social work essay bipolar assessment

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• Published: 07 July 2015

Psychosocial treatment and interventions for bipolar disorder: a systematic review

• Stella Miziou 1 ,
• Eirini Tsitsipa 1 ,
• Stefania Moysidou 1 ,
• Vangelis Karavelas 2 ,
• Dimos Dimelis 2 ,
• Vagia Polyzoidou 3 &
• Konstantinos N Fountoulakis 2  

Annals of General Psychiatry volume  14 , Article number:  19 ( 2015 ) Cite this article

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Bipolar disorder (BD) is a chronic disorder with a high relapse rate, significant general disability and burden and with a psychosocial impairment that often persists despite pharmacotherapy. This indicates the need for effective and affordable adjunctive psychosocial interventions, tailored to the individual patient. Several psychotherapeutic techniques have tried to fill this gap, but which intervention is suitable for each patient remains unknown and it depends on the phase of the illness.

The papers were located with searches in PubMed/MEDLINE through May 1st 2015 with a combination of key words. The review followed the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses statement.

The search returned 7,332 papers; after the deletion of duplicates, 6,124 remained and eventually 78 were included for the analysis. The literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and only in a selected subgroup of patients at an early stage of the disease who have very good, if not complete remission, of the acute episode. Cognitive-behavioural therapy and interpersonal and social rhythms therapy could have some beneficial effect during the acute phase, but more data are needed. Mindfulness interventions could only decrease anxiety, while interventions to improve neurocognition seem to be rather ineffective. Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes.

The current review suggests that the literature supports the usefulness only of specific psychosocial interventions targeting specific aspects of BD in selected subgroups of patients.

Our contemporary understanding of bipolar disorder (BD) suggests that there is an unfavorable outcome in a significant proportion of patients [ 1 , 2 ]. In spite of recent advances in pharmacological treatment, many BD patients will eventually develop chronicity with significant general disability and burden. The burden will be significant also for their families and the society as a whole [ 3 , 4 ]. Today, we also know that unfortunately, symptomatic remission is not identical and does not imply functional recovery [ 5 – 7 ].

Since pharmacological treatment often fails to address all the patients’ needs, there is a growing need for the development and implementation of effective and affordable interventions, tailored to the individual patient [ 8 ]. The early successful treatment, with full recovery if possible, as well as the management of subsyndromal symptoms and of psychosocial stress and poor adherence are factors predicting earlier relapse and poor overall outcome [ 9 , 10 ].

In this frame, there are several specific adjunctive psychotherapies which have been developed with the aim of filling the above gaps and eventually improve the illness outcome [ 11 ], but it is still unclear whether they truly work and which patients are eligible and when [ 12 – 19 ].

The current study is a systematic review of the efficacy of available psychosocial interventions for the treatment of adult patients with BD.

Reports investigating psychotherapy and psychosocial interventions in BD patient samples were located with searches in Pubmed/MEDLINE through May 1, 2015. Only reports in English language were included.

The Pubmed database was searched using the search terms ‘bipolar’ and ‘psychotherapy’ or ‘cognitive-behavioral’ or ‘CBT’ or ‘psychoeducation’ or ‘interpersonal and social rhythm therapy’ or ‘IPSRT’ or ‘family intervention’ or ‘family therapy’ or ‘group therapy’ or ‘intensive psychosocial intervention’ or ‘cognitive remediation’ or ‘functional remediation’ or ‘Mindfulness’.

The following rules were applied for the selection of papers:

Papers in English language.

Randomized controlled trials.

This review followed the recommendations of the Preferred Items for Reporting of Systematic Reviews and Meta-Analyses (PRISMA) statement [ 20 ].

The search returned 7,332 papers, and after the deletion of duplicates 6,124 remained for further assessment. After assessing these papers on the basis of title and abstract, the remaining papers were (Figure  1 ). The number of paper reported for each intervention includes RCTs, post hoc analyses and meta-analyses together.

The PRISMA flowchart.

Cognitive-behavioural therapy (CBT)

The efficacy of CBT in BD was investigated in 14 studies which utilized CBT as adjunct treatment to pharmacotherapy or treatment as usual (TAU). They utilized some kind of control intervention which should not be considered as an adequate placebo. It is also interesting that the oldest study was conducted in 2003.

