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Evidence Based Psychotherapies for Adolescent Bipolar Disorder

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Bipolar Disorder

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Bipolar disorder is characterized by cycles of either manic episodes alone or manic/hypomanic episodes and depressive episodes.[1] Episodes of mania typically display feelings of high motivation, unrealistic achievement and extreme happiness, whereas depressive episodes typically display feelings of sadness, irritability, and changes in sleep and eating patterns.[2]

Psychotherapy

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Psychotherapies are treatments that help people with a wide variety of mental health concerns. While different forms of psychotherapies for adolescent bipolar disorder aim to remedy different aspects of the disorder, all aim to alleviate symptoms and decrease functional impairment in the client.

Overview of Psychotherapies
Therapy Key components Duration Results
Child- and Family-Focused Cognitive-Behavioral Therapy
  • Develop consistent routines
  • Learn to regulate emotions
  • Improve child's self-esteem and parent's self efficacy
  • Reduce negativity
  • Build social skills and networks
  • Teach parents self-care
  • Family-based problem solving and communication skill building
  • 12 weeks long
  • 60-90 minute weekly sessions
  • Decrease intensity of manic episodes
  • Decrease depressive symptoms in child
  • Overall improvement in client's functioning
Interpersonal and Social Rhythm Therapy
  • Develop understanding of disruptions in routine and manic/depressive episodes
  • Build skills for creating consistent routines, aka, social rhythms
  • Build self-efficacy and phase out of therapy
 Varies dependent on client need
  • Increases time between manic/depressive episodes
Mindfulness-Based Cognitive Therapy
  • Utilizes mindfulness-based practices such as mindfulness meditation
  • Focus on awareness of client's thoughts, feelings and behaviors
  • Learn to recognize how to monitor one's own thoughts
  • Increase self-care practices
  • 8 weeks long
  • 60-120 minute weekly sessions
  • Decrease in anxiety symptoms
  • Decrease in depressive symptoms
  • Increase mood regulation
  • Increase attention ability
Multi-Family Psychoeducational Psychotherapy Group therapy using treatment components from:
  • Psychoeducation
  • Family Systems therapy
  • Cognitive-behavioral therapy
  • 8 weeks long
  • 60-90 minute weekly sessions
  • Decrease in severity of mood symptoms
  • Increase in caregiver understanding of child's disorder and how to seek mental health care
  • Children report feeling more social support from caregivers

Child- and Family-Focused Cognitive-Behavioral Family (CFF-CBT)

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Purpose

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Cognitive behavioral cycle

CFF-CBT was created to address the unique needs of bipolar disorder in children and adolescents with bipolar disorder, including rapid cycling, mixed mood states and comorbid disorders.[3] This treatment has been tested to see if it will help address the high suicide attempt rate among children/adolescents with the disorder, and no significant effects were found. However CFF-CBT has been found to be effective for 7-13 year olds with both clients with and without non-suicidal self-injury behaviors.[4] Mediators of this intervention include: parenting skills and coping, family flexibility, and family positive reframing.[5]

Intended Population

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Children aged 7-13 and adolescents aged 13-17

Length of Treatment

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12 weekly sessions, with session time ranging from 60 to 90 minutes[4][3][5]

Treatment Components

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CFF-CBT focuses on 7 components comprising of the “RAINBOW” acronym[3]:

R: Routine; developing consistency

A: Affective regulation; includes psychoeducation on feelings, coping skills, and mood monitoring

I: “I can do it!”; this aims to improve self-esteem in the child, as well as self-efficacy in the parent

N: “No Negative Thoughts/Live in the Now”

B: Be a good friend/balanced life style (building social skills and teaching parents self-care

O: Oh, how do we solve this problem? (family-based problem solving and communication skills building)

W: Ways to find support (building a network of support)

Treatment Outcomes

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CFF-CBT has shown decreases in mania to a subclinical level, parent-reported youth depressive symptoms, increased involvement/fidelity to treatment, and improvements in the client’s overall, global functioning in comparison to psychotherapy as per usual.[4]

