46| Therapist:Ok, let’s start by having you make a sort of “problems
list,” and this will become our agenda for your therapy
and we’ll try to make sure we stay close to your goals. Of
course, they can change over time too. But this will give us
 a way of tracking our progress. What should we start with
(for your problem list)?
Patient: It would be so nice to be able to go back to school next
semester and be able to make it to all my classes and
actually complete the work.
Therapist: [handing patient a pad of paper] You can actually write
these down as we go for your own benefit.
Therapist: So would your first goal be to return for the fall semester?
Patient: Eventually, I would like to change my major and get a degree
in engineering.
Therapist: And that’s a really important personal goal?
Patient: Yes, but right now I’m not up for it.
Therapist: What’s interfering with achieving this goal, because that
should be on our problem list?
Patient: If I could actually make it to all my classes and do all the
work – I stopped going to classes I really loved and lost
interest in them.

[Patient and therapist spend some time discussing the importance of this goal
in terms of personal and family values before going on to the next problem,
which happened to be skipping her medication.]

A common problem is that goals are global and unrealistic.

For example, a young adult living with his parents was
preoccupied with increasing his chances for a successful
application to medical school, but was not picking up things
in his room, cleaning his clothes or attending to his
personal grooming. Treatment goals should be as concrete and
specific as possible. For example, whenever a patient lists
“high self-esteem” as a goal, we are inclined to ask, “How
would you behave differently if you had high self-esteem?”
or “How would your life be different if you had high self-
esteem?” or “How would your significant others know that
you had high self-esteem?” Making goals concrete forces the
patient to identify specific steps that must be taken and
sets the goal posts in a mutually agreed position, thus
eliminating goals that cannot be observed or specified. The
risk is that patients with a vague, global goal will never be
able to adequately assess if they have met their treatment
goals and expectations. This can lead to various kinds of
discounting or minimizing actual progress in treatment. Even
more problematic, the therapist will not be able to evaluate
meaningfully the progress in treatment if there are no clear
benchmarks set at the beginning. If goals are too complicated
or depend on the status of too many factors, then success in
achieving treatment goals may be elusive. The goal must be
something that the patient can achieve independently, with a
specific endpoint that is well defined. The next step is to
figure out how to implement these goals through successive
tasks that can be accomplished on a day-to-day basis. What
are the barriers that might get in the way of completing the
task on a daily basis, such as feeling too depressed to do
anything, or feeling that there are too many demands for
his/her time with other important chores? Once identified,
then what can the person do to offset these barriers?

Treatment goals and individualized treatment plans can also

be developed within groups (Bauer & McBride, 2003). The
camaraderie around sharing goals for improving life can
enhance group cohesion. Group members often |47| provide
useful feedback to other group members as to realistic and
appropriate goals. Group members can identify personally
relevant goals for change. Once a concern is elicited, then
it is important to determine: (a) in what situations the
problem occurs, (b) what the patient thinks is the cause of
the problem, (c) the frequency of problem occurrence, (d)
what strategies the patient used to cope, and (e) how
significant the patient would rate this problem on a rating
scale, e.g., from 1 (least) to 10 (most severe).

Structuring the Session: Use of Agendas and Session

Checklists
Once target goals have been established, the therapist can
begin to focus on the structure of individual sessions. A
standard session of structured therapy typically has the
following elements: (1) Check in including mood and symptoms,
medication use, and drug/alcohol use review; (2) bridge to
the past session, including noting any important themes that
were discussed, unfinished business from last session, and
homework assigned; (3) review of homework; (4) setting and
prioritizing items on the session agenda; (5) working through
the agenda; (6) assigning home practice relevant to
strategies developed in the session; (7) summarizing the
session, asking the patient to summarize key points; (8)
getting feedback from the patient about what was helpful and
most useful in the session and any problems that can be
identified.

Having a well-structured and consistent approach to

individual sessions has a number of advantages: (1) the
patient develops an expectation of what will transpire in
each session and what is expected of them in making each
session productive; (2) agenda-driven sessions help keep the
focus on problems and tactics highly relevant to the
resolution of treatment goals; and (3) finally, it is helpful
in reducing a crisis-oriented treatment in which the problem
of the moment comes to dominate what should be a
methodological, strategic, focused, and problem-oriented
treatment. Particularly for patients who are in the incipient
stages of a hypomanic or manic phase of the illness,
structuring the session can effectively set limits on
tangential, disorganized, distracted behaviors, or problems
with attention. In these situations, special effort will need
to be made to redirect the patient back to the agenda and to
reduce tangential or unhelpful discussions. It is
particularly important to emphasize session structure for
patients who are over activated, disorganized, confused, or
tangential. For patients who are depressed, this structured
treatment approach provides consistency and direction at a
time when they may be feeling immobilized and helpless.

The session checklist attached in Appendix 2: Checklist for

Session Agenda is intended to help the practitioner document
session content and material covered to assure that treatment
progresses in a fashion consistent with the treatment
protocol. At the end of every session, practitioners are
encouraged to review items on the Session Checklist that have
been covered in the session. In group sessions, material
covered in each session may vary due to group dynamics or the
needs of individual members.

Setting the Agenda

As early as possible during the course of therapy (usually in
the first or second session) it is important to begin setting
an agenda for each session to minimize the tendency toward
unstructured use of time. The goal is to set a clear agenda
|48| for the session as quickly as possible, hopefully in the
first 5–10 minutes of the session. It is likely that many
patients have had past experiences with unstructured
therapies that tend to proceed without a clear structure or
identification of problems that need to be addressed. For
this reason we caution therapists not to begin with open
ended questions such as “How have you been feeling over the
past week.” This type of question often leads to a long
unstructured monologue without clear goals or problems to
work on. We prefer starting with more directed questions that
are specific to problems experienced and mood shifts, or that
follow up about specific problems addressed in the last
session. For example “Have you had any more mood shifts over
the past week where your mood suddenly abruptly changed?” A
number of questions can serve as useful prompts to develop a
problem-oriented agenda: “What’s the most important thing
that we should focus on today?”; “If we can identify one or
two problems that I can help you with, what would those
be?”; “How can I be helpful with this problem?”; “Let’s
jot down one or two things that are most the important for
you to talk about today.” It is especially important to get
to a problem-focused agenda early in the session if the
patient begins to go into a great deal of detail about last
week’s events without identifying a specific problem that
can be worked on. Sometimes, the following prompts can be
very helpful “Can you give me the major headlines about what
has happened, rather than all the details so we can decide
what is most important here for us to address” or “Can you
summarize this a bit by telling me more specifically what is
most important and how I can help you?” or even “Is this
the most important problem that you wanted us to address
today?”

The therapist can explain that the major advantage of

structuring the session is to make the best use of available
time. The agenda should be developed in collaboration with
the patient. We recommend that the agenda be written out on a
white board or easel paper for both individual and group
therapy so that it can be referred to easily by both the
therapist and the patient when necessary to keep the session
on track. The first item on the agenda, almost invariably,
will be to complete a check on the patient’s status at the
time of the session. Often patients are asked to complete
some brief measure of their mood while in the waiting room,
and this becomes the focus for the initial review in the
session.

The second item on the agenda will be a review of work

completed in the home practice assignment. Practice outside
sessions is critical to the success of this treatment
strategy. It is important to review the patient’s home
practice and comment on its relevance to the particular issue
under consideration in therapy at the moment, as this will
encourage continued adherence in completing home practice.
Often patients will fail to complete home practice
assignments anyway, and this needs to be dealt with. We will
discuss more about this problem in greater detail later.

After review of homework, the next agenda item might be to

initiate strategies that will be helpful in accomplishing a
therapy goal. This could be the introduction of a specific
skill that needs to be learned, or the continued practice of
a skill that was introduced earlier. During early sessions,
getting more history about a certain event or period in the
patient’s life might also be an item on the agenda. In
addition to items the therapist wants to include on the
agenda, the patient should always be asked what they would
like to include. Once the list is completed, the items should
be prioritized in terms of |49| time allotted for discussion
of each item. This is particularly important when patients
consistently come to therapy with some type of crisis. During
the early stages of therapy, the therapist will likely be
inclined to put such items first on the agenda, and often the
entire session may be absorbed in trying to resolve the
crisis. While this may be essential at some points, the
therapist should be alerted that it is very difficult to make
progress in therapy when sessions are consistently crisis
oriented. Prioritizing time allotment can help control this.
It is also helpful with individuals who have a crisis
orientation to put their items last on the agenda so that
other items can receive attention.

We underscore that, in individual or group sessions, if the

patient presents with suicidal ideation or plans, a severe
family crisis, or high-risk change in mental status, this
must take priority over any other agenda items. In some
cases, clients will require more practice on certain skill
areas to master the required skills. If this occurs, certain
content will need to be shifted into the next session.
Focusing on Specific Agenda Topics
Once the agenda is fixed and times for each item have been
allotted, the focus shifts to items included on the agenda.
The range of topics can be quite variable. Initially, topics
usually reflect a blend of skills the patient needs to learn
to achieve therapy goals, combined with specific concerns and
barriers that might arise during the course of skill
acquisition. Throughout the session, it is a good idea to ask
the patient to summarize points that have just been covered.
This enables the therapist to determine fairly quickly
whether the patient understands the material as presented or
whether more concrete strategies need to be used to
facilitate patient comprehension. Having the patient
routinely provide brief summaries of topics on the agenda
also alerts the patient to pay close attention to topic
details because of the expectation of having to provide topic
summaries. This heightened attention combined with the
completion of active summaries also will help her or him
encode and remember the key points for application outside of
the session.

Home Practice Assignments

The patient should leave therapy with some concrete idea
about what she or he should be doing during the week to learn
or practice a task that has been the focus of therapy. These
tasks might range from simple things, such as placing small
notes at strategic places in their home where they are
visible and can remind them to do a certain task (e.g., take
medication), thinking about a positive feature of themselves,
to more complex things, such as completing unhelpful thought
records, setting up an opportunity to examine the evidence
for a particular belief they have about a person, completing
an activity monitoring schedule, or engaging in practicing
being assertive or initiating conversations. Home practice
assignments should be developed collaboratively with the
patient, and should be clearly relevant to material being
covered in the therapy session. The patient must understand
the rationale for the particular assignment and agree, or at
least be willing to accept the possibility, that completion
of the specific home practice will enable him or her to
eventually achieve specific personal goals. The assignments
should involve an activity that can be accomplished fairly
easily within the time span and, for the most |50| part, can
be done without having to rely solely on the occurrence of
other factors or the cooperation of other individuals. It is
vital that the patient not only understands the rationale and
what is to be done for the out-of-session practice, but that
the therapist is confident that the patient has the
capability to complete the assignment. To be sure that this
is the case, the therapist may often need to demonstrate what
the patient needs to do, and have the patient practice the
task before leaving the session. For example, if the
assignment is to complete an activity monitoring form, it is
almost always a good idea to work with the patient to
complete the assignment for the past day or two together, and
have the patient complete the remaining days before the next
session. Commonly, home practice assignments include
interacting with other family members, fellow employees, or a
potential new friend to accomplish some goal-related task.
Practicing what one should do in role play with the therapist
is often necessary to help the patient be well-prepared for
the upcoming interpersonal encounter. Possible barriers to
successful completion should be reviewed and suggestions made
on how to minimize the impact of these. We also recommend
asking the patient “How confident are you that you can
complete this assignment?” Low confidence ratings suggest
that we should focus more on barriers or motivational issues
that are interfering with completing assignments. Sometimes
simply asking “What would make you feel more confident about
completing this?” can lead to a very useful discussion in
terms of skills required or negative, hopeless thoughts, or
other issues that are interfering and indicate the need to
reevaluate the home practice assignment. Attention to these
points will increase adherence in doing home practice
assignments.

Helping Patients Complete Home Practice Assignments

Patients often have difficulty completing homework
assignments, and this may be linked directly to problems with
attendance and dropping out of treatment altogether. In our
experience, patients often need in-session coaching to
successfully complete their homework assignments – a key
requirement for a skills-based treatment model that requires
active participation. It is essential that the therapist
practice any anticipated homework exercises in the session
first before assigning them as homework for the patient.
Patients may avoid coming to sessions because they feel
guilty or inadequate for failing to complete homework
assignments. Patients often worry that the therapist will be
angry with them for not following through or having problems
completing homework. For this reason, therapists can explain
that they want to work with a patient even if they find it
difficult to complete the homework. It is always useful for
the therapist to take responsibility for problems completing
homework (“Perhaps I didn’t explain the homework clearly or
that we didn’t address barriers that might come up. How
could I help make sure I do a better job next time?”). In a
previous section, we also addressed the potential impact of
feelings of hopelessness and demoralization as barriers to
completing therapy tasks. If the patient appears to have
these types of emotional reactions regarding homework
assignments, these reactions should be addressed directly
with the patient before finalizing any assignments.

|51| Final Summary of the Session

After homework has been assigned, several minutes should be
saved for the patient to make a final capsule summary of the
session. The therapist might say something like: “Now we’ve
covered a lot of material here today, and I wonder if we
could just take a few moments here to summarize the session?
What do you see as some of the key points that we brought up
during the session?” It is very useful to ask the patient to
write down key points. This helps assess understanding and
facilitates processing to promote retention of information.
The therapist should praise the patient’s response and also
mention any items that were omitted. The therapist might also
ask how the home practice fits into the picture, i.e., how
will the home practice help achieve the goal.

Feedback and Scheduling Next Appointment

Finally, the patient should be offered the opportunity to
make any additional thoughts or questions about the session.
The therapist might ask questions such as:

What was good or most helpful about today’s session?

How is the therapy progressing?
How could the session time or therapy be made more
useful?
Is there anything I said or did today that was
irritating or upsetting to you?
What would you like to see changed?

Explain to the patient that such information will be

helpful in adjusting the pacing and content of future
sessions. The therapist should also take the time to comment
on progress, and, where possible, give positive feedback to
the patient. Once this is completed, the time for the next
appointment should be determined and a reminder card given to
the patient.

Trouble Shooting
In our experience as supervisors, we see that several
components involved in conducting a structured therapy
session as described above are particularly difficult for
professionals who are beginning to use this type of therapy.
The first problem encountered by therapists who are used to
working in an unstructured approach is developing an agenda
quickly to guide the remainder of the session. Therapists
often start a session by asking a general question (“How
have you been doing over the last week?”). We prefer using
an approach that inquires more specifically about mood
related symptoms and other problems that the patient would
like to address so that we can quickly focus on problem
solving and other skills that might help the patient. To
reduce the time spent checking in, the therapist can signpost
important issues by asking: “Would you like to put this on
today’s agenda?”

A second related problem is a failure to elicit brief

summaries throughout the session, which, as noted above,
facilitates reflective learning, encoding, and processing of
information. Capsule summaries also serve to reorient the
patient and therapist to the main work of the session and
help eliminate nonproductive therapy tangents. Often a well-
timed capsule summary can alert the patient to session drift
and help reorganize the session. However, as the therapist
becomes more adept at setting and prioritizing items on the
agenda, a brief summary and feedback can follow conveniently
as the transition between agenda items.

|52|A third problem pertains to time management during the

session. Initially, therapists
on the agenda. We suggest that
conversation as follows: “OK,
going to need about 10 minutes
go over Activity Scheduling. I
tend to include too many items
the therapist structure the
we have four items here. I’m
near the end of our session to
think you’re ready for that,
then we have these other three items that you brought up.
Which of these is the most important and which is the
least?” “OK, for sure you want to cover the conversation
you had with your wife and what this means, and the complaint
about the neighbors is least important?”…. “How much time
do you think we need to cover the conversation with your
wife?”….“That’s good! So we might not have enough time to
get into the problem with the neighbor. Will it be OK if we
save that for another session?”

Related to the time management issue, therapists frequently

get preoccupied with agenda items and fail to allow adequate
time to develop the home practice assignment adequately.
Often the therapist will quickly throw something together
without discussing it with the patient or summarizing the
rationale for doing it. Homework is a critical feature of
this therapy, and, from the outset, the therapist needs to
emphasize its importance. Failure to allocate time for
discussing homework is not consistent with a priority level
that will facilitate adherence. Similarly, failure to review
the home practice at the beginning of the session will
detract from its importance and likely increase the
occurrence of poor adherence.