This first study lasted 12 months and concerned 103 BD-I patients during the acute depressive phase and randomized them to 14 sessions of CBT or a control intervention. There was not any placebo condition. These authors reported that at end point fewer patients in the CBT group relapsed in comparison to controls (44 vs. 75%; HR = 0.40, P  = 0.004), had shorter episode duration, less admissions and mood symptoms, and higher social functioning [ 21 ]. It was disappointing that the extension of this study (18 months follow-up) was negative concerning the relapse rate [ 22 ].

A second trial included 52 BD patients and was also negative concerning the long-term efficacy after comparing CBT plus additional emotive techniques vs. TAU [ 23 ]. On the other hand, the comparison of CBT plus psychoeducation vs. TAU in 40 BD patients reported a beneficial effect even after 5 years in terms of symptoms and social–occupational functioning. However, that study did not report the rate of recurrences and the time to recurrence [ 24 ]. A study in 79 BD patients (52 BD-I and 27 BD-II) compared CBT plus psychoeducation vs. psychoeducation alone and reported that the combined treatment group had 50% fewer depressed days per month, while at the same time the psychoeducation alone group had more antidepressant use [ 25 ]. Another study on 41 BD patients randomized to CBT vs. TAU reported similar results and an improvement in symptoms, frequency and duration of episodes [ 26 ].

An 18-month study compared CBT vs. TAU in 253 BD patients and reported that at end point, there were no differences between groups with more than half of the patients having a recurrence. It is interesting that a post hoc analysis suggested that CBT was significantly more effective than TAU in those patients with fewer than 12 previous episodes, but less effective in those with more episodes [ 13 ]. Similar negative results were reported concerning the number of episodes and time to relapse by another 12-month study of CBT vs. TAU in 50 BD patients in remission [ 17 ]. Again, negative findings concerning the relapse rate were reported by a 2-year study on 76 BD patients randomized to receive 20 sessions of CBT vs. support therapy [ 15 ]. Finally, the use of combined CBT and pharmacotherapy in 40 patients with refractory bipolar disorder suggested that the combination group had less hospitalization events in comparison to the group in the 12-month evaluation ( P  = 0.015) and lower depression and anxiety in the 6-month ( P  = 0.006; P  = 0.019), 12-month ( P  = 0.001; P  < 0.001) and 5-year ( P  < 0.001, P  < 0.001) evaluation time points. However it is interesting that after the 5-year follow-up, 88.9% of patients in the control group and 20% of patients in the combination group showed persistent affective symptoms and difficulties in social–occupational functioning [ 27 ].

The use of CBT in BD comorbid with social anxiety disorder is of doubtful efficacy [ 28 ], while there are some preliminary data on the efficacy of an Internet-based CBT intervention [ 29 ] as well as recovery-focused add-on CBT [ 30 ] and CBT for insomnia [ 31 ] in comparison to TAU.

The review of the available data so far give limited support for the usefulness of CBT during the acute phase of bipolar depression as adjunctive treatment in patients with BD, but definitely not for the maintenance phase. During the maintenance phase, booster sessions might be necessary, but the data are generally overall negative. Probably, patients at earlier stages of the illness might benefit more from CBT. Unfortunately the type of patients who are more likely to benefit from CBT constitutes a minority in usual clinical practice.

Psychoeducation

The basic concept behind psychoeducation for BD concerns the training of patients regarding the overall awareness of the disorder, treatment adherence, avoiding of substance abuse and early detection of new episodes. The efficacy of psychoeducation in BD was investigated in 30 studies, all of which utilized psychoeducation as adjunct treatment to pharmacotherapy or TAU. All these studies utilize some kind of control intervention which should not be considered as an adequate placebo. It is also interesting that the oldest study was conducted in 1991.

The earliest psychoeducational study was open and uncontrolled and reported that giving information about lithium improved the overall attitude towards treatment [ 32 , 33 ]. A similar small study was conducted a few years later and reported similar results [ 34 ]. However, the first study on the wide teaching of patients to recognize and identify the components of their disease with emphasis on early symptoms of relapse and recurrence and to seek professional help as early as possible had not been conducted until 1999. It included 69 patients for 18 months and compared psychoeducation (limited number of sessions; 7–12) vs. TAU. It reported a significant prolongation of the time to first manic relapse ( P  = 0.008) and significant reductions in the number of manic relapses over 18 months (30 vs. 52%; P  = 0.013) as well as improved overall social functioning. Psychoeducation had no effect on depressive relapses [ 35 ].

