More than Medication—Achieving Psychotherapy Goals in Patients with Bipolar Disorder in Challenging Settings

Introduction

Although the use of medications is crucial to the effective management of bipolar disorder, there is increasing evidence that other modalities reduce relapse but often are neglected in the outpatient management of the patient with bipolar disorder.^1–4 For example, both psychoeducation and cognitive-behavioral therapy (CBT) were found to be effective in a literature review of available evidence on reducing relapse rates, and there was some evidence supporting interpersonal rhythms therapy and family-focused therapy.^1,2 Individuals with bipolar disorder have syndromal or subsyndromal symptoms of depression 40 to 50 percent of the time.³ A cognitive-behavioral psychotherapeutic approach was used in a recent prospective study done in London, England. One hundred and three people with bipolar disorder type I were followed for a 30-month period. They were divided into two groups: cognitive therapy and general supportive case management. Service utilization and total costs were measured at three-month intervals. The group receiving cognitive therapy had significantly better clinical outcomes in terms of reduction of overall service need and overall cost to the system. In another study, the efficacy of several adjunctive psychotherapies for the maintenance treatment of bipolar disorder was reviewed. Psychoeducation was found to be very helpful to enhance adherence and for early identification of prodromal signs.⁴

Despite studies showing that various modalities of psychotherapy significantly reduce relapse rates, treatment is often solely medication management. This may be due to the perceptions that psychotherapy can do little for the seriously mentally ill patient, the focus on psychopharmacology for control of each symptom (even if it means significant polypharmacy with troublesome side effects), and the constraints of reimbursement systems focused solely on somatic treatments with little time and continuity allotted for psychotherapy by psychiatrists.

The case we describe in this article illustrates the challenges of managing a recently diagnosed college graduate student with bipolar disorder. The patient showed improvement once she was better able to recognize early symptoms and allow her family to assist in treatment without her feeling controlled. Not uncommonly, this disorder strikes people in their young adult years—often in college as with this woman. Although members of this college-aged patient population are adults, often their families still are very much involved in their lives both financially and emotionally. This involvement often creates expectations of the treatment by the parents or guardians who, not so long ago, were the decision-makers for the healthcare of their children.

Case Presentation

Ellen, a 24-year-old woman, presented to a college student mental health service for psychiatric consultation. Two years previously, she had been diagnosed with bipolar disorder while an undergraduate student at a different institution.

Ellen described herself during her teenage years as “moody” and suffered an episode of depression at the age of 16 following the breakup of a relationship. She sought psychotherapy, which she found helpful.

While in college, Ellen had another significant episode of depression during which she was hospitalized following a suicide attempt. She was started on sertraline, and the depression was managed for several months, although in retrospect, Ellen felt that she “still wasn't right.” Nonetheless, during this period, she was pleased with her increase in energy and productivity in her school work. During this time, her psychiatrist noted an increased rate of speech, and although the psychiatrist had always felt that Ellen was somewhat histrionic, the psychiatrist was troubled by Ellen's mood lability and easy tearfulness. Ellen also began drinking more and found herself seeking short-term sexual relationships more so than ever, which Ellen attributed to “just enjoying college.” At this point, the psychiatrist diagnosed Ellen with bipolar disorder. With concern about symptoms of hypomania, the psychiatrist convinced Ellen to try a mood stabilizer, valproic acid; however, within a few weeks, Ellen stopped taking it due to weight gain.

Practice Point: Medication Use for Woman of Child-Bearing Age

Treating women during their child-bearing years poses particular challenges to the psychiatrist, especially in women diagnosed with bipolar disorder. For years, there has been an association with lithium used in the first trimester of pregnancy and the development of Epstein's anomaly. Currently, this risk is felt to be less than one percent.⁵ With the use of anticonvulsants in the last decade for the treatment of bipolar disorder, valproic acid is widely used in men and women for control of the symptoms of bipolar disorder. However, from a practical standpoint, valproic acid probably should not be used by women during their child-bearing years due to the risk of major congenital abnormalities, especially neural tube defects. Figures for major congenital abnormalities range from 5 to 30 percent with high-dose valproic acid (above 1100mg/day).^6,7 Additionally, 21 percent of the children whose mothers who took valproic acid during pregnancy had minor neurological dysfunctions.⁸ No other mood stabilizing medication carries such substantial risk; therefore, with several alternatives, valproic acid should be reserved for those women who do not respond or partially respond to other treatment regimens.

Carbamazepine has been found to carry a one-percent risk of neural tube defects and higher risks for craniofacial defects, fingernail hypoplasia, and developmental delay.⁹

To date, no associated risks to the developing fetus have been described in women who used lamotrigine, topiramate, and gabapentin during pregnancy.¹⁰ The atypical antipsychotic olanzapine showed no increased teratogenic risk in a small sampling of women.¹¹

To complicate psychopharmacological treatment for women of child-bearing age even further, one needs to be cautious with the concomitant use of oral contraceptives, as carbamazepine and topiramate reduce levels of oral contraceptives due to induction of the cytochrome p450 system.¹² Additionally, oral contraceptives reduce the lamotrigine plasmas levels, so dosage adjustments must be made.¹³ In summary, extreme caution must be used in treating women of child-bearing age, with regular discussions of family planning and contraception, and when possible, medications other than valproic acid should be utilized as the first options.