4.2.3 The Middle Phase of Treatment: Skill Building

– Filling the Tool Box
Given that BD is a chronic illness with a fluctuating course
through the life span, the goal of interventions should be to
provide the patient with durable skills that can be
maintained with a minimal amount of external treatment
support. Treatment is conducted in highly structured, agenda-
driven sessions with the goal of teaching the specific basic
skills of monitoring, detection of prodromes, and acquisition
of appropriate coping skills to improve mood stability and to
minimize the occurrence of depressive or manic episodes.

Monitoring Mood, Thoughts, and Behaviors

An important initial treatment task is for each patient to
develop strategies that support daily mood and activity level
monitoring. We believe that monitoring (initially external
and then internalized) is the sine qua non of this therapy,
without which patients are not able to identify prodromes of
illness and take action before the severe cognitive and
behavioral changes that are consistent with an acute episode
actually occur. Patients must have at least partial awareness
and acceptance of this axiom of treatment in order for
therapy to be effective. Therefore, some time and effort must
be expended to be sure that this is the case. Use of a road
map can often be a helpful analogy to emphasize the point. A
road map is of very little use in finding your way unless you
can identify your own location in relation to the other
points on the map. Similarly, if you hope to have impact on
mood (or behavior) you must be aware of the level and kind of
mood at any moment in time and its relation to other current
contingent situations or thoughts.

|53|A critical initial task in the treatment of BD is

introducing daily mood monitoring. Several monitoring tools
exist and are readily available (Sachs & Cosgrove, 1998).
Variations of mood monitoring charts can be found in
virtually every manual that is designed for use in structured
skill-building therapies.The life chart method (NIMH-LCM),
discussed as an important initial assessment tool for
reviewing the previous course of BD, can be modified to
gather prospective information. We have included a revised
version of the mood graph from Basco and Rush (2007). The
scale on their mood graph has been changed to incorporate a
range of normal mood, which we refer to as the “comfort
zone.” This adaptation emphasizes normalizing fluctuations
in mood so that small mood shifts are not seen as
catastrophic indications of an impending bipolar episode. It
is particularly important that patients with BD become
sensitized to small mood shifts to identify early prodromes.
Both Lam and his colleagues (Lam et al., 2010) as well as
Basco and Rush (2007) emphasize the value of identifying
prodromes or early warning signs of an impending episode. See
Appendix 6: Identifying Signs of Depression or Mania and
Appendix 7: Identifying Early, Middle, and Late Signs of
Depression or Mania. Another rationale for redesigning the
Mood Graph is to assure that patients appreciate the fact
that normal mood does not equal “0,” e.g., normal mood
consists of a myriad of daily shifts. If patients are
frightened of mood changes they will be likely to avoid
monitoring affective shifts, with the result that they will
be unable to detect changes appropriately.

It is often appropriate to introduce mood monitoring in the

first or second individual or group session, with the
rationale that patients should become experts in tracking
their own mood states. A rationale that can be given is:
 “Mood monitoring is a way of taking charge of your health. If you can
begin to identify slight mood shifts, this will allow you to plan for
strategies to prevent more serious mood swings. Imagine an individual
on a bicycle starting to go down a slight incline and applying the
brakes. Compare this to an individual who attempts to forcefully apply
the brakes near the bottom of the hill. Getting an early warning sign
of problems will give you important leverage in dealing with mood
shifts.”

Another useful technique is to always begin sessions with a

check-in, in which patients are asked to bring in their mood
graphs for review. This provides a quick overview of how
things went over the week and positively reinforces mood
monitoring. If patients have forgotten to do their mood
graphing or have neglected to bring it to session, work in
the session to reconstruct the week retrospectively. While
retrospective mood recall is subject to a number of errors,
this in-session activity highlights and reinforces the
importance of mood graphing.

Patients often raise concerns about mood monitoring. A few

of these are listed here:

It is painful to focus on mood changes. If this is a

concern, it is often helpful to consider the types of
thoughts that are evoked by thinking about moods. Many
patients report either catastrophic thoughts or highly self-
critical beliefs about minor mood changes. Examining these
can be very helpful.

Catastrophic beliefs about emotions. Many patients tend to

equate minor shifts in mood with a full-blown relapse.
Discussion regarding the idea of a |54| continuum of severity
can be very helpful. Some report fears that experiencing
emotions may trigger further episodes. In one study, more
than two-thirds of patients with BD I reported trying to
avoid major positive accomplishments or to dampen positive
mood states, because they were frightened about relapse in
the context of such good mood states (Edge et al., 2013).
When patients report this, we find it helpful to build a
better understanding of mood changes along a continuum and to
highlight that mood monitoring may help them begin to
recognize these shades of difference. One patient described
being afraid anytime that he laughed at a dinner party that
he was becoming manic. By helping him consider other signals
in addition to his emotion or laughter, he was able to feel
safer about small variations in mood state. This type of
issue is important to address, because avoidance and numbing
of feelings is likely to interfere with life satisfaction as
well as the ability to monitor emotions and mood over time.

Beliefs regarding lack of control. Many patients report

feeling as though their moods are biologically driven and
outside of their control. While we agree that there is
evidence of innate vulnerability to reactivity and heightened
arousal, this type of belief system can result in a lowered
sense of self-efficacy and a tendency to give up in the face
of heightened emotions, reactivity, or impulsivity.
Practicing small mood management strategies in session can
help challenge these beliefs and illustrate the potential
power of learning new skills.

We address a number of typical concerns rasied by patients

in Clinical Vignette 4: Responding to Mood Monitoring
Concerns.
Clinical Vignette 4
Responding to Mood Monitoring Concerns
Patient: I’m a rapid cycler, my moods are constantly shifting. I
have so many mood shifts in one day; I cannot keep track of
them.
Response: This is an important issue that many people face. Perhaps
you could consider the way Wall Street reports on daily
stock movements as a way of handling this problem with your
mood charting. When reporting on the movements of stocks,
newspapers list the “high,” “low,” and “close.” I
wonder if this would work for you.
Patient: My mood never changes – it’s always the same until I end
up in the hospital.
Response: A lot of people think that’s the case, before they actually
try to monitor their mood on a daily basis. Would you be
willing to do an experiment for a week? Would you be willing
to monitor your mood and pay close attention to whether
there might be just small variations in your mood? Maybe you
have very small mood changes that you don’t notice. Why
don’t we set up your scale so that it has tenths of a unit
between each number?
Patient: I don’t just have mood changes, I have other problems too.
My mood doesn’t tell the whole picture. Sometimes my mood
is combined with feeling irritable, anxious, or agitated.
How do I monitor these feelings?
Response: Let’s work together to see what type of mood charting would
work best for you. It’s best to individualize this so that
it’s more personally meaningful for you. Do you have any
ideas how we might do that? [If patient doesn’t respond]
Perhaps we look at separately tracking the other feelings
you’re having such as anxiety, irritability, and agitation.
|55| Patient: I don’t think it’s very useful for me to spend time
monitoring my mood.
Response: Would you be willing to give it a try and see if it is
helpful? Let’s have you do this as an experiment to see
what you can learn about your mood.
Patient:
 I’m too disorganized to remember to do mood charting every
day.
Response: Let’s find ways that you can remind yourself to complete
your mood graph. Some people like to pick a specific time of
day – just before dinner, after dinner, or before bedtime
– do you think this would help?
Patient: Sometimes my mood is really mixed – I feel depressed and
manicky at the same time – how do I chart this?
Response: What you are a saying makes a lot of sense – moods aren’t
one dimensional. How could we capture the different
dimensions of your mood?
Patient: I don’t like the mood chart you use; I’ve got my own
format.
Response: That’s great! The important thing is to consistently track
you mood. If your own method works better, stick with that.
Patient: I forgot to do my mood charting.
Response: That can happen. One way to help you remember is to put your
mood graph somewhere in a prominent place. Some people put
it on the refrigerator door. Some put it by their bed, so
that it is the last thing they see as they are getting ready
for bed. Some put it on the mirror in their bathroom. Do you
think his would be helpful?
Patient: I don’t really know what my mood is.
Response: Let’s practice having you check your mood in the session
with me, and we’ll try to help you understand more about
what you are feeling.

Developing an “Unhelpful” Thought Record

Thought records have two essential functions: (1) helping the
patient identify and process unhelpful thoughts and feelings
related to situational events, and, (2) beginning to gain a
more objective perspective on their thoughts. Initially,
thought records can be used to deepen the patient’s
understanding of their thoughts, feelings, and reactions
without any attempt at cognitive restructuring or changing
their problematic appraisals. This ability to accurately
monitor, identify, and process thoughts and feelings is a
prerequisite to the second step. In this first phase of using
the thought record, we often use a card listing
feelings/emotions (“Emotions Library Card”) as a prompt to
help the patient identify the subtle nuances and mixtures of
emotions that may be present. The consistent use of thought
records enable patients to experience more vividly the
relation between their appraisal of particular situations and
their feelings and behaviors at a particular moment in time.
As noted earlier in the discussion of models, individuals who
are experiencing unusual changes in mood often have an
unrealistic appraisal or “unhelpful thoughts” about
themselves, the situation they are currently in, and what
might happen in the future. Furthermore, there are a number
of characteristic ways that individuals tend to distort
incoming information, such as negative filtering,
overgeneralization, mind reading, etc. Beck et al. (1979) and
Burns (1999) provide more detailed information on common
thinking errors.

Once an individual begins to focus on their automatic

thoughts and critically examine distorted appraisals of a
particular event or set of events, she or he becomes more
amenable to consider constructive and more helpful ways of
thinking that enable better perspective-taking. This “self-
intervention” can have a notable effect on typical negative
emotional and behavioral reactions. As patients |56| continue
to practice the skills of monitoring and evaluating their
thoughts, they become more skilled in identifying cognitive
distortions, and eventually become quite effective in more
balanced and adaptive ways of thinking.

As is the case with mood monitoring charts, many different

types of thought records are used in clinical settings. Some
of the earlier ones were labeled as “Dysfunctional Thought
Record” or “Automatic Thought Record.” We refer to our
version as an “Unhelpful Thought Record” (see Appendix 8:
Unhelpful Thought Record – Weighing the Evidence). We prefer
to use the term “unhelpful thoughts” with patients as this
has a less pathologizing connotation than thinking “errors”
or “maladaptive thoughts.” We put emphasis on the fact that
a particular sequence of thoughts in reaction to an event may
be unhelpful in maintaining mood stability, rather than
labeling these unhelpful thoughts as distorted or incorrect
appraisals. Once individuals have learned to identify
unhelpful thoughts, it is useful to identify specific types
of unhelpful thoughts. Unhelpful thoughts are characteristic
ways in which individuals tend to make incorrect or unhelpful
appraisals.

It is a good practice to review these unhelpful thoughts in

session and then give the patient a list to study at home so
he or she they can quickly identify typical distortions in
thinking about events that are associated with negative
emotional states. As patients become more skilled in
identifying and classifying unhelpful thought patterns, they
become more effective in quickly developing countering
thoughts. Burns (1999) has developed a list of strategies,
commonly referred to as “Ten Ways to Untwist your
Thinking,” to help the patient in challenging unhelpful
thoughts.

Learning how to complete a thought record takes time, and

most patients need assistance early on in accomplishing this
task within the therapy session. Never assign a thought
record for homework without first practicing it in the
session. Typically, especially with patients who have some
cognitive impairment, the therapist provides practice
opportunities in several sessions before the patient is asked
to doing it independently outside of the session. However,
with help most patients can learn to do thought records, and
eventually with continued practice they may learn to do this
task automatically in a situation as they are having an
emotional reaction, without the need to use a form. The
thought record can be used in group as well as individual
therapy. In Clinical Vignette 5: Learning to Use the Thought
Record in a Group Treatment Setting, we illustrate how the
“unhelpful” thought record can be used in a group treatment
setting. Group-based treatment offers several potential
advantages in terms of cost effectiveness and the ability to
impact several group members during a single intervention by
relying on the group process.

Clinical Vignette 5
Learning To Use the Thought Record in a Group
Treatment Setting
Therapist: This would be a good time to see how the thought record
works. Does anyone recall a situation where they became
upset that they would be willing to share?
Frieda, a 35-year-old single female who lives with her parents, agreed to
share an upsetting event with the group. The therapist used an easel to write
down Frieda’s comments so that the whole group could observe how the thought
record can be used.

|57| Frieda: Ok, this is one where I didn’t lash out, but I got so
depressed.
Therapist: What was the event? Let’s write that down here. Why don’t
you write them down, too, Frieda in your blank thought
record?
Frieda: Ok. Well I made a new friend and I expected that she’d call
me and she did not call.
Therapist: Ok. [Therapist writes verbatim what the patient says]
Frieda: So then my thoughts were that she doesn’t like me.
Therapist: Ok, “She doesn’t like me.”
Frieda: And I’m too old and boring.
Therapist: “I’m too old and boring.” Thank you for sharing this with
us.
Frieda: She’s mad at me.
Therapist: Ok. Any other thoughts?
Frieda: She doesn’t want to hang out with me.
Therapist: Ok.
Frieda: I’m too fat. I’m a depressing person. And I still live at
home with my mom and dad.
Therapist: Ok. [Still writing]
Frieda: [spontaneously] Boy, I get strange thoughts.
Therapist: What was it like writing down these thoughts?
Frieda: Oh, it was weird, because I don’t know where these thoughts
come from. It doesn’t even make sense. It doesn’t have
anything to do with the event.
Therapist: That’s a wonderful example. You’ve just said something
important, which is these are kind of automatic thoughts
that come into your mind without any prompting, and you may
not even be aware of them and they may have little to do
with the event.
Group Member: But to us it does.
Therapist:
 Ok, it feels like it does. So then if we looked at your
feelings [goes to next column]: now, if you look you had a
series of thoughts, and I wonder if there were some that
were particularly painful or upsetting.
Frieda: I started to hurt.
Therapist: Was there a particular thought that was connected with the
hurt?
Frieda: Well, that’s got me. Well, the worst was that I was still
living at home.
Therapist: Ok, what was the feeling that you had?
Frieda: Oh, that I was incompetent.
Therapist: Well, that’s kind of a thought. Let’s put that over here
in the thought column. What feeling did you have?
Frieda: Shame.
Therapist: Ok, so you had a whole series of thoughts. Let’s talk more
about how those affected your mood.
Frieda: It made me more depressed.
Therapist: Any particular thoughts that made you depressed?
Frieda: Well the main one is that I’m still living at home.
Therapist: Sounds like this was an interesting experience for you to
look at these thoughts after writing them down. Sounds like
you felt it wasn’t clear how this event caused all of these
thoughts.
Frieda: Yeah, and the funny thing was that the reason she didn’t
call was that she was depressed herself.
Therapist: How did you find out? Did you try to reach her?
Frieda: Yeah, I wrote to her and asked, “Are you mad at me?”
|58| Therapist:So can we look at some of the thoughts that Frieda had here
and see if we can find any thinking errors?
Group Member: To me shame is the basic thing. You’re not valuable.
Therapist: Let’s look at our list of thinking errors. What would that
be if we looked at our list?
Group Member: One thing is that there is a lot generalizing about yourself
from one event and it’s not based on a lot of evidence.
Therapist: Let’s start with the first, “She doesn’t like me”. Is
there a thinking error there?
 Frieda: Well, one thing is, I can’t tell what people think.
Group Member: That’s right. When I go out and I see people looking at me
and I begin to imagine all sorts of things they are
thinking. But I really can’t tell what they’re thinking
and I forget that.
Therapist: That’s right. Then let’s look at the next thought, “I’m
old and boring”. Is there a thinking error? How would that
fit?
Group Member: Kind of labeling.
Therapist: Yeah, what else?
Group Member: Making an assumption, right? Jumping to a conclusion.
Therapist: What about taking it personally. How would you apply that?
Group Member: As you go through the day people look at you and you wonder
what they’re thinking and you don’t know, so we read our
own concerns into it.
Frieda: Right!