In a more systematic way, the efficacy of the adjunctive group psychoeducation was tested by the Barcelona group. Their trial included 120 euthymic BD patients who were randomly assigned to 21 sessions of group psychoeducation vs. non-specific group meetings. The study included a follow-up with a duration of 2 and 5 years. The results suggested that psychoeducation exerted a beneficial effect on the rate of and the time to recurrence as well as concerning hospitalizations per patient. At the end of the 2-year follow-up, 23 subjects (92%) in the control group fulfilled the criteria for recurrence versus 15 patients (60%) in the psychoeducation group ( P  < 0.01). This beneficial effect was high and was not reduced after 5 years (any episode 0.79 vs. 0.87; mania 0.40 vs. 0.57; hypomania 0.27 vs. 0.42 and mixed episodes 0.34 vs. 0.61), except for depressive episodes (0.91 vs. 0.80) [ 36 – 38 ].

The literature suggests that psychoeducation should be broad and that enhanced relapse prevention alone does not seem to work. This was the conclusion from another study with a different design. That study reported that only occupational functioning, but not time to recurrence, improved with an intervention consisting of training community mental health teams to deliver enhanced relapse prevention [ 39 ]. Additionally, a study with a 12-month follow-up and with a similar design to the first study of the Barcelona group, but with 16 sessions, reported no differences between groups in mood symptoms, psychosocial functioning and quality of life. It did find, however, that there was a difference in the subjectively perceived overall clinical improvement by subjects who received psychoeducation. The authors suggested that characteristics of the sample could explain this discrepancy, as patients with a more advanced stage of disease might have a worse response to psychoeducation [ 16 ]. In accordance with the above, a post hoc analysis of the original Barcelona data revealed that patients with more than seven episodes did not show significant improvement with group psychoeducation in time to recurrence, and those with more than 14 episodes did not benefit from the treatment in terms of time spent ill [ 40 ]. A 2-year follow-up in 108 BD patients investigated psychoeducation plus pharmacotherapy vs. pharmacotherapy alone. Psychoeducation concerned eight, 50-min sessions of psychological education, followed by monthly telephone follow-up care and psychological support. The results suggested that psychoeducation improved medication compliance ( P  = 0.008) and quality of life ( P  < 0.001) and had fewer hospitalizations ( P  < 0.001) [ 41 ]. Another study randomized 80 BD patients to either the psychoeducation or the control group and reported that the psychoeducation group scored significantly higher on functioning levels (emotional functioning, intellectual functioning, feelings of stigmatization, social withdrawal, household relations, relations with friends, participating in social activities, daily activities and recreational activities, taking initiative and self-sufficiency, and occupation) ( P  < 0.05) compared with the control group after psychoeducation [ 42 ].

A prospective 5-year follow-up of 120 BD patients suggested that group psychoeducation might be more cost-effective [ 43 ]. In support of the cost-effectiveness of psychoeducation was one trial in 204 BD patients which compared 20 sessions of CBT vs. 6 sessions of group psychoeducation and reported that overall the outcome was similar in the two groups in terms of reduction of symptoms and likelihood of relapse, but psychoeducation was associated with a decrease of costs ($180 per subject vs. $1,200 per subject for CBT) [ 44 ] Currently, there are some proposals of online psychoeducation programmes, but results are still inconclusive or pending [ 45 , 46 ].

More complex multimodal approaches and multicomponent care packages have been developed and usually psychoeducation is a core element. One of these packages also included CBT and elements of dialectical behaviour therapy and social rhythms and has shown a beneficial effect after the 1-year follow-up in comparison to TAU [ 47 ]. Another included a combination of CBT plus psychoeducation and reported that it was more effective in comparison to TAU in 40 refractory BD patients concerning hospitalization and residual symptoms at 12 months follow-up [ 27 ]. A collaborative care study on 138 patients and follow-up of 12 months also gave positive results [ 48 ]. One multicentred Italian study assessed the efficacy of the Falloon model of psychoeducational family intervention (PFI), originally developed for schizophrenia management and adapted to BD-I disorder. It included 137 recruited families, of which 70 were allocated to the experimental group and 67 to the TAU group. At the end of the intervention, significant improvements in patients’ social functioning and relatives’ burden were found in the treated group compared to TAU [ 49 ]. In general, the beneficial effect seems to be present concerning manic but not depressive episodes [ 50 , 51 ], while a benefit on social role function and quality of life seems also to be present [ 50 ].