Case Presentation—Symptoms Continue

After Ellen was hospitalized again for another suicide attempt, which followed a “high” time in her life, Ellen and her parents accepted the diagnosis of bipolar disorder. Ellen started taking another mood stabilizer, lamotrigine, which offered improvement in her mood lability. However, depressive symptoms continued to be problematic. She managed, however, to graduate from college and was accepted into graduate school in another state.

The transition to another university proved extremely difficult for Ellen, which prompted her to visit the psychiatric consultant at student mental health services. Her symptoms included initial insomnia with frequent awakenings, significant dysphoria, mood lability with tearfulness, mildly pressured speech, and thoughts of death, although she denied suicidal ideation or intent. Prior treatments with the addition of a SSRI further destabilized her mood, according to records from the previous psychiatrist. Thus the new psychiatrist initiated regular psychotherapy sessions with Ellen to address the depressive symptoms, after adding a hypnotic medication for sleep.

Practice Point—Combined Use of Psychotherapy and Pharmacotherapy for Management of Bipolar Disorder

Recent studies support a combination of psychotherapy and pharmacotherapy as being superior to pharmacotherapy alone when measuring clinical outcome and cost-effectiveness for patients with frequent relapses of bipolar disorder.^3,14 Evidence supports the following four approaches for psychotherapeutically supporting the bipolar patient:

Identify signs of relapse and make plans for early detection and response. Kupfer, et al.,¹⁴ compared interpersonal and social rhythm therapy to intensive case management in 175 acutely ill persons with bipolar disorder type I. They found the relapse rate for bipolar patients who did not receive psychotherapeutic support was 50 percent and the relapse rate for patients who met regularly with a psychotherapist was 20 percent.

Use education to increase agreement between doctor, patient, and family about what is being treated and why. Colom and Lam⁴ compared 21 sessions of education (education group) to 21 sessions of nonstructured meetings (control group). They found that the education group had about one-third the number of hospitalizations as the control group during that time period.

Encourage the patient to work on stress management, problem-solving, and improving relationships. When treating the patient with bipolar disorder, the clinician should monitor the exposure to expressed emotion in the environment.¹⁵ Patients who themselves are manifesting high expressed emotion and optimisim (i.e., hypomanic or manic) have been shown to benefit less from cognitive therapy.¹⁶

Emphasize to the patient the need to stay on medication even when feeling good. Havens and Ghaemi¹⁷ have discussed the challenge of doing psychotherapy with manic patients. As they point out, “manic patients are hopeful but their hopes and dreams are usually brief and soon damaged by the realities of life.” They recommend that the therapist try to existentially “be with” the manic patient, but then counterprojectively give perspective to the patient about the manic worldview, without completely denying it. When holding therapy sessions with patients who are stable from a mood standpoint, the clinician should review the symptoms and behaviors of mania and depression that have been problematic in the past for the patient, emphasizing that medical adherence will help reduce the likelihood of concerning symptoms in the future.

Encourage the patient to establish regular daily rhythms for sleep, exercise, and eating activities. Russel and Browne¹⁸ promote strategies to “stay well with bipolar disorder” that include not only acceptance of the diagnosis and education about bipolar disorder, but also an awareness of themselves and how stress and their environment affect wellbeing. They encourage patients to identify early warning signs, manage sleep with regular patterns, eat healthy foods, exercise regularly, limit caffeine and alcohol, and establish a healthy support system.

Case Presentation—Identifying Triggers and Management of Symptoms

With her unhappy transition to a new campus, Ellen found that she was engaging in less “partying behaviors of drinking and hooking up for sex.” To her surprise, she realized that the weekends were more tolerable when she attempted to go to bed at a regular time. This set the stage for discussion about regular sleep patterns and exercise. The eating habits proved more challenging, as Ellen was overly concerned about any weight gain. She was slender, but not underweight, and did not have signs or symptoms of bulimia or anorexia. Ellen described herself as a “picky vegetarian,” and if foods were not available that she enjoyed, she preferred to skip a meal. Reluctantly, Ellen agreed to make more of an effort to eat regular meals that included protein.

Although still unhappy with the university atmosphere, including her lack of friends at the new campus and ambivalence about continuing graduate school, Ellen did not deteriorate any further while participating in twice-weekly sessions over the next three weeks, as one might have previously expected given her history. Ellen was comforted in knowing that she could call the new psychiatrist on the phone, if necessary, and she felt that she had developed a stronger therapeutic alliance with the new psychiatrist than with her previous psychiatrists. She did not call her psychiatrist more than twice a week during her major struggles, which primarily revolved around stress created by her graduate course work. Generally, during these calls, Ellen calmed down within a few minutes of talking with the psychiatrist.