Here is a list of the steps in completing a typical thought

record:

1. Identify the distressing event, which should be

specific, concrete, and time-bound.
2. Identify the automatic thoughts associated with
distress.
3. Rate the strength of each belief from 0% to 100%, where
100% means absolute belief in the thought.
4. Identify the emotions (may be a complex mixture)
5. Rate the strength of each emotion from 0% to 100%, where
100% means the highest intensity you have ever
experienced.
6. Categorize problems in thinking (optional).
7. Use the helpful hints to challenge unhelpful ways of
thinking.
 8. Develop more adaptive ways of construing the situation
and rate how strongly they are believed.
9. Re-rate the emotions experienced earlier and list any
new emotions.
10. Determine whether change occurred in the intensity of
the emotions and reinforce the link between new
cognitive perspectives and reduced distress.

Cognitive Restructuring and Core Beliefs

Individuals who are severely depressed or those who have a
history of chronic mood disorder may have great difficulty
identifying problematic appraisals and may find substantial
evidence from past bipolar episodes to conclude that they are
“incompetent,” “defective,” “a hopeless case,” or a
“loser.” These core beliefs about self may have developed
concurrently with the emergence of the illness during late
adolescence and young adulthood thus complicating how to
untangle the sense of self from the effects of BD.
Problematic core beliefs can become reinforced through the
experience of multiple episodes |59| in which the individual
may have felt unable to control their mood. When addressing
complex problems that involve fundamental beliefs about the
sense of self being altered by BD, a simpler approach of
asking “What’s the evidence for this thought?” is unlikely
to be helpful. The types of basic cognitive restructuring
often employed with unipolar depression might be invalidating
and fail to address the “existential truth” behind the
patient’s worry. In BD, the therapeutic focus shifts from
testing out the evidence for the thought to developing
kinder, compassionate, or more useful responses. The
therapist might ask “Is this a helpful thought?” or “Does
having this thought help you lead a more meaningful and
richer life?” and focus on the utility of having this
thought rather than on the validity of the thought. Another
approach is to ask people to consider how they would coach a
close friend with the same types of life experiences. The
concept of the “good coach” who helps one persevere and
grow, rather than critically judging oneself, can be a
helpful context. Sometimes, the therapist may need to model
being this type of good coach to help the patient begin to
internalize their own version of a gentler stance.

Clinical Vignette 6: Hopelessness and Worries About My

Self, My Future, and My Illness illustrates an approach to
more complex problems that are not easily addressed using an
evidence-oriented thought record. This 20-year-old woman had
withdrawn from public school after a severe manic episode
with psychotic features and completed her high school degree
in a home school. Now she is living at home with her mother
and having great difficulty with the sense that she has
gotten off track because of her disorder and that she feels
hopeless about her future despite the fact that she is a very
bright and capable young woman. In this vignette, we explore
more validation and acceptance based approaches to coping
with her worries and we use a very powerful “two chair”
role play technique where the therapist role plays the
patient’s worried thoughts and tries to help them respond in
a kinder, compassionate or more effective way. Note that at
the end of this role play, the most helpful responses are
summarized by the patient and written down on a 3 × 5 card
for future reference.

Clinical Vignette 6
Hopelessness and Worries About My Self, My Future,
and My Illness
Patient: I have a lot of fear about my future and having what I
consider to be a good life…I just feel like I have a
capacity where I could be doing something…you know, I mean
I guess it’s really important for me to have a purpose and
that I have the potential to do something that would be
meaningful, but then I feel like I am also restricted by
this [illness] and it might not happen [sounding very
tearful]. I might fail to follow through because of
something emotional that might come up.
Therapist: So you’re really hoping you can do something important,
have an important purpose, but you’re worried that your
illness might restrict you from having a really important
meaningful life.
Patient: Yeah, something could come up related to my illness. And
then I could get off track. I feel like I have already been
sidetracked by this illness for the last couple years.
|60| Therapist:There’s a worry that you might get side-tracked again…get
up on the horse but get knocked off.
Patient: I mean I guess it’s good because I am learning to be more
tenacious about what I want.
Therapist: Being tenacious is a wonderful quality.
Patient: But it’s so humiliating and I feel so embarrassed [crying]
Therapist: This is really tough stuff…
Patient: Yeah, this worry is about my future, feeling like my life is
not going to turn out OK.
Therapist: So we are addressing a real core worry, so it’s powerful,
because if we can get a handle on this it’s going to make a
big difference for you if you can develop some confidence…
[Patient and therapist agree to do a role play where the therapist voices
some of the patient’s doubts and sees if the patient can come up with any
countering responses]
Therapist: (in role): So I’m hoping I could have some important
purpose in my life and do something really meaningful, but
I’m afraid that this won’t happen for me because of this
illness I won’t be able to have the kind of like I want to
have.
Patient: (tearing up): Well Sally, you are having a lot of good
people helping you through this…you have your mom and two
really good doctors and you’re getting the right
combination of medication and you are going to come to a
point when you are going to recognize if you are getting
into a depression or manic episode. (sounding increasingly
tearful and sad here) and you’re going to know how to deal
with it once it comes up…if you just keep having people
around you who are supportive, you are going to figure out a
way to cope with this. In a healthy way so your life can
have meaning…
Therapist: Can I interrupt? It seems like you started out saying the
right things but you sounded really sad and worried.
Patient: I think I wanted to start crying right away but had to hold
it back.
Therapist: Am I being too intense here, is this too difficult?
Patient: No.
Therapist: We are really addressing the core issue of worry about
yourself and worry about your future. Would it be OK to do
this role play one more time and write down the most helpful
countering thoughts for you to address your worry? We want
to help you not get so caught up in the worry anxiety cycle.
Patient: Yeah, worry can make me not want to do anything, not try
’cause I’m scared.
Therapist: So worry can be counterproductive.

[Therapist reflects on the worry – giving up cycle and gives some examples
of how the patient might adopt a more reassuring or compassionate tone]
Therapist: You’ve been through some really difficult things so it’s
understandable that you would be so worried.
 Patient: It’s really good to hear this

[They reengage in a second role play with the goal of incorporating more
acceptance of the worry.]
Patient: (in role): Well, Sally, I think your worry is really valid
because you’ve had some serious problems.

[Sally repeats some of the main points above in a slightly more confident
manner, but sounding quite a bit less worried].
|61| Therapist:Now you have added a part about acknowledging the worry, do
you think that was helpful?
Patient: Yeah, I think if I say to myself but don’t acknowledge it
(the worry), it feels like all these things are true but
you’re not hearing what I’m feeling.

[Therapist and patient write down key points on a 3 × 5 card.]

Therapist: What was most helpful?
Patient: I think “You have a right to be worried, you’re not
crazy”

Coping Card Developed in Session

COPING CARD: Reassuring thoughts when worried about future

Acknowledgement: you have a right to be worried.

You are equipped with a lot of tools you can use to help manage your
illness.
As long as you are an active participant in your treatment, you are
going to find that you are able to have purpose and meaning in your
life.

Addressing Stigmatizing Thoughts – Helping Patients

with Guilt and Shame Over Episodes
Table 20 Unhelpful Thought Record: Guilt and Self-Blame Over Past Mania

Event Memories of being manic or delusional (when

alone, isolated, or bored)
Negative Automatic Thoughts How could I have done that?” “I could lose
important relationships or damage them if it
happens again”

Feelings (rating of intensity 0 Ashamed 50%

–100%) Fear 50%
Shameful/bad
Regret 50%
Horrified

Thinking Errors Mind reading

All or nothing thinking

Unhelpful Behaviors Avoids thoughts

More Helpful Behaviors Call siblings

Countering Thoughts “I’m an unfortunate person”

“I can take steps to protect myself and
others”
“I’ve been successful at being stable for a
number of years”

It is almost axiomatic that patients with BD suffer from

guilt and shame over their behavior in past manic and
hypomanic episodes. Depression is often compounded by
excessive quilt and shame over risk-taking and pleasure-
seeking behaviors associated with the manic phase. Use of
automatic thought records can be helpful in addressing some
of the cognitive distortions for |62| patients who suffer
from excessive shame and guilt during dysthymic or depressed
periods. By becoming more aware of the frequency of these
types of thoughts, and how much these thoughts can interfere
with moods, energy, and motivation, patients can become more
motivated to try to change their harsh self-critical
thoughts. See Table 20, Table 21, and Clinical Vignette 7: I
Called My Mother Names.
Table 21 Thought Record: Developing Coping Strategies for Shame and Social
Embarrassment

Event Person from my past showed up

Thoughts He remembers me
He’s wondering how I am now
He saw me when I was really depressed

Feelings Fearful
Ashamed
Shame

Thinking Error (Projection, mind reading)

Responses Withdrawal and avoiding others

Alternative/Adaptive thoughts I’m okay now

What’s on my mind is not necessarily on their
mind
I have a disorder just like mom
I am on a medication regimen that works and
I am doing the right thing

Coping strategies Actively deal with the problem

Clinical Vignette 7
I Called My Mother Names
When depressed, Frederick often ruminated about bad behavior during past
manic episodes. He was particularly upset by an incident in which he had been
very rude to his mother during an irritable manic phase shortly before her
death. Bill often replayed this and other incidents in his head over and over
again, becoming progressively more depressed, ashamed, and guilty. During
these periods he would isolate himself and withdraw socially, which further
contributed to his depression.
His ongoing guilt was addressed in a group therapy intervention in which
Frederick discussed shameful acts. The therapist asked Frederick to write
down the most distressing thoughts: (see Table 20). Frederick was able to
review some of the unhelpful behaviors (isolation, withdrawal, attempts to
avoid these painful thoughts) that resulted in increased distress and
depression and develop more helpful responses (contacting others). As a
result of this exercise, he was also able to develop a more compassionate
 view of his illness and a more motivating helpful view of what he could do to
stay stable.

|63|Behavioral Strategies – Monitoring and

Regulating Activity by Activity Scheduling
For patients who are depressed and whose daily activities are
greatly reduced, behavioral activation is a behavioral
treatment aimed at increasing activity levels to reduce
escape avoidance behaviors and increase positive
reinforcement and mastery (Martell, Addis, & Jacobson, 2001).
This approach is well-established in the treatment of
unipolar depression. In this approach, the activity schedule
(see Appendix 4: Activity Log – Daily List of Healthy
Behaviors) to monitor baseline activity and to plan gradual
increases in activity levels. The work of Lewinsohn and his
colleagues (Lewinsohn, Munoz, Youngren, & Zeiss, 1986) has
clearly demonstrated the relationship between depression and
daily life events. For example, when a major negative life
event occurs, such as the loss of a job or a relationship,
this often results in decreases in daily pleasant events, and
then mood is lowered. When mood is lowered, individuals tend
to become less active. This in turn decreases the likelihood
that the individual will engage in activities that will bring
pleasure and meaning into their lives, and the level of
pleasant events becomes even lower. A person gets depressed
so they withdraw and become socially isolated, which may
negatively affect their job performance, decrease positive
social interactions, etc. This makes the depression worse,
which in turn decreases activity even further, and so the
vicious downward spiral goes on, leading to a clinical mood
disorder and all the relevant sequelae. Conversely, as the
number of pleasurable events increases, mood typically
improves.

Figure 2 The Downward Spiral Demonstrating the Interaction of Thoughts,

Feelings, and Behaviors

Most patients readily accept the idea of the “downward

spiral” between mood and lowered activity. Figure 2, “The
Downward Spiral,” captures this idea pictorially and can be
useful as a handout to the patient to explain the concept of
“outside-in” work, starting with behaviors rather than
thoughts, feelings, or motivation. If depressed patients
increase their level of pleasant activities on a daily basis,
then mood is improved and symptoms of depression are reduced.
If this problem is approached systematically, patients can
and do develop the skills required to increase and sustain
pleasurable |64| activities at a level that tends to offset
negative life events, and this in turn can decrease the
frequency and severity of subsequent depressive episodes.
Several skills are needed to accomplish this. First, patients
must learn to monitor mood, which we discussed earlier. As
they begin to do this on a routine basis, they are encouraged
to look for events of the day that may be affecting their
mood. As an initial experiment, we ask patients to rate their
mood, engage in a small pleasant activity, and then re-rate
their mood. Together, we examine whether this helped their
mood, and then implement next steps from there.

This realization becomes the rationale for the next step,

and that is to identify pleasurable events or activities that
are feasible given resources and symptom levels. The patient
and therapist collaborate to generate a short individualized
list of pleasant activities that are practical to do on a
daily basis, but are not being done by the patient at the
present time. These activities could include very simple
things such as having coffee with a friend, reading a good
book, visiting the local museum, walking and sitting by a
nearby creek, spending 5 minutes outdoors enjoying the
sunshine, etc. We try to help patients identify several
potential activities based on what has been pleasurable in
the past or activities that clearly relate to important
goals. The next step is often breaking these activities down
into smaller more manageable steps consistent with their
current baseline daily activity. For patients who are at a
low level of daily activity due to severely depressed mood,
focusing on just 2 or 3 new activities over the week might be
sufficient, because adding too many new activities can be
overwhelming. When patients are very symptomatic, new
activities may include basic self-care such as showering and
wearing clean clothes daily. See an example of this more
simplified version of an activity log in Table 22 and
Appendix 4: Activity Log – Daily List of Healthy Behaviors.

Although procedures for activity scheduling are very well-

developed in the depression literature, there are special
considerations that should be taken into account for BD. As
described above, people with BD may become more activated and
energized by goal progress and potential rewards than others
do, and these periods of excessive activation can predict the
onset of manic symptoms (Johnson et al., 2012). Particular
concern is warranted when the excessive activity interferes
with sleep or circadian rhythms. For this reason, we set very
modest activation goals with our BD clients. We also consider
the issue of hyperactivation, which is one of the prodromal
features of mania.

For patients who are overactivated, the activity schedule

can be used in just the opposite manner – to reduce
excessive stimulation and activity. It is often helpful to
review the daily activity schedule to review signs of too
much activity and excessive goal pursuit. Activities should
be monitored to improve regular routines and to reduce
interference with sleep. Patients are asked to reduce hyper-
exciting activities (romance, shopping, public appearances,
parties) and to instead, to focus on calming, soothing
behaviors. If patients are pursuing too many goals, Lam
recommends helping patients to prioritize key goals (Lam et
al., 2010).

|65| Table 22 Sample Simplified Activity Log, Listing Healthy Behaviors

Healthy Behaviors✔ Difficulty Mon Tues Wed Thur Fri Sat Sun
Leaving house for a
20 minute walk
7–8; 8–9
Eating regular meals 7–8
Major Goal:
Grooming/ personal
self-care
Brushing teeth (2 ×
day)
0
Showering (4 ×
week)
0
Shaving (2 × week) 0
Clean clothes (4 ×
week)
4
Shopping for food (3
× week)
8
Laundromat (1 × 2
weeks)
8
Errands ( ? × week) 8
Major Goal: Daily
social contact
Call to
friend/family member
5
Call to Dr. Reiser 2
Meeting a
friend/family member
7

Daily activity logs should include mood monitoring,

|66|
and the patient should bring these logs to the therapy
session. Figure 3 illustrates a form that could be used for
tracking pleasant events. The therapist can make a graph
showing the coincident changes between activities and mood
level, which can become a focus of discussion in the session.
Patients quickly experience an “Aha!” insight, recognizing
the power of pleasure in their own lives. The “take-home
message” for the patient is: (a) Certain kinds of events
control mood; (b) You can control many of these events; (c)
Therefore, you can control mood. Once this message is fully
appreciated the groundwork is in place for continued problem
solving to increase daily pleasant events.

Figure 3 Tracking pleasant events

Addressing Maintenance of Social Routines and Sleep

Loss
Disruption of daily routines is a major issue for most
patients with BD. Although there is clear experimental
evidence that sleep loss can trigger mania, manic symptoms in
turn can intensify chaotic schedules and sleep loss.
Similarly, insomnia is an important prodrome to depression,
and yet once depression arises, sleep problems may intensify.
The importance of attempting to rectify sleep and daily
routine stability in these patients cannot be overestimated.
Beyond the use of activity schedules, techniques drawn from
the insomnia literature and specifically cognitive behavioral
therapy for insomnia (CBT-I) can be very helpful. Among
these, patients should try to set a regular bedtime and wake
time, and should not shift these on weekends or for social
activities. Excessive caffeine should be avoided. Cognitive
strategies and relaxation strategies may help with thoughts
that are interfering with falling asleep. Addressing insomnia
is strongly encouraged but full discussion of CBT-I is beyond
the scope of this manual (see Harvey et al., 2015).