Interpersonal and Social Rhythm Therapy (IPSRT)

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Purpose

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IPSRT is based on the social zeitgeber hypothesis[6], which states that regularity in social routines and interpersonal relationships acts as a protective factor for mood disorders. Thus, this treatment focused on maintaining regularity in daily routines, quality of social relationships and social roles, and management of consequences of rhythm disruptions.[7]

Intended Population

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IPSRT is intended for all individuals with bipolar disorder, and has been found to be effective in adolescents.[8]

Length of Treatment

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Length of treatment varies dependent on client needs.[8]

Treatment Components

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IPSRT is structured in three phases[9]:

  1. Initial phase: Explores the clients history in order to explore links between disruptions in routines to affective episodes. This stage also includes education on the rationale of the treatment[9]
  2. Intermediate phase: Focused on reorganizing the client's social rhythms, reinforcing new social rhythms and building confidence in using techniques that are taught in the treatment[9]
  3. Final phase: Reduction in frequency of visits in order to work towards termination of therapy and self-efficacy[9]

Treatment Outcomes

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If applied early in the acute phase of bipolar disorder, IPSRT may prolong time to relapse in depressive/manic episodes.[10]

Mindfulness-Based Cognitive Therapy (MBCT)

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Purpose

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Mindfulness approaches aim to enhance one’s ability to focus their attention on the present moment in a non-judgmental manor.[10] In treatment for Bipolar Disorder, mindfulness approaches may focus on awareness of the client’s patterns of thoughts, feelings and bodily sensations both specific and non-specific to their experiences related to the disorder.[10] Moreover, when comorbid with anxiety, bipolar disorder has higher risk of suicide attempts, therefore MBCT aims to decrease these anxiety symptoms.[11]

Intended Population

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MBCT is intended for all populations with bipolar disorder.[11]

Length of Treatment

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MPCT is typically offered in 1-2 hour weekly sessions over an 8-week period in a group setting (Perich et al 2012; Weber et al 2010).[12][13] Participants are also assigned homework, including varying lengths of meditation practice.[13]

Treatment Components

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MPCT combines aspects of classical CBT and mindfulness-based stress reduction therapies. The themes addressed in each session are[14]:

Session 1: Automatic pilot

Session 2: Dealing with barriers

Session 3: Mindfulness of the breath

Session 4: Staying present

Session 5: Allowing and letting be

Session 6: Thoughts are not facts

Session 7: How can I best take care of myself

Session 8: Using what has been learned to deal with future moods

Treatment Outcomes

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Treatment outcomes include decreases in anxiety and depressive symptoms and mood regulation in patients with bipolar disorder, but there has been no evidence in prevention of recurrences.[10][11] MBCT has also been found to improve attentional readiness, and attenuated activation of non-relevant information processing during attentional readiness, which are usually decreased in individuals with Bipolar Disorder compared to those without.[15]


Multi-Family Psychoeducational Psychotherapy (MF-PEP)

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Purpose

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MF-PEP is a group-based evidence based treatment for children with bipolar disorder, which is meant to increase the ability for the treatment to be readily implemented into the community.[16] While MF-PEP creates a support system within the family for the child through being a family-based intervention, it also serves to increase social support for care givers through being a group-based therapy.

Intended Population

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MF-PEP is intended for children with depressive and bipolar disorders and their caretakers.[16][17]

Length of Treatment

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MF-PEP is an 8-session long treatment, with sessions typically ranging from 60-90 minutes. [16][17]

Treatment Components

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MF-PEP combines psychoeducation, family systems, and cognitive behavior therapy techniques, aiming to target depressive and bipolar disorder symptoms and how these symptoms cause impairment. [17] In MF-PEP, sessions are delivered in a combination of settings, including all children and parents together, as well as separating all children and caregivers into their own respective groups. [17]

Treatment Outcomes

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Treatment outcomes for MG-PEP include an increase in caregiver's understanding of the child's disorder, and a decrease in mood symptom severity within the children which has been seen to be maintained through an 18-month follow-up. [18] Additionally, MF-PEP has been found to have a positive effect on parent's help-seeking behaviors for mental health care, leading to access to higher-quality services. [18] Lastly, children report feeling a stronger sense of social support from their caregivers after participating in the intervention.[17]