The comparison of 12 sessions of psychoeducation vs. TAU in 71 BD patients reported that at 6 weeks, the intervention improved treatment adherence [ 52 ], while another on 61 BD-II patients reported no significant effect on the regulation of biological rhythms when compared to standard pharmacological treatment [ 53 ]. No significant effect was reported concerning the quality of life by another recent study on 61 young bipolar adults [ 54 ]. On the contrary, a trial on 47 BD patients reported that a psychoeducation programme designed for internalized stigmatization may have positive effects on the internalized stigmatization levels of patients with bipolar disorder [ 55 ].

There is preliminary evidence that a Web-based treatment approach in BD (‘Living with Bipolar’—LWB intervention) is feasible and potentially effective [ 56 ]; however, other Web-based attempts returned negative results [ 57 ]. Automated mobile-phone intervention is another option and it has been reported to be feasible, acceptable and might enhance the impact of brief psychoeducation on depressive symptoms in BD. However, sustainment of gains from symptom self-management mobile interventions, once stopped, may be limited [ 58 ].

One meta-analysis of 16 studies, 8 of which provided data on relapse reported that psychoeducation appeared to be effective in preventing any relapse (OR: 1.98–2.75; NNT: 5–7) and manic/hypomanic relapse (OR: 1.68–2.52; NNT: 6–8), but not depressive relapse. That meta-analysis reported that group, but not individually, delivered interventions were effective against both poles of relapse [ 59 ].

In summary, the literature suggests that interventions of 6-month group psychoeducation seem to exert a long-lasting prophylactic effect. However this is rather restricted to manic episodes and to patients at the earlier stages of the disease who have achieved remission before the intervention has started. Although the mechanism of action of psychoeducation remains unknown, it is highly likely that the beneficial effect is mediated by the enhancement of treatment adherence, the promoting of lifestyle regularity and healthy habits and the teaching of early detection of prodromal signs.

Interpersonal and social rhythm therapy (IPSRT)

Interpersonal and social rhythm therapy is based on the hypothesis that in vulnerable individuals, the experience of stressful life events and unstable or disrupted daily routines can lead to affective episodes via circadian rhythm instability [ 18 ]. In this frame, IPSRT includes the management of affective symptoms through improvement of adherence to medication and stabilizing social rhythms and the resolution of interpersonal problems. Four papers investigating its efficacy were identified.

The first study concerning its efficacy in BD included 175 acutely ill BD patients and followed them for 2 years. It included four treatment groups, reflecting IPSRT vs. intensive clinical management during the acute and the maintenance phase. The results revealed no difference between interventions in terms of time to remission and in the proportion of patients achieving remission (70 vs. 72%), although those patients who received IPSRT during the acute treatment phase survived longer without an episode and showed higher regularity of social rhythms [ 60 ]. In spite of some encouraging findings from post hoc analysis, there were eventually no significant differences between genders and concerning the improvement in occupational functioning [ 61 ]. More recently, a 12-week study in which unmedicated depressed BD-II patients were randomized to IPSRT ( N  = 14) vs. treatment with quetiapine (up to 300 mg/day; N  = 11), showed that both groups experienced significant reduction in symptoms over time, but there were no group-by-time interactions. Response and drop-out rates were similar [ 62 ]. Finally, one 78-week trial investigated the efficacy of IPSRT vs. specialist supportive care on depressive and mania outcomes and social functioning, and mania outcomes in 100 young BD patients. The results revealed no significant difference between therapies [ 63 ].

Overall, 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.

Family intervention

The standard family intervention for BD targets the whole family and not only the patient and includes elements of psychoeducation, communication enhancement and problem-solving skills training. It also includes support and self-care training for caregivers. Fifteen papers concerning the efficacy of family intervention in BD were found.

The first study on this intervention took part in 1991 and reported that carer-focused interventions improve the knowledge of the illness [ 64 ]. Since then, there have been a number of studies which in general support the use of adjunctive family-focused treatment. There are different designs and approaches which were tested in essentially open trials.