Developing Coping Plans

As is the case in all other facets of this therapy,
collaborative work with patients is a key to success in
identifying useful coping strategies that are |67| personally
meaningful and likely to be used in an effective and timely
manner. A key goal in many effective treatment approaches for
BD is to help the patients develop specific, realistic, and
concrete coping plans that will enable them to take
constructive action when they next experience the beginning
of an episode of mania or depression. To be effective, coping
plans must be individually tailored to each patient and must
reflect specific strategies that have high feasibility and
are likely to occur (Lam et al., 2010). The underlying
philosophy around development of coping strategies is a
belief that patients can and must take an active,
participatory role in treatment if they are to receive the
full benefits of therapy. To actively manage their BD,
patients will need to learn about their illness and develop a
collaborative relationship with their healthcare
professionals including: (1) becoming an expert in medication
and actively participating in decisions about healthcare and
medication; and (2) monitoring and regulating their mood by
identifying key cognitions and behaviors; and (3) developing
better coping strategies for dealing with prodromes of the
illness.

Developing coping strategies can be initiated simply by

inquiring about what has been most helpful in the past and
making a list of potential strategies. The therapist and
patient will carefully review the list and prioritize the
best strategies in terms of feasibility and likelihood of
achieving success. It is very important to inquire: “How
likely is it that you will use this coping strategy?” or
“How confident are you that you will actually use this
coping strategy” or “What would be the good thing about
using this strategy the next time you start to have a mood
shift?” There are useful psychoeducational materials that we
routinely recommend to patients that can provide a discussion
of the rational for coping strategies; however, these
materials cannot substitute for an individualized approach.
Some therapists have experimented with using a list of
standard coping strategies; again, we find it preferable to
“discover” strategies with the patient. This discovery
process, and ultimately testing out solutions in action, is
an extremely powerful tool in helping the patient believe in
the value of these coping skills.

Developing Coping Strategies for Hypomania

Many patients will show temporary deficits in neurocognition
during manic periods. This may interfere with enacting highly
cognitive, complex coping strategies such as cognitive
restructuring in that moment. For mania, more effective
strategies tend to include very basic behavioral strategies,
such as the strategies described above for modifying
hyperactivation, as well as other strategies such as
protecting sleep and contacting the doctor for extra
medication (Lam et al., 2010).

Although many of the techniques for coping with mania are

behavioral, some strategies involving trying to identify
hyperpositive, grandiose thinking associated with mania and
hypomania. Periods of high confidence will certainly be
difficult to tackle using cognitive challenges in the moment
they occur and the patient is likely to view the therapist as
critical and become angry. Nonetheless, some cognitive
strategies are available that aim to delay impulsive
behaviors with a high likelihood of negative consequences. If
the patient is willing, “The devil’s advocate role play
technique” (Newman et al., 2002) can be quite helpful. In
this procedure the therapist plays the role of the
|68| patient and the patient as therapist explores with you
the risks of hypomanic behavior. When done in a group setting
it is not uncommon for other group members to contribute
ideas to the patient, and this sometimes can solidify a
balance sheet of advantages and disadvantage if one continues
to engage in hypomanic behaviors. “The 48-hour rule”
(Newman et al., 2002) is a strategy where the therapist or
group suggests that if it’s a great idea right now then it
will still be a good idea in 48 hours. “So, would it be a
good idea to wait and see?” The goal is to help the patient
slow down and avoid reckless, impulsive decision-making.
“Ask two friends first” is a technique where the patient
agrees that before they go out and act on their idea they
will ask two trusted friends first concerning their opinion.
Again, the goal of this intervention is to get the patient to
slow down and get feedback before engaging in overly
impulsive goal-driven behaviors. Sometimes an effort to use a
cost/benefit analysis in the session identifying both the
advantages of engaging in a risky behavior and the
disadvantages or costs can be quite useful in slowing the
patient down. We have also frankly resorted to just
expressing our concern about the patient harming themselves
in discussions of the potential to engage in risky
unprotected sexual behavior or drug and alcohol use. “More
sitting and listening” (Newman et al., 2002) emphasizes the
need to exert control overactivity, impulsiveness, and over-
activity by paying more attention to feedback and the
importance of the interpersonal and social context.

Table 23 Behavioral Strategies to Combat Hypomania

Increase monitoring of hypomanic symptoms

Use a schedule for sleep, to reduce over activity, and help organize the
patient
Encourage patient to call doctor for a PRN
Avoid activating situations
Instruct patient and family members to reduce conflict and overstimulation
 Assign priorities to tasks (Basco & Rush, 1996)
Address sleep disruption
Reframe hypomania as stress and have patient review “coping with stress
list”
Assign calming and soothing activities
Invoke the 48-hour rule (Newman et al., 2002)
Ask two friends first
“More sitting and listening” (Newman et al., 2002)
Reviewing the evidence – use Socratic questioning to review patient’s
previously developed “Signs of Mania Worksheet”
Use a role reversal and have patient argue against the impulse
Develop a specific advantages/disadvantages list for an impulsive plan
Collaborate with the patient to review possible negative outcomes
Review previously developed “Coping Plan”
Help patient challenge overly positive predictions (“It’s all going turn out
great” – predicting the future) and emotional reasoning (“I know I am going
to win the lottery because I feel so lucky today, I can’t lose”)

We routinely work with clients to consider the areas of

their life that might be vulnerable to damage during manic
periods, and to consider ways to avoid this damage. As
examples, many clients will limit their access to checkbooks
and credit cards when they become aware of early warning
signs of mania. |69| One of our clients committed to avoiding
romantic encounters during periods of hypomania. Some clients
will try to avoid talking in public or with their supervisors
about new potential goals until they have had a night of
solid sleep. Strategies such as reviewing previous manic and
hypomanic periods for periods of excessive confidence and
related costs can help a patient begin to gain insight into
these fluctuations and the need for protective measures to
prevent immediate actions guided by such feelings. Table 23
lists a number of such therapeutic strategies culled from
several sources.

Developing Coping Strategies for Depressive Episodes

As noted above in our introduction to the Psychosocial
Approaches to Treatment section, there are many resources for
helping patients cope with depressive episodes and Beck et
al. (1979) still remains a classic text. Many coping
strategies for depression are linked to increasing
pleasurable activities and reducing avoidable behaviors as
discussed in the section above – Behavioral Strategies –
Monitoring and Regulating Activity by Activity Scheduling.
For depression, effective strategies might include: getting
organized, keeping busy, getting extra social support,
distracting from negative thoughts, reevaluating worried and
negative thoughts, and maintaining a routine and increasing
exercise/activity. On the other hand, less effective coping
strategies often involve reducing activity, doing nothing,
trying to trigger hypomania, or staying in bed. Ultimately
any coping strategies must be developed collaboratively with
the patient. Although there are clearly a wealth of
approaches to coping with depression, it is important not to
overwhelm the patient who is feeling amotivated and
unenergetic – choosing one or two simple approaches to
start with, often including behavioral activation, is
typically best. Many patients will express pessimism about
whether these approaches can help in the face of serious
depression; we find it best to collaborate in taking an
empirical approach to this question, encouraging patients to
try out a strategy and rate their mood before and afterward.

4.2.4 The Final Phase: Maintaining Treatment Gains

The final three or four weekly sessions should be devoted to
preparing for termination of therapy, how to maintain the
gains made in therapy, and how to improve life management to
minimize precipitating stressful events. Because of the
chronic nature of this disorder and the limits to currently
available treatments, relapse or recurrence is more the rule
rather than the exception. Thus, following the guidelines for
relapse prevention (Marlatt, 1996), considerable emphasis is
placed on strategies to minimize the occurrence of future
episodes. During this period the therapist and patient review
what has been learned. Discussion is focused specifically on
the possibility of relapse, particularly what kinds of
situations might precipitate an episode and what the patient
might do in anticipation of these to minimize the probability
of a full-blown episode. That is, what skills should be
applied in what situations to avoid or abort an impending
episode?

We recommend that at the conclusion of the formal weekly

therapy sessions, several booster sessions be included at
biweekly and then monthly |70| intervals, in order for the
patient to independently use the tools learned in therapy to
combat or prevent severe mood swings. Booster sessions also
serve as a “check-in” time to see how the patient is using
her or his newly acquired skills. If possible, continued
check-in sessions at monthly intervals over a prolonged
period can be immensely helpful to some patients in
solidifying their skills and minimizing the probability of
relapse or reoccurrence. During the final sessions, patients
are encouraged to discuss: (1) what ending therapy means, (2)
their ideas about what was more helpful and what was less
helpful during treatment, and (3) their feelings about the
therapist as a person. Talking directly about these issues
helps create a more positive ending, and will give the
patient a sense of closure, which is very important. Thought
records focusing on their concerns about termination can help
them gain perspective on their abilities to maintain their
gains.

Developing a Coping and Wellness Plan

The “Coping and Wellness Plan” is a specific, highly
individualized set of strategies collaboratively developed
with the patient that consolidates the patient’s skill
development in therapy, by reviewing newly acquired skills
and preparing for possible problems in the future. Usually,
it takes about two to three sessions to create this document
before the final summary session. It is a good idea to start
this plan early in initial treatment sessions and have the
patient update the plan throughout the course of therapy.

1.Review skills learned in therapy . Development of the

plan begins by asking the patient to review and write down
skills learned through therapy. The patient is told: “Let’s
spend some time reviewing what you have learned in therapy
that you feel is going to be useful for avoiding serious mood
swings. Spend a few minutes now to think about all of the
skills you learned, and list them in the categories of the
cognitive, behavioral, and interpersonal skills you have
learned during therapy.”
 Identify situations that are potential triggers
2. .
Collaborate with the patient in generating a list of the
situations that are likely to arise in the future that may
exacerbate symptoms and result in mood swings. In BD,
symptoms can be triggered by shifts in medications,
substances of abuse, and sleep loss and schedule shifts.
Depression can be triggered by negative life events, whereas
mania can be triggered by exciting life events that involve
goals being achieved (Johnson et al., 2008). It is helpful
for patients to consider these as they develop their personal
list of triggers. For example: “What kinds of high-risk
situations might occur in the future that would trigger
thoughts, emotions, or behaviors that could start an
episode?” Encourage the patient to take time to think
carefully about the fact that there are certain situations
likely to arise in the future that will tend to disrupt their
lives in some way that may precipitate an episode. Say to the
patient, “Now is a good time to think about which situations
or events might do this, and to make a list, so that you can
see how the tools you have learned in therapy will help you
handle these situations differently the next time around.”
List some relevant examples and comment, “Any one of these
events may be stressful, but they do not necessarily have to
result in an episode if you’re prepared. You can use the
tools you have learned here to offset the stress and keep
stability in your life. By developing your own personal list
of events or situations that are (a) likely to occur after
|71| therapy ends, and (b) likely to cause you to disrupt
your life and slip into an episode of depression or mania,
you can prepare yourself for the kinds of high risk
situations might you experience that might send your
thoughts, feelings, and behaviors into a whirlwind, whether
up or down.”

3. Identify appropriate coping strategies and potentially

unhelpful coping strategies. After the list is generated,
ask the patient to think of specific behavioral and cognitive
skills (from the earlier list) that would help in each
particular situation. “Now that you have this list, try to
think of which specific skills that you listed earlier would
help with each particular situation.” It is helpful to start
this process in session so that the therapist (and other
group members, if therapy is being conducted in a group) can
discuss the details and make additional notes about which of
the ideas raised by the patient might be most helpful.
Identifying problematic coping strategies (withdrawal,
oversleeping, using drugs or alcohol, excessive activity,
etc.) that have been used in the past that may serve to
maintain or amplify problematic mood states is also an
extremely important exercise. The patient can continue the
activity as a homework assignment and additional points can
be added during the next session.

4. Recognizing early warning signs. It is helpful to

review the early warning signs that patients generated
earlier in the course of therapy through discussion and
through personal review of previous episodes, to sensitize
patients to be on the alert for these in the future, in
sufficient time to make immediate plans for constructive
action. See Appendix 7: Identifying Early, Middle, and Late
Signs of Depression or Mania and Clinical Vignette 8:
Identifying Early Warning Signs, which illustrate strategies
for identifying early warning signs in a group therapy
format.

The topic can be introduced by the therapist reminding the

patient that it is important to be prepared for future
problems, should they arise. Some variation of the following
conversation could introduce the topic:

“Knowing your ‘early warning signs’ is crucial to

maintaining your well-being. Future negative events are
likely to occur, and you may be successful in implementing
your coping plan to handle them. However, there may be times
when, for some reason, the tools you have are not adequate
and do not prevent a mood swing. This can happen, despite our
best efforts. It is nothing to be ashamed of. The important
thing for you is to know when you have reached a point where
you know you’re not able to handle the situation, so that
you can seek professional assistance before it gets even
worse. The answer, of course, is different for each person.
It can be helpful now to think back to the early warning
signs we generated earlier in our work together. It’s
helpful to list these so-called warning signs, so that you
can be more sensitive to their occurrence in the future. This
will help you learn to take action right away.” Finally,
such discussions about potential future problems helps
normalize this phenomenon, which can minimize the stigma
associated with failed attempts to adapt, and thus may lead
to more rapid attempts to obtain help when needed.

|72| Clinical Vignette 8

Identifying Early Warning Signs
Therapist: Can we go back now to the symptom checklist? Did others have
any problems listing symptoms they have when they’re
depressed and when they’re manic?

Group Members agreed that they had little difficulty thinking of some
symptoms, and during the conversation many were able to add symptoms that
they had forgot to include.
Therapist: Ok, now we want to start thinking about what are the
earliest possible indicators that you’re getting depressed
or starting into a manic stage.
Group Member: I have depression all the time it seems.
Therapist: Ok, let’s start by finding out what makes depression worse.
What are things that make your depression worse? [Therapist
writes items on the white board.] If any of these apply to
you and you don’t have them on your list, it’s a good idea
to write them down.
Group Member: Not enough sleep.

Group members continue to list different factors, including: isolation,

weight gain, lack of support, irritating advice, not taking medication on
schedule, hearing or seeing something that sets off a chain of negative
thoughts.
Therapist: Ok. Now let’s list some of the things that make mania
worse.
Group Member: Not enough sleep. [Group laughs]

Group continues to list items while therapist writes them on the white board.
List included: ruminating on stressful situations, sense of urgency,
uncontrollable sense of pressure, having trouble prioritizing things, having
people tell me what I can and can’t do, not taking medication on schedule,
having weird thoughts, trying to get things done and people or something gets
in the way, getting irritable.
Therapist: Okay. These are pretty good lists of things that make
depression and mania worse. We want to keep working on the
idea of finding out what are the earliest possible signs
that we’re sliding into a deeper depression or into a manic
state. Paying attention to these things on the list may help
 us begin to spot changes in ourselves earlier than we have
before. For our home practice this week does anyone have a
good idea about how we can do this?
Group Member: Well one thing is if we keep trying to add things to our
lists, maybe we can spot more things that get to us early
on, and we can notice how that’s affecting us.
Group Member: Also if we think about the level of these different things.
Maybe some start off real gradual and we don’t notice it.
Maybe if we tried to see if that’s the case. Like what am I
doing or experiencing before I notice that I’m starting to
have sleep problems.
Therapist: Well those are good suggestions. Any others?
Group Member: Maybe there are things that occur before the things that we
notice. I think it would be helpful to look for things like
that.
Therapist: Okay. Our assignment for next week will be to continue
looking for items to put on our list, and keep thinking
about what might be happening even before or just as our
mood is starting |73| to change significantly. Going back
to our symptom list, the features we’ve listed here are
pretty obvious and we have little difficulty in identifying
them. However, in many of us there may be early subtle signs
that we and others don’t see right away. So what we want to
do is to see if we identify signs that occur very early,
even before we see these more obvious symptoms. We can use
the handout I gave you to list what we think are early,
middle, and late symptoms for us and bring this in next
week. Oh, and also we want to keep monitoring our mood. So
for next week we’ll have our mood graphs to hand in, and
we’ll have our list of early middle and late signs started
so that we can finish it during our session.