Key Point—Access to the Psychiatrist

It is important for the patient with bipolar disorder to understand that he or she is not required to overcome severe symptoms of depression or pretend to be well before receiving treatment. This understanding allows the patient to build trust in the psychiatrist, which is different than “boundary” or “limit-setting” issues. An example of this is when one of the author's patients drove herself to the mental health clinic for a session but found she could not get out of the car. The psychiatrist walked out to the parking lot and held a therapy session with her there in the patient's car. The patient later told the psychiatrist that this was a turning point in her therapy and in her trust of the psychiatrist.

Case Presentation—Continued Indentification of Triggers

As mid-terms approached, Ellen feared that she may fail the semester, and she feared telling her parents this. Ellen described her mother as a perfectionist who “would never allow me to quit school.” She felt her mother always “pushed her to do well” and was very critical of Ellen, and Ellen often perceived herself as “failing in mother's eyes.” Ellen had a closer relationship with her father, although she criticized him for “not standing up to my mother.” Ellen's ambivalence toward continuing graduate school greatly increased, but she felt that to drop out was not only a “waste of money” but would create unbearable tension between herself and her mother. Ellen's depression worsened, and Ellen's daily phone calls home to her father worried him. Ellen's father contacted the psychiatrist, and with written permission, the psychiatrist consulted with the father. On one occasion, the psychiatrist held a joint session with Ellen's father and Ellen. With the supportive atmosphere of the therapy session, Ellen shared with her father her desire to quit graduate school, which he accepted. The conversation about the mother's anticipated response was more difficult, as Ellen's father clearly wanted his daughter to share that news with her without him being present, knowing that his wife would not be pleased.

Key Point—Monitor Presence of Expressed Emotion

There is evidence that a patient with bipolar disorder who receives a higher frequency of critical comments from relatives has greater frequencies of manic and depressive episodes.¹⁶ This issue can be addressed in psychotherapy through a discussion of how to set appropriate boundaries. It is also helpful to talk about the concept of expressed emotion with the patient, so that he or she can gain greater insight into some of the interpersonal dynamics in the environment.

Case Presentation—Conference Call to Ellen's Mother

Following the joint therapy session, Ellen talked to her professors, and although she managed to get through the mid-term exams without failing, she realized that continuing graduate school at this time was simply not in her best interest. Before returning home, Ellen's father genuinely offered his support to his daughter by helping her to explore options other than graduate school. With the father and Ellen both present, a conference call from the psychiatrist's office was made to Ellen's mother. The psychiatrist took the lead in recommending that the stresses of graduate school were contributing to mood lability and depression in Ellen, and that pressures from the family to continue in school would likely lead to another hospitalization. Over the course of the hour, Ellen's mother realized that Ellen's decision to quit graduate school was not based on impulsivity, but rather was based on a decision that Ellen had discussed extensively with others after carefully weighing the pros and cons. Thus, reluctantly, Ellen's mother supported her daughter's decision to discontinue school at this time.

Key Point—Patients Should Be Discouraged from Acting on Feelings During Times of Significant Symptoms

The clinician should discuss with the patient the concept of suspending acting on feelings during times of significant symptoms, because symptoms can distort logical thinking. An example of this is when another patient of the author's was ready to end a 10-year relationship with his girlfriend because she “didn't love him anymore.” The psychiatrist encouraged him to postpone this action until his symptoms were more stable. Once he was more stable, couples counseling revealed that she loved him very much, but was fearful of talking with him at times because she was concerned that it would cause him to become more upset. He interpreted this quietness as a lack of involvement on her part.

Case Presentation—External System Challenges

Prior to leaving graduate school, Ellen asked the psychiatrist if follow-up phone calls would be possible as she shifted care to another psychiatrist in her home area. During one of these follow-up phone calls a month later, Ellen stated she was doing well; however, since she was no longer in school, she was not covered by her father's insurance. Without a job at the time, she was having a difficult time paying for her medications and she was finding it a challenge to find a psychiatrist who would accept a lower fee. Her psychiatrist from graduate school recommended that Ellen contact the pharmaceutical assistance program and the local community mental health center, assuring Ellen that during the transition, she would continue to be available if necessary.

Practice Point—Treatment Costs May Affect Patient Adherence

Medications for bipolar disorder are costly, which may affect patient adherence. The psychiatrist needs to anticipate this problem and be active in accessing help to obtain entitlements for patients when needed. Some patients may try to “stretch” their medicines between appointments by taking lower doses than prescribed or try to taper themselves off medication because they know they can no longer afford to purchase it. The clinician should investigate programs available through pharmaceutical companies, the use of sample medication, and funds that may be available through the mental health department (state or county). The National Alliance on Mental Illness (NAMI) is another helpful resource.