One intervention design consists of 21 1-h sessions which combine psychoeducation, communication skills training and problem-solving training. The sessions take place at home and included both the patient and his/her family during the post-episode period. The treatment has shown its efficacy vs. crisis management in 101 BD patients in reducing relapses (35 vs. 54%) and increasing time to relapse (53 vs. 73 weeks, respectively) [ 65 , 66 ]. It was also reported to reduce hospitalization risk compared with individual treatment (12 vs. 60%) [ 67 ]. It is important that the benefits extended to the 2-year follow-up were particularly useful for depressive symptoms, in families with high expressed emotion and for the improvement of medication adherence [ 66 ]. Similar results were reported by a study of 81 BD patients and 33 family dyads, which reported that the odds ratio for hospitalization at 1-year follow-up was related with high perceived criticism (by the patients from their relatives), poor adherence and with the relatives’ lack of knowledge concerning BD (OR: 3.3; 95% CI 1.3–8.6) [ 68 ].

Adjunctive psychoeducational marital intervention in acutely ill patients was reported to have a beneficial effect concerning medication adherence and global functioning, but not for symptoms [ 69 ]. Neither adjunctive family therapy nor adjunctive multifamily group therapy improves the recovery rate from acute bipolar episodes when compared with pharmacotherapy alone [ 14 ]. These interventions could be beneficial for patients from families with high levels of impairment and could result in a reduction of both the number of depressive episodes and the time spent in depression (Cohen d  = 0.7–1.0) [ 70 ]. In this frame, in those patients who recovered from the intake episode, multifamily group therapy was associated with the lowest hospitalization risk [ 71 ].

Another format included a 90-min duration, delivered to caregivers of euthymic BD patients; after 15-months, it was reported to have both reduced the risk of recurrence in comparison to a control group (42 vs. 66%; NNT: 4.1 with 95% CI 2.4–19.1) and also to have delayed recurrence [ 72 ]. It was particularly efficacious in the prevention of hypomanic/manic episodes and also in the reduction of the overall family burden [ 73 ]. It had been shown before that carer-focused interventions improve the knowledge of the illness [ 64 ], reduce burden [ 74 ] and also reduce the general and mental health risk of caregivers [ 75 ].

Another format of intervention included 12 sessions of group psychoeducation for the patients and their families. It has been f o und superior to TAU in 58 BD patients concerning the prevention of relapses, the decrease of manic symptoms and the improvement of medication adherence [ 76 ]. Finally, the comparison of family-based therapy (FBT) vs. brief psychoeducation (crisis management) in 108 patients with BD reported that the outcome depended on the existing levels of appropriate self-sacrifice [ 77 ].

Overall, the literature supports the conclusion that interventions which focus on families and caregivers exert a beneficial impact on family members, but the effect on the patients themselves is controversial. The effect includes issues ranging from subjective well-being to general health, but it is almost certain that there is a beneficial effect on issues like treatment adherence.

Intensive psychosocial intervention

There are three papers investigating various methods of intensive psychosocial intervention. ‘Intensive’ psychotherapy has been tested on 293 acutely depressive BD outpatients in a multi-site study. Patients were randomized to 3 sessions of psychoeducation vs. up to 30 sessions of intensive psychotherapy (family-focused therapy, IPSRT or CBT). The results suggested that the intensive psychotherapy group showed higher recovery rates, shorter times to recovery and greater likelihood of being clinically well in comparison to patients on short intervention [ 78 ]. The functional outcome was also reported to be better after 1 year [ 79 ]. A second trial randomized 138 BD patients to receive collaborative care (contracting, psychoeducation, problem-solving treatment, systematic relapse prevention and monitoring of outcomes) vs. TAU. The results suggested that collaborative care had a significant and clinically relevant effect on the number of months with depressive symptoms, as well as on severity of depressive symptoms, but there was no effect on symptoms of mania or on treatment adherence [ 48 ].

Cognitive remediation (CR) and functional remediation (FR)

Cognitive remediation and functional remediation tailored to the needs of BD patients include education on neurocognitive deficits, communication, autonomy and stress management. There are five papers on the efficacy of CR and FR.