5. Know what to do when early warning signs occur . It is

important to have an established concrete plan that provides
details on what to do in the event that warning signs
surface. What is the best way to contact the patient’s
psychiatrist if medication is urgently needed? Who can the
patient call for social support? What activities are to be
avoided? What might be a good back-up plan in case
appropriate help cannot be obtained, etc.? Organizing answers
to such questions into a plan of action can help consolidate
therapy gains into a long-term maintenance plan. Finally, the
patient should be reminded that an important resource can be
found in the homework assignments and other materials
collected during the course of therapy, and should be
encouraged to review periodically the written notes and
workbook materials.

Examples of two completed Coping and Wellness Plans are

attached in Table 24 and 25 and also see a blank version of
this form in Appendix 9. It can be seen from these examples
that coping plans do not need to be complex to be useful.
Feasibility and user friendliness should be the main
criteria: the likelihood that the patient finds the plan
meaningful and is likely to use it in the event of having
problems. You will note that there are a number of quite
idiosyncratic items on the coping plan list that are
personally meaningful to the patient. This is a good example
of why boilerplate coping plans are to be avoided. In one
case (Table 25), the patient sent his finalized coping plan
to the therapist some weeks after therapy had ended with the
following note: “I’ve been working on my plan, and trying
to look at it every once in a while to deal with little bumps
along the road. Let me know what you think.” This indicates
that the patient found this plan personally meaningful and
useful and had actually referred to it several times to
address “bumps along the road.”
Table 24 Coping and Wellness Plan for a Patient in a Depressed Episode:
Example 1

Vulnerabilities:

Isolation
Trying to do everything on my own
Visions of sainthood
Romance woes
Immersion in foreign cultures?

|74| Signs of Illness:

Emotional detachment
Self-isolation
Feeling inexplicably frustrated by everything
Dwelling on loneliness
The “gray cloud” mood

Coping plan in case of difficulties:

Good coping strategies:

Do something active, even if it’s unrelated
Ask for help from people you confide in
Stay positive. The negative is temporary and will pass
Unhelpful coping strategies:
Avoidance
Overthinking
Fighting it (mental warfare, overcontrolling)

Staying well plan:

EXERCISE, at least every other day

Eat well
Don’t drink too much
Enjoy simple pleasures
Make time and effort for friends and family
Be grateful for what you have (meditation?)
Live one day at a time
Be open about the issue, even when you think it might be off-putting

Other important things to keep in mind:

Extreme suffering is not the same as love/caring

There are times when my needs require more immediate attention than those of
others
You can make new goals when old ones fail
It’s OK to follow your heart if you are equipped with the tools to survive
the consequences
It’s lonely on the “pedestal,” so don’t put yourself or others on one
You’re a good person, just going through a hard time
 You do the best you can with what you know and are capable of at the time

Table 25 Coping and Wellness Plan for a Patient in a Depressed Episode:

Example 2

Warning Signs:

Sleep is interrupted – tossing and turning, trouble staying asleep, early

morning awakening with anxiety
Losing my natural gregariousness, outgoing nature; staying alone, avoiding
people, not checking email and voicemail
Lack of appetite
Increased anxiety and worry
Loss of interest in sports
General loss of interest
Not being interested in exercise
Don’t feel like going to work

|75| Coping Plan:

Talk to wife about early warning signs

Check in with people at work I trust
Communicate with family members, including brother, mother, and close friends
Call HMO nursing line to get a prescription for sleep medicine if needed
Call Dr. W (psychiatrist)
Call Dr. M (HMO psychologist)
Call Dr. Reiser
In an emergency, call HMO emergency hotline and take aggressive action
Be aggressive about getting timely care at Kaiser

Action Plan to Stay Well:

Exercise five days a week: biking 1 hour, swimming 30 minutes

Don’t sweat the small stuff
Go to work each day – it’s important to maintain routines in structure
Help cook dinner – taking charge at home
Talk to people – maintaining high levels of social activity
Mingle throughout the neighborhood
Stay positive
Be “the man” around the house – disciplining kids, taking active role,
taking charge, helping to do laundry and clean the house
Go to supermarket to help with the shopping
Spend more time with kids – Y adventure guides
Regular check-ups with HMO doctors; Dr. M at least every 6–8 weeks
Take medication as prescribed
4.3 Family-Focused Treatment
We often find it helpful to supplement individual treatment
with family techniques. In Bipolar Disorder: A Family-Focused
Treatment (Miklowitz, 2008), there are three main phases of
treatment – psychoeducational, communication skills
training, and problem-solving – and a final maintenance
phase including ongoing crisis intervention and relapse
prevention.

In the immediate aftermath of an initial episode of BD,

families are likely to experience disorganization,
demoralization, and intense guilt and self-blame that can be
experienced as destabilizing and disastrous. The goal in the
first phase is to provide information and support to the
patient and family members, offering a realistic
understanding of BD and a rationale for treatment that
provides hope for the future. This will involve, at minimum,
helping family members understand the ongoing role of
medication in treatment, identify specific symptoms of BD,
identify warning signs of impending episodes, and develop a
shared understanding of the basic treatment approaches
identified in treatment approaches described above, including
mood monitoring, identifying prodromes of illness, and
developing coping plans. See Table 26 for a sample agenda for
family sessions.

|76| Table 26 Sample Agenda for Initial Family Sessions

Set goal of supporting family and keeping patient stable.

Explain the rationale for ongoing treatment with medication as well as
psychotherapy.
 Reduce blaming and guilt – everyone is doing the best they can.
Identify early warning signs.
Develop a plan about how to monitor warning signs (who is responsible for
what).
Help the patient identify “helpful things family members can do.”
Help the patient identify “unhelpful things family members should avoid
doing.”
Develop an action plan for relapses.

After initial assessment meetings, which should always

involve family members (see Section 1.7), and
psychoeducational sessions, it is often useful to meet
individually with the patient for several sessions to develop
a strong therapeutic alliance and an initial treatment plan
focusing on monitoring and identifying early warning signs.
This plan can be shared with family members, and family
members can jointly develop a list of agreed upon “warning
signs” in a collaborative fashion with the patient and the
therapist.

The goal is to limit this list to specific warning signs of

manic and depressive episodes and to avoid general behaviors
that may be the focus of family conflict but are nonspecific
to BD. Frequently, in adolescents and young adults, conflicts
about increasing autonomy and independence can become
intermingled with concerns about the symptoms of BD
(especially mania and hypomania). It can be useful to
differentiate high-risk behaviors with a potential for harm
or serious consequences from annoying or irritating behaviors
that are unpleasant but not life-threatening.

Table 27 Identifying Warning Signs Collaboratively in a Family Context

Sleeping less than 4 hours a night*

 Withdrawing from classes
Rushing to make up and losing sleep
“I can do anything” energy – excessive multitasking
Unable to concentrate on studies
Always feeling angry
Driving recklessly*
Drinking too much*
Reversed sleep cycle – too tired to attend class
Pressure to get things right away
Inviting certain friends over the family doesn’t approve of

Note.*items the family could not agree on

In the example presented in Table 27, after several

individual sessions with the patient, the therapist met with
the family and collaboratively developed a list of agreed-
upon early warning signs. The therapist worked to prioritize
|77| high-risk behaviors where family members could readily
agree on health or safety risks from other behaviors that did
not pose an imminent hazard. The intent of this exercise is
not to come up with the perfect list, but to establish a
cooperative and collaborative framework in which family
members work together toward mutually acceptable goals for
treatment. Unresolved items are best deferred for further
discussion, keeping the focus on areas of agreement. Indeed,
in this instance, the family could not agree on some items
(starred in the table) which were left for further
discussion.

Finally, when excessive monitoring of possible bipolar

symptoms causes conflict between family members and the
patient, it is useful to reframe the families’ intrusiveness
or excessive concern as a natural caring response. This
creates a possible framework for further discussion of what
is a more optimal level of concern and monitoring. Clinical
Vignette 9 addresses balancing family concern for possible
symptoms and high-risk behaviors with excessive intrusiveness
that can be viewed as a threat to autonomy by adolescents and
young adults. The Thought Record presented in Table 28
presents linked work in individual therapy focused on
ameliorating problematic appraisals of self and associated
self-critcism.

Clinical Vignette 9
Why Are You Sleeping So Much? Are You OK?
Andrea, a bright and high-achieving 21-year-old college student, returned to
live at home after a serious period of depression followed by a manic episode
in her first year at college. During her manic episode Andrea had engaged in
a number of behaviors that were frightening and disturbing both to her and to
her family. As a result, her mother was particularly concerned and attempted
to closely monitor changes in her behavior, including any significant changes
in sleep and wake cycles and other behavioral changes associated with the
onset of hypomania and mania. In mother’s view, there would be realistically
disastrous consequences for failing to identify signs of instability that
might indicate the emergence of new symptoms. Unfortunately, this sometimes
resulted in a high level of conflict between mother and daughter. Whenever
Andrea felt criticized by her mother, she tended to experience episodes of
depression that were destabilizing and interfered with her functioning at
college.
During a conjoint family therapy session, Andrea reported that she had become
severely dejected and depressed because she felt that her mother thought she
was a “lazy” person. This resulted in her staying in bed throughout the day
and missing several of her scheduled activities, and feeling significantly
more depressed. In the thought record summarized in Table 29, the therapist
attempted to illustrate the “downward spiral” into depression that occurred
in the context of concerns expressed by the mother which were experienced by
the daughter as both critical and intrusive.
The therapist attempted to help Andrea develop countering thoughts that would
assist her in feeling less criticized and disrupt some of her negative self-
 labeling, and pointed out her tendency to sabotage herself by missing classes
and other important activities when she felt criticized. This resulted in a
serious “downward spiral,” in which minor criticisms were perceived as
major threats to self-esteem and precipitated further withdrawal, isolation,
and self-blaming. The final outcome was that what might have started out as a
relatively minor setback became a much more serious depressive episode that
interfered with daily functioning and threatened important longer-term goals.

Many of the CBT interventions described can be applied

|78|
in a family context. For example, “unhelpful thought
records” can help identify and resolve problematic responses
to family interactions that could trigger episodes
depression. In these thought records – which can best be
developed in conjoint family interviews – we tend to
emphasize the interpersonal context of the individual’s
behaviors and point out chains of interactions and responses
that are problematic. Additionally, this helps family members
develop empathy, and more fully understand and appreciate the
internal experience of the identified patient and identify
unhelpful responses and interactions. Attempt to do this in a
“no-blame” framework, with the understanding that everyone
in the family is doing the best they can to cope with a
highly stressful, destabilizing situation. Clinical Vignette
10: Reducing Family Conflict Over Excessive Monitoring
illustrates the adaptation of standard CBT strategies to the
familial context in a way that is helpful to all family
members and reinforces more adaptive communication and
behavioral patterns.

Table 28 Thought Record: “I’m a Lazy Person Staying in Bed All Day”

Situation I’m trying to nap and mom says, “Get up, you’ve been
watching TV all day.”
Thoughts I’m lazy
I don’t care about my future
I’m less of a person (95%)
I’m not motivated
I’m not good enough (99%)
If mom thinks I’m lazy then I must be lazy (90%)
I am bad person
Whatever my mom says about me is true.
My thoughts and feelings are not valid.

Feelings Dejected
Depressed
Irritable
Annoyed
Sensitive
[Anxious]

Behaviors Stay in bed more (“my escape”) [avoidance]

Avoids studies [Self-sabotaging behaviors]
Loss of focus on goals [feels worse]
Difficulty scheduling, as schedule has become less
structured

Alternative Thoughts If I really was a lazy person, I wouldn’t be trying

this hard in school.
If I was lazy, I wouldn’t care about spending time
with friends.
If I was lazy, why would I attend school, I would be
skipping classes.
My friend tells me I’m important, therefore, I do make
a difference.
Other friends see my ideas as valuable.

|79| Clinical Vignette 10

Reducing Family Conflict Over Excessive Monitoring
Patient: There are still times when she’ll [the mother] think I’m
sleeping too much. Then, I see her reading the “Bipolar
Book” [ The Bipolar Disorder Survival Guide by David
Miklowitz] right when I wake up. And that gets me stressed
out.
Therapist: That’s like waving the red flag?
Patient: Yes.
Therapist: Let’s go back to where we left off last week. I think we
identified a kind of interaction between the two of you
where you [mother] become concerned and there are a lot of
reminders and cues you give to make sure that your daughter
is “on track.” And then you [daughter] get very irritated
and it kind of ends up in a very angry explosive incident.
Patient: It’s not helpful. I read in the book that stress causes
more problems.
Therapist: Yeah. I think we came to the conclusion that this wasn’t
really working for either of you; that it was backfiring and
making things less stable. So one big goal here is to get
the two of you working together in a way that doesn’t
create such a high level of conflict. We would like to meet
each of your goals without increased conflict. Is that
right?
Mother: Yes, I’m frustrated, so frustrated.
Daughter: Yes.
Therapist: So we had an experiment going to see how things would go
without any reminders about medication or mood graphing last
week. How did things go? Were you able to get on the same
page?
Patient: Well, sometimes she had to remind me and other times I did
it on my own. But with the medication I definitely had that
covered. She didn’t have to remind me at all.
Therapist: Did she remind you?
Patient: No. I know that’s what I should be doing anyway.
Therapist: Is the medication an area that the two of you are succeeding
in?
Patient: Yeah.
Therapist: So let’s start there. Why is that working for you?
Patient: It’s just ingrained; especially since the fact that my mom
doesn’t remind me anymore. Sometimes [in the past] I wanted
to not take medication because of the things she’ll say.
Right before I get a chance to take the medication she’ll
remind me. It makes me want to rebel.
Therapist: So medication is an area you have been successful in,
following through and doing it yourself. Have you missed
 doses or days in the past 2 weeks?
Patient: No.
Therapist: To me this is an example of what is working.
Mother: Yeah.
Therapist: It seems like it’s working – you’re able to not worry
about it too much and stay clear, and that’s helping her.
Mother: Yeah.
Therapist: And the outcome is what?
Mother: She’s taking it [the medication].
Therapist: And how does that affect your relationship with your
daughter?
Mother: It’s more positive. I don’t say a thing and she just does
it.
Therapist: So the outcome is positive here and you feel less worried?
Mother: Yeah. I really appreciate her taking her medication.
Therapist: So you have a more positive relationship in this area and
that encourages you [daughter] to take more responsibility
and feel good about doing it yourself. And that helps you
[mother] not feel too |80| worried. So this is a good
model. How could we take this success and apply it to other
areas where you are still having problems? We all agree this
is good outcome where you feel less conflict, right? You
feel less angry and frustrated, right?
Mother and daughter:Hmm.
Therapist: Does this sound like I’m getting it right here?
Daughter: Definitely.

4.4 Self-Help Approaches and the

Recovery Model
There is an increasing interest in incorporating evidence-
based approaches into a broader philosophical understanding
of recovery from mental illness, the “recovery model.” It
would be impossible to begin discussion of recovery from BD
without reference to the profound impact that Kay Jamison has
had, both on our understanding and conceptualization of this
disorder and on our hopefulness about the ability of patients
to recover from the most severe episodes of illness and
rebuild meaning and purpose in their lives. As Dr. Jamison
noted in her introduction to Manic-Depressive Illness
:
“Manic-depressive illness magnifies common human experiences
to larger than life proportions. Among its symptoms are
exaggerations of normal sadness and fatigue, joy and
exuberance, sensuality and sexuality, irritability and rage,
energy and creativity.” (Goodwin & Jamison, 2007, p. xix)

Table 29 Integrating Evidence-Based Treatment and the Recovery Model:

First Principles

Treatment is a collaborative enterprise.

Accept the patient as the most important resource in therapy and learn from
the patient’s experience, strengths, and past efforts in resolving problems.
Teach patients the skills they need to manage their health-related problems.
Treatment goals are ultimately defined by the patient.
Don’t forget “big picture” treatment goals:
Increased independence
Increased responsibility
Satisfying relationships
Good quality of life
Providing opportunities for housing, education, and employment.