See also:

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  1. ICD-10 Diagnostic Criteria
  2. Evidence-Based Assessment for Bipolar Disorder
  3. Bipolar disorder in children
  4. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research
  5. Treatment of bipolar disorder

References

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  1. ↑ Diagnostic and statistical manual of mental disorders : DSM-5. (5th ed.). Arlington, VA: American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force.. 2013. ISBN 978-0-89042-554-1. OCLC 830807378. https://www.worldcat.org/oclc/830807378. 
  2. ↑ Anderson, I. M.; Haddad, P. M.; Scott, J. (2012-04-05). "Bipolar disorder". BMJ 345 (dec27 3): e8508–e8508. doi:10.1136/bmj.e8508. ISSN 1756-1833. http://dx.doi.org/10.1136/bmj.e8508. 
  3. ↑ 3.0 3.1 3.2 West, Amy E.; Weinstein, Sally M.; Peters, Amy T.; Katz, Andrea C.; Henry, David B.; Cruz, Rick A.; Pavuluri, Mani N. (2014-11-01). "Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder: A Randomized Clinical Trial". Journal of the American Academy of Child & Adolescent Psychiatry 53 (11): 1168–1178.e1. doi:10.1016/j.jaac.2014.08.013. ISSN 0890-8567. PMID 25440307. PMC PMC4254579. https://jaacap.org/article/S0890-8567(14)00617-0/abstract. 
  4. ↑ 4.0 4.1 4.2 MacPherson, Heather A.; Weinstein, Sally M.; West, Amy E. (2018-05-01). "Non-Suicidal Self-Injury in Pediatric Bipolar Disorder: Clinical Correlates and Impact on Psychosocial Treatment Outcomes". Journal of Abnormal Child Psychology 46 (4): 857–870. doi:10.1007/s10802-017-0331-4. ISSN 1573-2835. https://doi.org/10.1007/s10802-017-0331-4. 
  5. ↑ 5.0 5.1 Fristad, Mary A.; MacPherson, Heather A. (2014-05-01). "Evidence-Based Psychosocial Treatments for Child and Adolescent Bipolar Spectrum Disorders". Journal of Clinical Child & Adolescent Psychology 43 (3): 339–355. doi:10.1080/15374416.2013.822309. ISSN 1537-4416. PMID 23927375. PMC PMC3844106. https://doi.org/10.1080/15374416.2013.822309. 
  6. ↑ Grandin, Louisa D.; Alloy, Lauren B.; Abramson, Lyn Y. (2006-10). "The social zeitgeber theory, circadian rhythms, and mood disorders: Review and evaluation". Clinical Psychology Review 26 (6): 679–694. doi:10.1016/j.cpr.2006.07.001. https://linkinghub.elsevier.com/retrieve/pii/S0272735806000651. 
  7. ↑ Frank, Ellen; Kupfer, David J.; Thase, Michael E.; Mallinger, Alan G.; Swartz, Holly A.; Fagiolini, Andrea M.; Grochocinski, Victoria; Houck, Patricia et al. (2005-09-01). "Two-Year Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With Bipolar I Disorder". Archives of General Psychiatry 62 (9): 996. doi:10.1001/archpsyc.62.9.996. ISSN 0003-990X. http://dx.doi.org/10.1001/archpsyc.62.9.996. 
  8. ↑ 8.0 8.1 Crowe, Marie; Inder, Maree; Joyce, Peter; Moor, Stephanie; Carter, Janet; Luty, Sue (2009-01). "A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent". Journal of Clinical Nursing 18 (1): 141–149. doi:10.1111/j.1365-2702.2008.02571.x. http://doi.wiley.com/10.1111/j.1365-2702.2008.02571.x. 
  9. ↑ 9.0 9.1 9.2 9.3 "Interpersonal and Social Rhythm Therapy | Background". www.ipsrt.org. Retrieved 2019-12-05.