One uncontrolled study in 15 BD patients applied a type of CR and focused on mood monitoring and residual depressive symptoms, organization, planning and time management, attention and memory. The results suggested that there was an improvement of residual depressive symptoms, executive functions and general functioning. Patients with greater neurocognitive impairment had less benefit from the intervention [ 80 ]. The combination of neurocognitive techniques with psychoeducation and problem solving within an ecological framework was tested in a multicentre trial in 239 euthymic BD patients with a moderate–severe degree of functional impairment ( N  = 77) vs. psychoeducation ( N  = 82) and vs. TAU ( N  = 80). At end point, the combined programme was superior to TAU, but not to psychoeducation alone [ 81 , 82 ]. Finally, a small study in 37 BD and schizoaffective patients tested social cognition and interaction training (SCIT) as adjunctive to TAU ( N  = 21) vs. TAU alone ( N  = 16). There was no difference between groups concerning social functioning, but there was a superiority of the combination group in the improvement of emotion perception, theory of mind, hostile attribution bias and depressive symptoms [ 83 ]. A post hoc analysis using data of 53 BD-II outpatients compared FR vs. psychoeducation and vs. TAU, but the results were negative [ 84 ].

Mindfulness-based interventions

Mindfulness-based intervention aims to enhance the ability to keep one’s attention on purpose in the present moment and non-judgmentally. Specifically for BD patients, it includes education about the illness and relapse-prevention, combination of cognitive therapy and training in mindfulness meditation to increase the awareness of the patterns of thoughts, feelings and bodily sensations and the development of a different way (non-judgementally) of relating to thoughts, feelings and bodily sensations. It also promotes the ability of the patients to choose the most skilful response to thoughts, feelings or situations. There are eight studies on the efficacy of mindfulness-based intervention in BD.

The first study concerning the application of mindfulness-based cognitive therapy (MBCT) in BD tested it vs. waiting list and included only eight patients in each group. The results suggested a beneficial effect with a reduction in anxiety and depressive symptoms [ 85 ]. A second study included 23 BD patients and 10 healthy controls and investigated MBCT vs. waiting list and the results were compared with those of 10 healthy controls. The results suggested that following MBCT, there were significant improvements in BD patients concerning mindfulness, anxiety and emotion regulation, working memory, spatial memory and verbal fluency compared to the waiting list group [ 86 ]. The biggest study so far concerning MBCT included 95 BD patients and tested MBCT as adjunctive to TAU ( N  = 48) vs. TAU alone ( N  = 47) and followed the patients for 12 months. The results showed no difference between treatment groups in terms of relapse and recurrent rates of any mood episodes. There was some beneficial effect of MBCT on anxiety symptoms [ 87 , 88 ]. Recently, the focus has expanded to analyze the impact of MBCT on brain activity and cognitive functioning in BD, but the findings are difficult to interpret [ 86 , 89 , 90 ].

A study which applied dialectical behaviour therapy in which mindfulness represented a large component also reported some positive outcomes [ 91 ]. One study on mindfulness training reported negative results in BD patients [ 92 ].

In conclusion, the literature does not support a beneficial effect of MBCT on the core issues of BD. There are some data suggesting a beneficial effect on anxiety in BD patients. So far, there are no data supporting its efficacy in the prevention of recurrences.

The current review suggests that the literature supports the usefulness only of psychoeducation for the relapse prevention of mood episodes and unfortunately only in a selected subgroup of patients at an early stage of the disease who have very good if not complete remission of the acute episode. On the other hand, CBT and IPSRT could have some beneficial effect during the acute phase, but more data are needed. Mindfulness interventions could only decrease anxiety, while interventions to improve neurocognition seem to be rather ineffective. Family intervention seems to have benefits mainly for caregivers, but it is uncertain whether they have an effect on patient outcomes. A summary of the specific areas of efficacy for each of the above-mentioned interventions is shown in Table  1 .

An additional important conclusion is that concerning the quality of the data available: the studies on BD patients suffer from the same limitations and methodological problems as all psychotherapy trials do. It is well known that this kind of studies suffers from problems pertaining to blindness and the nature of the control intervention. Additionally, the training of the therapist and the setting itself might play an important role. It is quite different to apply the same intervention in specialized centres than in real-world settings in everyday clinical practice. Even worse, research is not done in a standardized way and the gathering of data is far from systematic. The studies are rarely registered, adverse events are not routinely assessed, outcomes are not hierarchically stated a priori and too many post hoc analyses have been published without being stated as such. There is a lack of replication of the same treatment by different research groups under the same conditions.