A growing number of researchers and consumers have

emphasized the importance of recovery as a broader construct
than symptom remission (Jones et al., 2015). The heart of
recovery is rediscovering meaning and purpose, not just the
amelioration of psychiatric symptoms or the stabilization of
mood. What is the point of merely being “well,” if life has
no meaning or purpose? As Bill Anthony has indicated in his
vision of the meaning of recovery, “Recovery involves the
development of new meaning and purpose in one’s life as one
grows beyond the catastrophic effects of mental illness”
(Anthony & Spaniol, 1994, p. As we interviewed a group of
patients who had been stable for over 2 years, a constant
theme emerged that BD was becoming simply one facet of a
rich, varied, and interesting life, and having the disorder
was no longer viewed |81| as an overwhelming threat or
disaster. As one patient put it quite graphically: “Recovery
means not waking up in the morning and having your first
thought be, ‘Oh shit! I have bipolar disorder.’ Instead I
find myself thinking about what I am going to do today.” As
illustrated in Table 29: Integrating Evidence-based Treatment
and the Recovery Model: First Principles, this broader view
of the disorder and the meaning of recovery can be integrated
into our clinical work by emphasizing the importance of self-
management and the need to make a lifelong commitment to get
well and stay well.

The following sections describe some key areas that are

likely to be addressed in relationship to guilt, shame,
stigma, hopelessness, and the need to work toward
“remoralizing” the patient.

4.4.1 Combating Social Stigma

In a chapter summarizing a dialog between psychiatrists and
“consumer-practitioners,” Blanch, Fisher, Tucker, Walsh,
and Chassman (1997, p. 70) make the following observations:
“‘Recovery’ relates not only to the experience of
symptoms, but also to the secondary assaults of stigma,
discrimination and abuse: One person noted ‘Dealing with
internalized stigma was almost as difficult and took as much
away from my life as the symptoms did’.. Hope is perhaps the
most fundamental factor in recovery” (p. 70). Patients with
BD are exposed to real world discrimination and
stigmatization in healthcare, insurance, and social and job
settings. It is not surprising that hopelessness, stigma, and
demoralization are profound problems for individuals with
this disorder. Clinical Vignette 11: Combating Demoralization
and Hopelessness provides some examples of interventions that
target some of the core issues that contribute to ongoing
demoralization and reinforce negative schema.

Clinical Vignette 11
Combating Demoralization and Hopelessness
Tanya, a 22-year-old Asian-American woman, began therapy during a severe
depression in which she often felt “numb,” immobilized, “robotic,”
“muddle-headed,” and would stay in bed for several days at a time.”
Although very bright and with an advanced degree in engineering, she was
reduced to doing project-oriented consulting and felt that her last project
had been an abysmal failure. She assumed that she was viewed as grossly
incompetent and would never be offered another consulting project. Tanya was
assigned The Feeling Good Handbook by David Burns (see Self-help Resources in
Appendix 10). After several sessions, Tanya agreed to schedule several
pleasant events that involved increasing her social contacts.
When she returned for the next session, Tanya reported that she had been
unable to follow through on the assignment and reported feeling increasingly
depressed. We discussed her difficulty following through on these assignments
and developed a Thought Record).
Tanya reported feeling very apathetic, numb, doubtful and hopeless in
conjunction with these thoughts. After identifying some of the cognitive
distortions associated with these thoughts (e.g. “I’ll be too robotic”,
“I’ll be disappointed anyway, so why bother”, “I’ll never do well at
this”), Tanya slowly developed more rational responses (e.g. “Even so,
it’s better than doing nothing.”, “Maybe I will be |82| disappointed, but
I might not be 100% disappointed”, “Making some attempt will be better than
staying in bed.”) It took time for Tanya to come up with alternative ways of
thinking. Even though it is often time-consuming for severely depressed
patients to complete this type of exercise, it is important to let patients,
rather than therapists, to develop the alternate responses.
At the end of the exercise, Tanya felt more hopeful and less anxious about
homework, and renewed her commitment to the the tasks the next week.
It should be noted that for patients like Tanya who are severely depressed,
one exercise is unlikely to have a lasting impact and multiple efforts will
need to be made over time to address hopelessness and demoralization. In
fact, after 2–3 weeks of feeling significantly better, Tanya returned to
therapy after a 2 week break unable to do her homework and feeling very
hopeless again. She began the session with the statement, “I feel like I
took a nosedive,” and she rated her mood as –3 on a +5 to –5 scale. She
had not followed through on homework and had the following thoughts:
“I don’t really care anymore about making an effort, because it won’t make
a difference.”
“I want to crawl in a hole and not deal with the world right now.”
“I’m frustrated that I made an improvement and slid back.”
“When I make progress, there’s always some glitch; something bad happens.”
These thoughts left her feeling numb, blank, and hopeless. She noticed
several thinking errors, including “emotional reasoning” (“I feel like it
won’t make a difference, therefore, it won’t make a difference”),
predicting the future, overgeneralization, magnifying problems, and
minimizing positives (“When I make progress, something bad always
happens”). With some effort she was able to come up with several countering
thoughts:
“I am feeling more hopeful about my therapy.”
“Things don’t always stay bad; I have felt better in the past.”
“Even if I do slide back, I’m getting help and have good support systems.”
At the end of this exercise the patient felt somewhat less hopeless and rated
her mood as a –1 or –2 on the +5 to –5 scale. This may seem to be only
modest progress, but in an additive fashion these small steps help the
patient move forward.
4.4.2 The Role of Self-Help and Support Groups
For maintenance of gains long-term, self-help support groups
can be extremely helpful. Many patients we have treated who
have been most successful have developed strong support
systems, in part through organized self-help groups. Active
participation in self-help groups reflects the same active
self-management efforts that are a key to long-term illness
management and recovery. There are a number of well-organized
and dedicated organizations (see Appendix 10: Self-Help
Resources) that offer education and support for individuals
with serious mental health problems and for their families.
These groups provide extremely helpful education, social
support, and help to destigmatize the illness in ways that
are not available to the professional therapist.

4.5 Mechanisms of Action of

Psychosocial Approaches
|83|

This section reviews empirical support for the hypothesized

mechanisms of action specific to empirically based
psychological treatments (EBTs) for BD. Before we review
mechanisms specific to treatment of BD, it would be useful to
acknowledge the importance of a broader approach recognizing
that evidence-based practice includes both the use of
empirically supported treatments and recognition of the role
of common factors (Laska, Gurman, & Wampold, 2014). In this
section, we focus on the potential role of specific mediators
in the treatment of BD without summarizing the broader
literature on common factors, which is beyond the scope of
this text. The reader is referred to Laska, Gurman, and
Wampold (2014) and Wampold (2013) for an excellent review of
this topic.

Miklowitz and Scott (2009) in a meta-analytic review of

disorder specific psychotherapies for BD (CBT, IPST, family
and group psychoeducation), note common characteristics of
these disorder-specific approaches to BD, which include: an
individualized case formulation, a clear rationale, open
collaboration with individuals and familes, emphasis on
psychoeducation and use of skill-based illness management
techniques post-therapy. They conclude:

The comparison treatments were most clearly distinguished from the

experimental treatments by the lack of systematic employment of
interventions and the absence of therapeutic ingredients such as:
problem-solving regarding stressful events or experiences (including
stigmatization), communication training, cognitive restructuring, or
sleep/wake cycle regulation. These components are candidates for the
active ingredients by which DSPs confer clinical benefits relative to
usual care or nonspecific psychotherapy. (Miklowitz & Scott, 2009, p.
118)

In psychoeducation, one of the primary aims is to improve

adherence with treatment, through promoting better
understanding of the rationale and process of treatment.
Consistent with this goal, patients who receive
psychoeducation have been found to be more likely to attend
outpatient therapy sessions, to have higher and more
consistent lithium serum levels, and to be less likely to
require emergency intervention (Scott et al., 2009). This
type of basic intervention has been found to more helpful
when patients have less knowledge about their illness (Even,
Richard, Thuile, Friedman, & Rouillon, 2007).
 Monitoring mood and activities is described in many
manuals, because it helps the patient be more aware of early
signs of a shift in mood, which is the first step in being
able to initiate coping strategies. In one nonrandomized
trial, depressive symptoms declined when BD patients were
taught mood monitoring as a stand-alone intervention.
Nonetheless, gains had dissipated by 6-month follow-up (Depp
et al., 2015).

In IPT, one of the core goals is to improve circadian

rhythms, by helping people learn to follow regular routines
in their daily activity and sleep. Findings indicate that IPT
is related to improvements in social rhythm regularity.
Moreover, those who more successfully stabilized their social
rhythms during the first 16 weeks of receiving treatment were
more likely to show improvements in their symptom outcomes
(Frank et al., 2005).

|84|Family-focused treatment involves strategies designed

to enhance patient’s and family member’s understanding of
the illness and treatment, as well as strategies designed to
improve family communication and to reduce family conflict.
As with other approaches, family-focused treatment does
appear to improve medication adherence, and this predicts
reduced mania over time (Miklowitz, George, Richards,
Simoneau, & Suddath, 2003). Although it has been difficult to
reduce family negativity, families do appear to show more
positivity in their interactions after receiving family-
focused treatment (Simoneau, Miklowitz, Richards, Saleem, &
George, 1999). The extent to which families show greater
positivity then predicts less depression over time (Miklowitz
et al., 2003).

CBT encompasses a wealth of strategies. Given that some of

these target improved understanding of the illness, the
rationale for medications, and maladaptive beliefs about
medications, it is not surprising that CBT has been found to
improve the odds that a person will sustain medication use
(see Cochran, 1984). In the first major randomized controlled
trial of CBT, patients assigned to CBT demonstrated more gain
in their abilities to cope with manic symptoms than did the
control group (Lam et al., 2003). In one study, patients were
randomly assigned to receive psychoeducation as compared to
CBT. Although outcomes were generally similar, patients who
received CBT were more likely to show reductions in their
maladaptively negative thought styles (Zaretsky, Lancee,
Miller, Harris, & Parikh, 2008).

4.6 Efficacy and Prognosis of

Psychosocial Approaches
In considering efficacy and effectiveness data on
psychosocial treatment, we focus on trials that used random
assignment to active treatment vs. a control group. Dozens of
studies support the efficacy of psychotherapy as an adjunct
to medications. Research has shown that psychotherapy can
improve knowledge of BD and willingness to engage in
medication treatment, and can reduce the number of manic and
depressive episodes, the severity of episodes when they do
occur, and hospitalization rates. Psychotherapy can also
improve quality of life, social functioning, work
productivity, and marital relationships (Gutierrez & Scott,
2004).

Perhaps the best studied psychological treatment approach

for BD is psychoeducation. Across a range of studies in
multiple countries, psychoeducation has been found to fare
better than unstructured psychotherapy (provided to control
for the level of attention that patients received) or
medication alone in reducing symptoms and improving
medication adherence (Swartz & Swanson, 2014). In one study
of 120 adults with BD I, relapse rates were 67% within two
years after treatment for those who received psychoeducation,
as compared to 92% for control patients who took part in
unstructured support groups. Psychoeducation was also related
to significantly fewer depressive and manic episodes, and
hospitalizations, and shorter hospitalizations (Colom, Vieta,
& Martinez-Arán, 2003). Beneficial effects of psychoeducation
were observed at a five-year follow-up within this study
(Colom et al., 2009). As noted above, |85| a recent meta-
analysis of psychosocial interventions for BD concluded that
psychoeducation was one of the most effective treatment
strategies (Miziou et al., 2015).

Considerable research has also focused on CBT, with several

early trials documenting that CBT appeared beneficial
compared to medication alone or routine care, with
improvements in medication adherence, hospitalization rates,
and rates of recurrence (Cochran, 1984; Hirschfeld et al.,
1998). In one study, adding CBT to routine care was
associated with substantially longer time to manic relapse
(65 vs. 17 weeks on average; Perry, Tarrier, Morriss,
McCarthy, & Limb, 1999). In considering this approach, it is
important to remember that there are several manuals, and
that they involve slightly different techniques. Some of the
randomized controlled trials have suggested that most manuals
are more powerful in reducing depression than mania (Scott,
Garland, & Moorhead, 2001). Nonetheless, in one study using
the Lam and Jones manual (Lam et al., 2003), patients
assigned to CBT demonstrated significantly less mania than
those assigned to treatment as usual, and relapse rates for
both poles were lessened: 44% of persons who received CBT
showed a relapse as compared to 70% of those who received
medication treatment (Lam et al., 2005). These improvements
in relapse rate in the CBT condition were noted by patient
report and were also evident in fewer hospitalizations in the
first year after treatment. Patients also appeared to attain
better psychosocial functioning (Lam et al., 2003). Findings
suggest, however, that longer-term booster sessions might be
needed, in that the benefits of CBT dissipated by two years
(Lam et al., 2005).

Some caution is warranted, in that attempts to test CBT in

the community have led to more mixed results. In one major
study, CBT was more helpful than treatment as usual among
those with less than 12 episodes, but was not more
efficacious than treatment as usual among those with 12 or
more episodes (Scott et al., 2006). Another small study found
a trend for CBT to be related to lower depression as compared
to supportive therapy, but findings were not significant
(Meyer & Hautzinger, 2012). Several studies have now provided
support for the efficacy of CBT offered in a group format
(Swartz & Swanson, 2014). Taken together, these findings
suggest the importance of reaching patients before they have
gone through years of recurrence, and provide the strongest
support for the techniques covered in the Lam approach to
CBT, which includes attention to reducing hyperstimulation
and coping with prodromes.

There is also strong evidence for family and couples

therapy. Early research suggested that offering couples
treatment could be helpful in BD (Davenport, Ebert, Adland, &
Goodwin, 1977). In a major trial of family-focused treatment
(FFT) as compared to crisis management among 101 persons with
BD I, Miklowitz and colleagues (2003) found that FFT was
related to lower relapse rates (52% vs. 17%), stronger
medication adherence, and lower depression, but not mania,
over time as compared to crisis management. In a second study
comparing FFT to individual patient management treatment, no
differences were noted in the first year of follow-up, but
lower rates of relapse (28% vs. 60%) and hospitalization (12%
vs. 60%) were noted in the second year for those in FFT as
compared to those who received the individual care (Rea et
al., 2003). Research on a different version of family therapy
suggested that |86| family therapy or family psychoeducation
were both helpful as compared to a control condition for
those with high family impairment, but did not appear
particularly helpful for those families who were already
showing good family functioning at hospital discharge (Miller
et al., 2008).

Findings remain mixed regarding family therapy for BD among

adolescents. In a first trial, 58 adolescents with bipolar
spectrum disorder were randomly assigned to receive FFT or
enhanced pharmacological treatment. Adolescents assigned to
FFT demonstrated a faster recovery and fewer weeks of
depression, although did not differ from those who were
enrolled in enhanced care in manic symptoms (Miklowitz et
al., 2008). In a more recent study of 145 adolescents with BD
I or II, FFT was related to less manic symptoms in the second
year of follow-up than enhanced care, but other outcomes,
including depression, did not differ (Miklowitz et al.,
2014). Multifamily group psychoeducation has shown promise in
adolescents with BD (Fristad, Verducci, Walters, & Young,
2009).

Initial research on interpersonal and social rhythm therapy

(IPSRT) suggested that it was helpful in rapidly improving
social functioning and preventing relapse when offered
acutely (until participants achieved remission). Nonetheless,
when IPSRT was offered on a biweekly and then monthly basis
for two years to those who had already achieved remission,
outcomes for IPSRT and clinical management did not differ
(Frank et al., 2005, 2008). A recent study found that
patients with bipolar spectrum disorder who were randomly
assigned to acute IPSRT did not differ from those assigned to
supportive psychotherapy, although both groups showed
decreases in symptoms and improvements in social functioning
across the one-year follow-up (Inder et al., 2015). Despite
this mixed evidence, IPSRT has shown promise for the
treatment of BD II, with outcomes comparable to mood
stabilizing medication (Swartz, Frank, & Cheng, 2012). A
recent review of psychosocial treatments for BD concluded
that “there are no convincing data on the usefulness of
IPSRT during the maintenance phase of BD. There are, however,
some data suggesting that if applied early and particularly
already during the acute phase, it might prolong the time to
relapse” (Miziou et al., 2015, p. 5).