  10. ↑ 10.0 10.1 10.2 10.3 Miziou, Stella; Tsitsipa, Eirini; Moysidou, Stefania; Karavelas, Vangelis; Dimelis, Dimos; Polyzoidou, Vagia; Fountoulakis, Konstantinos N (2015-12). "Psychosocial treatment and interventions for bipolar disorder: a systematic review". Annals of General Psychiatry 14 (1): 19. doi:10.1186/s12991-015-0057-z. ISSN 1744-859X. PMID 26155299. PMC PMC4493813. http://www.annals-general-psychiatry.com/content/14/1/19. 
  11. ↑ 11.0 11.1 11.2 Williams, J. Mark G.; Russell, Ian; Russell, Daphne (2008-06). "Mindfulness-based cognitive therapy: Further issues in current evidence and future research.". Journal of Consulting and Clinical Psychology 76 (3): 524–529. doi:10.1037/0022-006X.76.3.524. ISSN 1939-2117. PMID 18540746. PMC PMC2834575. http://doi.apa.org/getdoi.cfm?doi=10.1037/0022-006X.76.3.524. 
  12. ↑ Perich, T.; Manicavasagar, V.; Mitchell, P. B.; Ball, J. R.; Hadzi-Pavlovic, D. (2012-12-09). "A randomized controlled trial of mindfulness-based cognitive therapy for bipolar disorder". Acta Psychiatrica Scandinavica 127 (5): 333–343. doi:10.1111/acps.12033. ISSN 0001-690X. http://dx.doi.org/10.1111/acps.12033. 
  13. ↑ 13.0 13.1 Weber, B.; Jermann, F.; Gex-Fabry, M.; Nallet, A.; Bondolfi, G.; Aubry, J.-M. (2010-10). "Mindfulness-based cognitive therapy for bipolar disorder: A feasibility trial". European Psychiatry 25 (6): 334–337. doi:10.1016/j.eurpsy.2010.03.007. https://linkinghub.elsevier.com/retrieve/pii/S0924933810000817. 
  14. ↑ "Classes". mbct.com. Retrieved 2019-12-05.
  15. ↑ Howells, Fleur M; Ives-Deliperi, Victoria L; Horn, Neil R; Stein, Dan J (2012-02-29). "Mindfulness based cognitive therapy improves frontal control in bipolar disorder: a pilot EEG study". BMC Psychiatry 12 (1). doi:10.1186/1471-244x-12-15. ISSN 1471-244X. http://dx.doi.org/10.1186/1471-244x-12-15. 
  16. ↑ 16.0 16.1 16.2 MacPherson, Heather A.; Leffler, Jarrod M.; Fristad, Mary A. (2014). "Implementation of Multi-Family Psychoeducational Psychotherapy for Childhood Mood Disorders in an Outpatient Community Setting". Journal of Marital and Family Therapy 40 (2): 193–211. doi:10.1111/jmft.12013. ISSN 1752-0606. PMID 24749838. PMC PMC4198302. https://onlinelibrary.wiley.com/doi/abs/10.1111/jmft.12013. 
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Fristad, Mary A.; Verducci, Joseph S.; Walters, Kimberly; Young, Matthew E. (2009-09-01). "Impact of Multifamily Psychoeducational Psychotherapy in Treating Children Aged 8 to 12 Years With Mood Disorders". Archives of General Psychiatry 66 (9): 1013–1021. doi:10.1001/archgenpsychiatry.2009.112. ISSN 0003-990X. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/210303. 
  18. ↑ 18.0 18.1 MacPherson, Heather A.; Leffler, Jarrod M.; Fristad, Mary A. (2014). "Implementation of Multi-Family Psychoeducational Psychotherapy for Childhood Mood Disorders in an Outpatient Community Setting". Journal of Marital and Family Therapy 40 (2): 193–211. doi:10.1111/jmft.12013. ISSN 1752-0606. PMID 24749838. PMC PMC4198302. https://onlinelibrary.wiley.com/doi/abs/10.1111/jmft.12013. 
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