There are different theories on the mechanisms responsible for the efficacy of the psychosocial treatments. One suggestion concerns the enhancement of treatment adherence [ 93 ], while another proposes that improving lifestyle and especially biological rhythms, food intake and social zeitgebers could be the key factors [ 60 ]. Also, it has been proposed that the mechanism concerns the changing of dysfunctional attitudes [ 23 ], the improvement of family interactions [ 94 ] or the enhanced ability for the early identification of signs of relapse [ 35 ].

Overall, it seems that psychosocial interventions are more efficacious when applied on patients who are at an early stage of the disease and who were euthymic when recruited [ 14 , 95 ]. According to these post hoc analyses, a higher number of previous episodes [ 13 , 40 ] as well as a higher psychiatric morbidity and more severe functional impairment [ 96 ] might reduce treatment response, although the data are not conclusive [ 97 ]. Also, a differential effect has been proposed with neuroprotective strategies being better during the early stages [ 98 ] and rehabilitative interventions being preferable at later stages [ 99 ].

It is unclear whether IPSRT and CBT are efficacious during the acute episodes, but there are some data in support [ 13 , 60 , 78 ]. Maybe specific family environment characteristics might influence the response to treatment [ 70 , 100 ]. Probably, there were subpopulations who especially benefited from these treatments [ 13 , 70 ], but these assumptions are based on post hoc analyses alone.

It should be mentioned that most of the research concerns pure and classic BD-I patients, although there are some rare data concerning special populations such as BD-II [ 36 , 62 ], schizoaffective disorder [ 101 , 102 ], patients with high suicide risk [ 85 , 103 , 104 ] and patients with comorbid substance abuse [ 105 , 106 ].

It is interesting to note that the literature suggests that the benefits of psychosocial interventions if achieved could last for up to 5 years [ 36 , 107 ], although some patients might need booster sessions [ 23 , 108 ]. The complete range of the effect these interventions have is still uncharted. Although it is reasonable to expect a beneficial effect in a number of problems, including suicidality, research data on these issues are virtually non-existent [ 103 , 104 ].

Conclusions

In conclusion, the literature supports the notion that adjunctive specific psychological treatments can improve specific illness outcomes. Although the data are rare, it seems reasonable that any such intervention should be applied as early as possible and should always be tailored to the specific needs of the patient in the context of personalized patient care, since it is accepted that both the patients and their relatives have different needs and problems depending on the stage of the illness.

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Miziou, S., Tsitsipa, E., Moysidou, S. et al. Psychosocial treatment and interventions for bipolar disorder: a systematic review. Ann Gen Psychiatry 14 , 19 (2015). https://doi.org/10.1186/s12991-015-0057-z

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Understanding bipolar disorder booklet

What is bipolar disorder? What types of bipolar disorder are there? How does a diagnosis get made? What causes bipolar disorder? How can I help myself cope? What kind of treatments can help? What medication is available? What can I do in a crisis? How can friends and family help? Useful contacts

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Assessment Tools for Adult Bipolar Disorder

This article reviews the current state of the literature on the assessment of bipolar disorder in adults. Research on reliable and valid measures for bipolar disorder has unfortunately lagged behind assessment research for other disorders, such as major depression. We review diagnostic tools, self-report measures to facilitate screening for bipolar diagnoses, and symptom severity measures. We briefly review other assessment domains, including measures designed to facilitate self-monitoring of symptoms. We highlight particular gaps in the field, including an absence of research on the reliable diagnosis of bipolar II and milder forms of disorder, a lack of empirical data on the best ways to integrate data from multiple domains, and a shortage of measures targeting a broader set of illness-related constructs relevant to bipolar disorder.

The goal of this review is to summarize measures that are useful for the assessment of bipolar disorder among adults. We will focus, in particular, on measures pertinent to screening, diagnosis, and symptom monitoring. With the apparent success of lithium in treating bipolar disorder, research on the disorder languished until the 1990s. Interest in bipolar disorder assessment has been renewed in recent decades. Nonetheless, research on the accurate assessment of bipolar disorder is relatively sparse when compared with other disorders such as major depression. We begin by describing the forms of bipolar disorder, then turn to available measures for its diagnosis, including both interview and self-report measures. Later sections discuss interviews and scales used for assessing symptom severity, including self-monitoring.