Several trials are also available comparing different forms

of treatment. Two studies suggest that psychoeducation is as
helpful as CBT (Meyer & Hautzinger, 2012; Parikh et al.,
2012. This would suggest that, particularly if a client has
not already received basic psychoeducation, this might be a
very helpful starting point for treatment.

In the largest psychotherapy treatment trial to date, the

STEP-BD study, researchers compared CBT, IPSRT, FFT, and a
clinical management condition consisting of brief check-ins
to 293 persons with BD I who were enrolled during a
depressive episode (Miklowitz et al., 2007). CBT, IPSRT, and
FFT were all associated with greater decrease in depressive
symptoms compared to clinical management. CBT, IPSRT, and FFT
performed comparably, suggesting that none of the structured
treatments had a clear superiority. This relative equivalence
of treatments can suggest that common factors play a greater
role than active treatment ingredients (Wampold, 2013).
However, it is also possible that each of these treatments
provide some unique active mechanism that address specific
problems in BD (see the revew of Miklowitz & Scott, 2009). In
any case, therapists will want to carefully consider specific
client concerns and preferences before choosing treatment
options.
 |87|Finally, researchers have considered a program of
collaborative care management, which integrates state of the
art medication treatment, group psychoeducation, and enhanced
access to a nurse practitioner who can quickly respond to
phone calls and requests for medication adjustments. Across
two major studies, patients assigned to collaborative care
showed fewer weeks in manic episodes, better social
functioning, and higher quality of life as compared to
treatment as usual (Bauer & McBride, 2003; Simon, Ludman,
Unutzer, & Bauer, 2002). Taken together, the findings provide
strong support for integrated psychological and
pharmacological treatment, and for providing rapid access to
practitioners.

4.7 Problems in Carrying Out Treatment

There are a number of risks to consider in treating BD. In
this section we highlight a few of these: addressing manic
symptoms in session, suicide risk and management, treatment
nonadherence, and co-occurring substance misuse.

4.7.1 Addressing Manic Symptoms in Session

Patients with manic symptoms can present a therapeutic
challenge. The subjectively positive manic symptoms,
including the extreme sense of well-being, euphoria, energy,
productivity, and optimism present unique dilemmas for the
therapist. Hypomania in its milder forma can be associated
with productivity, patient perceptions of increased
creativity (which are often not judged high quality by
others), and surges in confidence, energy, and sexual
interest. Clinicians have long recognized that the pure
euphoria of mania is seductive and that patients often appear
to engage in a number of behaviors that suggest that they are
“addicted to mania.”

This romantic view of mania fails to address the patient’s

experience of dysphoric mania and mixed states in which
symptoms of depression, anxiety, and mania may coexist. In
our experience, these mixed states with significant anxiety,
unpleasant overactivation, and disorganized thinking are all
too common, although patients will tend to be selective in
their recall of the positive effects of mania. Unfortunately,
hypomania and manic states also include loss of judgment and
engaging in high-risk pleasure-seeking behaviors that
ultimately have very painful emotional, financial, and
interpersonal consequences. For the manic patient, the
combination of poor judgment and underestimating the risk and
negative consequences of impulsive actions, combined with a
heightened level of activation, often results in very
negative consequences. The damage done during even a brief
manic episode in terms of burning bridges and causing
financial and interpersonal damage can be absolutely
disastrous.

You may need to adjust your interviewing style with

patients who are present during hypomanic or manic episodes.
If you have already established enough rapport, and the
patient is able to listen to feedback, discussing current
manic symptoms can be a powerful way to help a patient
understand |88| more about these mood changes. We recommend
proceeding with great care, though, as irritability can
develop quickly. Patients in these states are likely to be
irritable, easily angered, distracted, and overactive
(talking too much, over-talking, not listening, etc.). They
may respond poorly to interruptions and directive statements.
A highly collaborative approach is needed, and, ideally, the
therapist helps the patient begin to weigh the evidence that
some changes in mood state might be present. This is fostered
greatly if the patient has already begun to develop their own
self-monitoring tools, as you can jointly review the
monitoring items that they deemed important, using their own
language. Regardless, we find it helpful to focus on the most
objective manic symptoms (e.g., “It sounds like you are
sleeping less” rather than “You seem very happy.”) It is
also critically important to address fear that the patient
may feel about incipient symptoms, as this can over-ride
their ability to listen and consider coping strategies. Any
symptom labeling should be done as a means to an end: the
chief goal is to implement coping strategies. A powerful tool
for helping patients assess the current risk for hypomania is
the use of a “Weighing the Evidence” (Basco & Rush, 2007)
intervention, where the therapist and patient review the
patient’s prior written record of manic or hypomanic
symptoms and try to collaboratively decide about the evidence
for a current mood shift. In Clinical Vignette 12: Helping
Patient Assess Risk of Hypomania, we illustrate a dialoge
with a patient that is intended to help them sort out their
current symptoms and the risk that these are indicative of a
hypomanic epidsode. Chief goals involve promoting calm by
“slowing it down” in the session and avoid overstimulating
the patient. Table 30 provides some suggestions that can be
helpful when attempting to work with patients in manic state.
It is important to use respectful caution when dealing with
individuals who are at the apex of a manic episode. Attempts
to impose constraints of any sort can often lead to violent
outbursts, for which the parties responsible later are often
exceedingly remorseful.

Clinical Vignette 12
Helping Patients Assess Risk of Hypomania
A 32-year-old Asian-American woman comes to group session 4 of a specialty BD
treatment group, indicating that she had only 3 hours of sleep last night.
She denies that she is at risk of becoming manic, despite feedback from other
group members, and in fact insists that this sleep loss is helpful in
combating depression. However, she does agree to participate in an exercise
reviewing the evidence that she might be becoming manic.
Therapist: So you’re telling me that there was such a pressure to do
things that you couldn’t sleep? Is that right? Did I
mishear you?
Patient: Yeah, that’s right.
Therapist: But you’re saying you’re not worried about becoming manic
or hypomanic?
Other Patient: When I lose that much sleep I become irritable and
hypomanic, but I feel like I can write a whole book.
Patient: Yeah, you discover all these talents. By pulling an “all
nighter” last week, I changed my body chemistry.
Therapist: This seems really important. Could we look at the evidence
that this is just a normal mood range for you or something
more?
Patient: Well, I’m a bit irritable. [Evidence of hypomania]
|89| Therapist:Okay, [going to board and writing] could we look at the
evidence for “I’m not hypomanic” versus the evidence for
“I am hypomanic.” Are you willing to work with me here?
Patient: Okay.
Therapist: Let’s look at the evidence that you’re really okay –
you’re not getting into trouble-hypomania.
Patient: I’m a little irritable.
Therapist: That’s probably on the side of hypomania. Right?
Patient: But, I’m not going on shopping sprees.
Therapist: Let’s look at all the evidence that you’re okay. What
else?
Patient: Well, I did go on a shopping spree, but I returned half the
stuff.
Therapist: I’m a little confused. Maybe we should put the shopping
spree on one side [Manic] and the returns on the other [not
manic]? [Laughter from group members]
Patient: I also feel more positive and optimistic. I realize now the
obsessive thoughts I had (when depressed) were unfounded.
Therapist: So all these are pretty much evidence that you’re feeling
better, right? Are these all reflections of your normal mood
state? Is this how you usually feel – optimistic and
positive all the time? So these are signs of normal mood for
you?
Patient: Well, my speech is a bit rapid.
Therapist: So, where is the evidence that you might be getting
hypomanic?
Patient: Irritability is a sign, right?
Therapist: And, I guess, shopping sprees, although you returned half
the stuff and that’s on the “evidence against” side.
Patient: I’m feeling more social too.
Therapist: What else should be on the list? What about you’re sleeping
4 hours a night?
Patient: Yes.
Therapist: So is this a balanced picture? How do you weigh the evidence
at this point?
Patient: Is there anything between normal and hypomania?
Therapist: Sure. Let’s put the question this way: Are you 100% sure
that you are in a normal mood state and there’s no
possibility that you’re getting hypomanic?
Patient: I’m 100% convinced I’m somewhere between normal and
hypomanic.
Table 30 Interview Style With the Hypomanic/Manic Patient

Dos Don’ts
Sit quietly Sit too close
Avoid any rapid movements Sit away from the door
Keep personal space Argue or debate
Use Socratic questioning Challenge or confront the patient
Use a calm tone of voice Blame or shame
Speak slowly Lecture
Use open-ended questions Tell the patient what to do
Engage patient in a collaborative fashion Be the expert on mania
Encourage “sitting and talking”

4.7.2
Suicide Risk Assessment and Management
|90|

As described in Section 1.4., a diagnosis of BD entails

suicide risk, with a quarter of patients reporting that they
have attempted suicide, and rates of death from suicide that
are 20–30 times those observed in the general population.
Major studies are available at this point of hundreds of
patients followed for multiple years (Slama et al., 2004),
and several comprehensive reviews are also available to help
understand risk factors, including one that statistically
examined 34 reports from 50,004 participants with BD
(Schaffer et al., 2015). Across these sources, several
symptom variables have been identified as predictors of
suicide attempts in those with BD I or BD II, including
suicidal thoughts, current depressive severity, early illness
onset, more depressive episodes, more than four
hospitalizations for depression, more mood episodes,
increasing severity of mania over time, history of anti-
depressant induced mania, co-occurring anxiety disorder,
substance or alcohol use disorder, or other co-occurring
psychiatric disorders, and episodes characterized by
agitation, panic, and prominent depressive symptoms during
mania (Leverich, Altshuler, & Frye, 2003; Schaffer et al.,
2015; Slama et al., 2004). Female gender and family history
of suicidal behavior are also a risk factor for attempted
suicide in BD patients (Leverich et al., 2003; Schaffer et
al., 2015; Slama et al., 2004). Several forms of adversity
can also predict suicidal behavior, including recent negative
life events, absence of social support and specifically a
lack of a confidant, and death of a significant other
(Leverich et al., 2003). Early physical or sexual abuse are
consistently tied to greater risk of suicide ideation and
attempts (Daruy-Filho, Brietzke, Lafer, & Grassi-Oliveira,
2011; Leverich et al., 2003).

Treatment can help address these risks. In one study of BD

and major depressive disorder, treatment was associated with
a markedly lower risk for completed suicide (6.4%) compared
to no treatment (29.2%) (Angst, Sellaro, & Angst, 1998).
Persons who receive mood stabilizing medication are also less
likely to die from suicide (Schaffer et al., 2015).
Aggressive treatment, especially emphasizing early
intervention and targeting depressive symptoms is life saving
in BD I and II.
 This section will now address guidelines for assessment of
suicide risk, accepted practices in managing risk, and
specific applications to patients with BD. Suicide risk,
specifically making a severe suicide attempt, is associated
with severe episodes of depression and dysphoric states in BD
I and II rather than manic or hypomanic states (Leverich et
al., 2003). It follows that many of the strategies used to
intervene in major depression to address hopelessness
(dysphoria and demoralization) will also be effective in
addressing suicide risk in the bipolar population.

Assessment of Risk Factors for Suicide

Our discussion of suicide risk is based on Practice
Guidelines for the Treatment of Psychiatric Disorders (APA,
2004), which can be viewed as a consensus document of best
practices. In addressing acute immediate suicide risk, the
clinician will have a two-fold task:

1. Identify specific factors/features that increase or

decrease risk of suicide and that are subject to
psychological/psychiatric interventions.
2. |91| Address the patient’s immediate safety and
determine the most appropriate interventions/treatment
settings.

Your most immediate task will be to assess the presence of

suicidal or self-harming thoughts, plans, behaviors, and
intent. This assessment will need to include a specific
consideration of methods that the patient is considering,
including the lethality of the method, expectations about
lethality, and the degree to which the chosen means is
immediately accessible. The interview should also explore the
frequency, intensity, timing, and persistence of suicidal
ideation. If current suicidal ideation is present, you should
explore in detail the presence of a specific plan for
suicide, including any steps taken to enact plans or prepare
for death. It would be wise to consider incidents of self-
harm, which are more common across disorders than previously
thought, and are particularly common in younger cohorts.

If the patient reports a specific method, it is important

to find out more about his or her understanding of the
lethality of the method, which may or may not be accurate –
inaccuracies can sometimes lead to accidental suicide.
Assessment of lethality will depend on how detailed and
specific the patient’s suicide plan is, to what extent an
especially violent and irreversible method is preferred, and
finally the strength of the patient’s intent to die. When
interviewing after a suicide attempt, it is important to ask
the patient if she or he is relieved or disappointed that the
attempt failed and if any significant predisposing
circumstances have changed since the attempt. Patients who
signal that they are disappointed should be viewed as at high
immediate risk of a second attempt.

The presence of hopelessness, impulsiveness, anhedonia,

panic attacks, or anxiety in conjunction with suicidal or
self-harming thoughts increases the risk of suicide. While
standardized assessment measures cannot substitute for an in-
person assessment, several assessment measures – including
the Index of Depressive Symptomatology (IDS), the Hamilton
Depression Rating Scale (HDRS), and the Beck Depression
Inventory (BDI-II) – have items that specifically assess for
suicidality and hopelessness. An additional measure, the Beck
Hopelessness Scale, a 20-question self-report inventory,
assesses the patient’s hopelessness and negative beliefs
about the future, both risk factors for suicide (Beck,
Weissman, Lester, & Trexler, 1974).

You will also want to carefully assess the following areas:

history of co-occurring psychiatric disorders, including
substance abuse, history of suicidal behaviors, early family
history (especially presence of physical or sexual abuse),
specific family history of suicidal behavior, current or
immediate psychosocial stressors, psychosocial supports, and
coping skills and assets. For patients with BD, the illness
itself is likely to contribute to the presence of a number of
psychosocial stressors, including interpersonal losses,
financial difficulties, family conflict, and employment-
related problems. You will want to assess for individual
strengths and assets such as: the presence of good coping
skills that might be adaptive in dealing with stress,
engagement in treatment, medication adherence, the presence
of a good therapeutic relationship, and the ability to
tolerate psychological pain and distress. These should be
considered alongside the risk factors we described above.

|92| Management of Suicide Risk

Patients with suicidal thoughts, plans, or behaviors should
be treated in the least restrictive setting that is safe and
effective. To do so, you should consider a broad range of
interventions that might be instituted for patients with
suicidal thoughts, plans, or behaviors. The range of possible
treatment options includes changing frequency and intensity
of sessions; involving immediate family members or
significant others; providing scheduled telephone follow-ups
to monitor the patient between sessions, consulting with
colleagues (highly recommended); referring patient for
immediate psychiatric assessment; consulting with other
mental health care providers; or recommending a more
restrictive setting, such as partial hospital, intensive
outpatient, residential, or inpatient treatment; and/or
instituting an immediate involuntary hospitalization. The APA
Guidelines suggest that hospital admission after a suicide
attempt is generally indicated if the patient is psychotic,
has had a significant change in mental status, has persistent
suicidal ideation, is distressed or regrets surviving, is
impulsive, severely agitated, demonstrates poor judgment; or
if the attempt was violent, near lethal, or premeditated and
the patient has limited psychosocial supports.

Good risk management strategies when working with suicidal

patients including the following (Bongar, Berman, Maris,
Harris, & Packman, 1998; APA, 2004):

Document suicide assessment and all aspects of

consultation and communication in detail.
Make every effort to identify factors that would
indicate an elevated risk of suicide.
Make every effort to reduce or eliminate this risk.
Routinely consider a second opinion.
Remove access to weapons.
 Consult with other mental health professionals.

More specific to BD, the following points are important to

consider. Given the large-scale findings that mood
stabilizers are related to lower suicide risk,
pharmacological treatment is a first step in addressing
suicidality. Psychological treatments geared toward reducing
depression are also extremely important. Providing such care
may require more frequent sessions and monitoring. We also
highly recommend problem-solving psychotherapy (Rudd, Joiner,
& Rajab, 2000), for helping the patient learn skills for
tackling the triggers to their suicidal thoughts. In
addition, the work of Stanley and Brown (2012) on developing
safety plans for suicidal patients provides an important
resource for clinicians. A systematic review of cognitive
behavioral interventions with suicidal patients supports the
efficacy of CBT in general for reducing suicide risk
(Tarrier, Taylor, & Gooding, 2008).

4.7.3 Improving Treatment Adherence

Nonadherence with prescribed medication is a significant
problem for patients with BD, according to a number of
estimates running as high as 40–50%. Although practitioners
are often frustrated by the nonadherence, it is worth noting
that similar estimates of nonadherence are observed in
chronic medical conditions in which symptoms are quiescent
for long periods, such as cardio |93| vascular disease.
Nonadherence in BD, though, poses significant risks,
including an increased risk of suicide, hospitalization, and
the potentially devastating social and financial consequences
associated with an acute manic or depressed episode. Several
strategies have emerged that appear to be particularly useful
in increasing medication adherence in this population. While
the causes of nonadherence are complex and multifaceted, a
collaborative treatment partnership in which the patient
feels empowered to actively discuss treatment options and
side effects will enhance treatment adherence. Conversely, an
authoritarian “Doctor knows best” approach is likely to
undermine adherence.

Effective interventions may use a number of strategies to

optimize adherence, including psychoeducation, basic skills
for enhancing memory, use of thought records to target
unhelpful or dysfunctional assumptions about medication, and
a motivational interviewing approach to help patients
evaluate the costs and benefits of medication and treatment
options. Given the diversity of available approaches, we
recommend following a hierarchy of problem-solving
strategies, starting with the most simple, pragmatic
solutions. We have illustrated some basic principles of a
collaborative problem solving approach in Clinical Vignette
13: Behavioral Tailoring for Medication Adherence. Research
supports the value of assisting the patient in developing
specific, concrete strategies to improve medication adherence
(Mueser et al., 2002). Meichenbaum and Turk (1987, p. 140).
Tables 31 and 32 review interventions designed to help the
patient remember to take their medication.

Clinical Vignette 13
Behavioral Tailoring for Medication Adherence
Therapist: Are there any other problems that we want to make sure we
address?
Patient: Yes. One consistent problem for me has been keeping up with
actually taking my medication. When I’m at home I’m fine,
but then back at school I stop taking it after about a
month. I don’t know why.
Therapist: Do you say to yourself that I’m going to stop, or do you
just find yourself not remembering?
Patient: I forget OK. I can’t figure out what’s going on
Therapist: And what’s the difference between home and school in terms
of taking your medication?
Patient: I guess I kind of planted in my head the idea that if Mom
asks me I need to say “Yes.”
Therapist: Do you depend on reminders from other people?
Patient: I guess it’s a kind of mental trick that I had better take
it in case Mom asks – she knows I have had trouble at
school.
Therapist: So, when no one asks you, that’s when you run into trouble?
Patient: Yes. I really don’t have any idea why or how that ends up
happening, it just happens.
Therapist: So you don’t seem to be doing on purpose, you just seem to
lapse suddenly.
Patient: Yes, suddenly I’ve been off my medications weeks and
feeling horribly depressed and not attending classes. I’m a
wreck.
Therapist: So its sounds important that this not happen again. It seems
like when you’re at home you have a cueing system that
eventually comes in and says, “Oh, by the way, did you take
your medicine?” and you’re using that to cue yourself –
problem is you don’t have that same cueing system in
college.
|94| Patient: What I could do is use a calendar and make a specific mark
each day signifying I took the pills.
Therapist: Ok, so you could mark your calendar. That’s a good
suggestion because when you check your calendar you’ll know
where you stand, particularly if you’re checking your
calendar all the time anyway for other things you’ve
 scheduled. Maybe we could assign this as homework over the
next week for you to keep a daily calendar on medication. I
think I warned you I might give homework.
Patient: Well, it’s my idea anyway – so this assignment is my
fault!
Therapist: So you accept responsibility for this one, since you
developed yourself.

Table 31 Behavioral Tailoring (Based on Meichenbaum & Turk, 1987)

Involve family members when appropriate

Alarms, small pocket timers, or use of PDAs with alarm
Drug reminder charts
Yellow “Post-Its” on the medicine cabinet or refrigerator
Special calendars (available from the Depression and Bipolar Support Alliance)
Medication boxes – separated by day and by time of dose
Special pill boxes with time alarm reminders
Medication strategically placed and coordinated with daily routine (e.g.,
bathroom sink, breakfast table)
Call patient to remind

Following the principle to proceed hierarchically to more

complex solutions, a next goal might be to assess whether
medication side effects are intolerable for patients. If so,
it may be helpful for them to learn that some medications can
be given at different times of day (e.g., at night, so that
sedating effects are less strong), at different doses, or be
replaced with parallel medications in the same class that
might have a different side effect profile. Careful
discussion, and even role plays, can help prepare them to
discuss these concerns with doctors in a constructive manner.
If these more behavioral approaches do not work, we recommend
considering whether the patient holds unhelpful beliefs about
medication and her or his illness that are compromising
adherence, covered below.
 In our experience it is rarely useful to become directive,
confrontational, or irritated with patients who have
adherence problems. As an alternative to more directive
approaches, motivational interviewing (MI) provides a
noncoercive strategy that supports the patient’s concerns
and issues. The goal of MI is to avoid the trap of becoming
directive and attempting to get patients to “comply” (e.g.,
give in), thereby damaging the therapeutic alliance and
increasing conflict. MI attempts to engage the patient in a
self-directed discussion of the pros and cons of medication
adherence, with a focus on helping the patient to recognize
how nonadherence is ultimately inconsistent with other
specified goals and values and may have negative consequences
that they do not wish to experience.

Table 32 summarizes key points from Meichenbaum and Turk

(1987) associated with beliefs regarding illness and
medication that may compromise adherence. Many patients
describe a desire to avoid reminders of the illness.
|95| Coupled with the high levels of stigma experienced by
those with BD, it should not be surprising that many patients
struggle with strong feelings about medications. Addressing
the patient’s unhelpful beliefs about medication and
stigmatizing beliefs about their illness directly can be done
through an “Unhelpful Thought Record.” Problems with
medication adherence are often tied up with stigmatizing and
unhelpful thoughts about the meaning of having a chronic
illness and taking a psychiatric medication. It is useful to
use an analogy of patients with diabetes who are faced with
managing a long-term illness through a variety of strategies,
including changes in behavior (eating and exercise), careful
monitoring of blood sugar levels, and consistent use of
medication to manage their illness. Patients can be asked
directly what thoughts they had before making a decision to
stop taking their medication. In some cases, patients will
indicate that they no longer “feel ill” and believe that
the medication is no longer required. One of our patients
reported that, “I knew I wasn’t ill any longer when my
thoughts became clearer and so I stopped taking my
medication.” In this case, the sense experienced by the
patient of clarity in their thinking was actually associated
with a hypomanic episode. The therapist developed a strategy
in which this sense of new clarity was actually interpreted
as a warning sign, indicating that it was time for the
patient to monitor closely and take action in terms of
instituting a coping plan. Often patients will articulate a
number of catastrophic beliefs about BD which results in
feelings of pessimism and hopelessness. Patients may hear
negative feedback from others that describe medications as
addictive, and they may fear addictive potential. This can be
addressed by explaining that addiction is usually considered
when substances elevate a person’s mood; the medications
prescribed for mood disorders, in contrast, tend to focus on
producing a more level mood. Patients can also experience
“dependence” on medication as threatening to their sense of
autonomy. This can be reframed as “taking control over the
illness” by managing their health proactively.

Table 32 Reasons for Nonadherence (Based on Meichenbaum & Turk, 1987)

Uncertainty about the effectiveness of treatment

Expectations about the course of illness
Experiences in treatment
 Concerns about side effects
Belief that costs outweigh potential benefits
Stigma associated with medication
Sense of hopelessness or fatalism
Conflicts with cultural or family belief systems

4.7.4 Treatment of Co-Occurring Substance Use

Disorders
As described above, more than 40% of patients with BD present
with a history of alcohol or substance use disorders.
Patients may use substances in an attempt to either
counteract specific symptoms of depression (e.g., insomnia,
depressed mood, lethargy) and hypomania/mania (agitation,
anxiety) or to pro |96| long hypomanic episodes. Because the
use of substances significantly impacts the course of the
illness, as well as medication and treatment adherence,
optimal treatment of the co-occurring disorder requires
concurrent treatment of both disorders. We recommend using
the motivational interviewing approach first developed by
Miller and Rollnick (2002) to assist patients in evaluating
the impact of their substance use. This approach places
emphasis on understanding benefits patients may perceive in
the use of substances, such as coping with stress, attempting
to avoid negative affect, escape from interpersonal
conflicts, reduce hyperactivation, or promote sleep. Equally
important, the therapist should understand the patient’s own
personal reasons for minimizing substance use. Recent work
suggests that motivational interviewing approaches like these
may be insufficient in BD (Jones, 2015); patients may need to
learn specific skills for reducing consumption of substances.
Depending on the severity of substance-related problems,
patients may need to receive treatment focused on substances
before it will be feasible to implement mood-focused skills.

4.8 Summary
Clinicians working with patients with BD are likely to
confront a number of clinical challenges, including suicide
risk, problems with treatment adherence, and co-occurring
substance use disorders. We have outlined strategies that
target each of these problems. To be successful, clinicians
need to be willing to be flexible in their treatment approach
and to incorporate specialized interventions into evidence-
based treatment.
 5
Further Reading
|97|

Basco, M. R., & Rush, A. J. (2007). Cognitive-behavioral

therapy for bipolar disorder. New York, NY: Guilford.

The earliest comprehensive psychosocial treatment manual

for bipolar disorder with many specific and useful tools.

Bauer, M., & McBride, L. (2003). Structured group therapy for

bipolar disorder: The life goals program. New York, NY:
Springer.

An-indepth group-based approach.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).

Cognitive therapy of depression. New York, NY: Guilford.

An excellent reference for basic techniques of cognitive-

behavior therapy.

Beck, J. (1995). Cognitive therapy: Basics and beyond. New

York, NY: Guilford.

An excellent reference for basic techniques of CBT.

Goodwin, F. K., & Jamison, K. R. (2007). Manic-depressive

illness. New York, NY: Oxford University Press.

An encyclopedic textbook addressing many aspects of BD.

Lam, D. H., Jones, S. H., Hayward, P., & Bright, J. A.
(2010). Cognitive therapy for bipolar disorder: A
therapist’s guide to concepts, methods and practice . New
York, NY: John Wiley. Crossref

The first CBT manual for BD to comprehensively address

prodromal symptoms.

Miklowitz, D. J. (2008). Bipolar disorder: A family-focused

approach. New York, NY: Guilford.

This comprehensive treatment manual covers the most well-

tested family-based approach with bipolar disorder.

Miklowitz, D. J. (2011). The bipolar disorder survival guide:

What you and your family need to know. New York, NY:
Guilford.

An excellent resource, clearly written for clients with BD

and family members. Includes valuable coping tools and
other resources.

Newman, C. F., Leahy, R. L., Beck, A. T., Reilly-Harrington,

N. A., & Gyulai, L. (2002). Bipolar disorder: A cognitive
therapy approach. Washington, DC: American Psychological
Association.

An excellent summary of cognitive strategies with BD.

Persons, J., Davidson, J., & Tompkins, M. A. (2001).

Essential components of cognitive behavioral therapy for
depression. Washington, DC: American Psychological
Association. Crossref
 An excellent teaching manual and reference for basic
techniques of CBT.

Scott, J. (2001). Overcoming mood swings: A self-help guide

to using cognitive behavioral techniques. New York, NY: New
York University Press.

An excellent self-help guide incorporating key cognitive

behavioral strategies for BD.
 6
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 7
Appendix: Tools and Resources
|109|

Appendix 1: Treatment Agreement

Appendix 2: Checklist for Session Agenda

Appendix 3: Activity Schedule

Appendix 4: Activity Log – Daily List of Healthy Behaviors

Appendix 5: Mood Chart Adapted From Basco and Rush (1996)

Appendix 6: Identifying Signs of Depression or Mania

Appendix 7: Identifying Early, Middle, and Late Signs of

Depression or Mania

Appendix 8: “Unhelpful Thought Record” – Weighing the

Evidence

Appendix 9: Coping and Wellness Plan

Appendix 10: Self-Help Resources

To complement material presented in this book a printable PDF

file of the appendices is available for download onto your
computer here.

The content may be used by purchasers of this book for

personal/professional use but not for any commercial use.
|110| Treatment Agreement
|111|
|112| Checklist for Session Agenda
|113| Activity Schedule
 Activity Log – Daily List of Healthy
Behaviors
|114|
 Mood Chart Adapted From Basco and Rush
(2007)
|115|
 Identifying Signs of Depression or
Mania
|116|
 Identifying Early, Middle, and Late
Signs of Depression or Mania
|117|
 “Unhelpful Thought Record” –
Weighing the Evidence
|118|

|119| Coping and Wellness Plan

|120| Self-Help Resources
Books
Amador, X. (2000). I am not sick, I do need help! A practical
guide for families and therapists. Peconic, NY: Vida Press.
Basco, M. R. (2015). The bipolar workbook: Tools for
controlling your mood swings. New York, NY: Guilford Press.
Berk, L., & Berk, M. (2008). Living with bipolar: A guide to
understanding and managing the disorder. Crows Nest, NSW,
Australia: Allen & Unwin.

Burns, D. D. (1999). Feeling good. New York, NY: Avon Books.

Caponigro, J. M., Lee, E. H., Kring, A., & Johnson, S. L.
(2012). Bipolar disorder: A guide for the newly diagnosed
.
Oakland, CA: New Harbinger.

Copeland, M. E. (1994). Living without depression and manic-

depression. Oakland, CA: New Harbinger.

Fuller Torrey, E., & Knable, M. (2002). Surviving manic

depression. New York, NY: Basic Books.

Granet, R., & Ferber, E. (1999). Why am I up, why am I down.

New York, NY: Dell.

Greenberger, D., & Padesky, C. (2015). Mind over mood (2nd

ed.). New York, NY: Guilford Press.

Jamison, K. (1995). An unquiet mind. New York, NY: Alfred A.

Knopf.
McMurrich Roberts, S., Sylvia, L. G., & Reilly-Harrington, N.
A. (2013). The bipolar II disorder workbook: Managing recurring
depression, hypomania, and anxiety. Oakland, CA: New Harbinger
Press.

Miklowitz, D. (2011). The bipolar disorder survival guide: What

you and your family need to know (2nd ed.). NY: Guilford Press.
Otto, M. Reilly-Harring, N., Knauz, R. O., Henin, Au., Kogan,J.
N., & Sachs, G. S. (2008). Living with bipolar disorder: A
guide for individuals and families. NY, NY: Oxford Press.

Scott, J. (2001). Overcoming mood swings: A self-help guide

using cognitive behavioral techniques. New York, NY: New York
University Press.

Websites
http://www.dbsalliance.org/: Website for the Depressive and
Bipolar Support Alliance (DBSA)

http://www.nami.org/: Website for National Alliance for the

Mentally Ill

http://www.stepbd.org/: Website for the Systematic Treatment

Enhancement Program for Bipolar Disorder

http://www.nimh.nih.gov/health/topics/bipolar-
disorder/index.shtml: Website for National Institutes of
Health

http://www.bipolarnews.org/: Website with information on life

charting and bipolar disorder research
http://www.nlm.nih.gov/medlineplus/bipolardisorder.html.
National Library of Medicine – Medline research database on
bipolar disorder

http://www.bpkids.org/: The Child and Adolescent Bipolar

Foundation

http://www.bpso.org/: Bipolar Significant Others

http://www.bipolarcaregivers.org/: Information for caregivers

Self-Help Organizations With Local Chapters

Depressive and Bipolar Support Alliance: A national support
group that promotes education, research related to bipolar
disorder, and sponsors local client run chapters and support
groups

National Alliance for the Mentally Ill: A national support

group that promotes education, research related to serious
mental disorders, including bipolar disorder, and sponsors
local chapters and support groups