NATURE OF BIPOLAR DISORDER

Several types of bipolar disorder are recognized by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association ( APA, 2000 ), differentiated by the severity and duration of manic symptoms. A diagnosis of bipolar I disorder is made based on a single lifetime episode of mania, which is in turn defined by euphoric or irritable mood, along with at least three additional symptoms (or four if mood is only irritable) that result in marked social or vocational impairment. The duration criterion for mania specifies that symptoms must last one week or require hospitalization. Bipolar II disorder, in contrast, is defined by a history of at least one hypomanic episode and at least one major depressive episode. Criteria for hypomania are similar to those of mania, but in milder form: instead of impairment, a hypomanic episode is marked by a distinct change in functioning. Cyclothymic disorder is an even milder subtype of bipolar disorder, and is diagnosed based on a period of at least two years of recurrent mood swings. By definition, these mood swings must be in both the “up” and the “down” directions, but do not meet full criteria for mania, hypomania, or depression. In addition, the symptomatic two-year period cannot include any two-month span that is free of mood swings.

Symptoms that are secondary to drugs such as cocaine, or medical conditions such as thyroid problems, will generally yield a diagnosis of substance-induced mood disorder or bipolar disorder not otherwise specified. Those with a vulnerability to bipolar disorder may become manic when prescribed antidepressants without an accompanying mood stabilizer ( Ghaemi, Lenox, & Baldessarini, 2001 ), yielding a diagnosis of substance-induced mood disorder with manic features.

Large epidemiological studies indicate a prevalence of 1% for bipolar I disorder and an additional 3% for bipolar II disorder ( Kessler, Berglund, Demler, Jin, & Walters, 2005 ). As many as three quarters of those with bipolar I disorder have also experienced an episode of major depression ( Karkowski & Kendler, 1997 ; Kessler, Rubinow, Holmes, Abelson, & Zhao, 1997 ). Comorbidity rates with anxiety disorders and substance abuse disorders have been reported as high as 93% and 61%, respectively ( Kessler et al., 1997 ; Regier et al., 1990 ), underscoring the need for effective assessments and treatments of bipolar disorder to take comorbid conditions into account.

Twin studies suggest that heritability accounts for more than 90% of the variability in the development of bipolar disorder ( Kieseppä, Partonen, Haukka, Kaprio, & Lönnqvist, 2004 ), leading many researchers to focus on medications such as lithium for treatment ( Prien & Potter, 1990 ). The course of the disorder, however, may be strongly affected by psychosocial variables. Manic episodes may be triggered by sleep disturbance ( Leibenluft et al., 1996 ) or excessive pursuit of goals ( Johnson, 2005 ). Depressive episodes within bipolar disorder share common triggers with unipolar depression, such as negative life events, maladaptive cognitive styles, and lack of social support ( Johnson & Kizer, 2002 ). Thus psychotherapy may serve as an effective addition to medication in the treatment of bipolar disorder ( Johnson & Leahy, 2004 ; Rizvi & Zaretsky, 2007 ).

ASSESSMENT TOOLS FOR DIAGNOSIS

The diagnosis of bipolar disorder is based on a review of symptoms and potential medical explanations for those symptoms, as there is no biological marker for the disorder. In clinical practice, symptoms are frequently reviewed in an unstructured manner. It should be noted, though, that when practitioners do not use structured diagnostic tools, as many as half of comorbid conditions go undetected ( Zimmerman & Mattia, 1999 ). Furthermore, many practitioners report that they do not routinely screen for bipolar disorder even among people with a history of major depression, many of whom would meet the diagnostic criteria for bipolar disorder ( Brickman, LoPicollo, & Johnson, 2002 ). Due to informal or poor screening, the average time between onset of symptoms and formal diagnosis is more than seven years ( Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994 ; Mantere, Suiminen, Leppamaki, Arvilommi, & Isometsa, 2004 ). Improper diagnosis has serious repercussions because antidepressant treatment without mood-stabilizing medication can trigger iatrogenic mania ( Ghaemi et al., 2001 ).

Several semistructured interviews have been developed to assess bipolar disorder in adults. The two most commonly used measures are the Structured Clinical Interview for DSM-IV (SCID) and the Schedule for Affective Disorders and Schizophrenia (SADS). We will not focus here on the Composite Interview Diagnostic Interview (CIDI; Robbins et al., 1988 ), which has been developed and used mostly in epidemiological surveys (e.g., Kessler & Zhao, 1999 ). Briefly, there is some evidence that the CIDI may systematically underdiagnose bipolar disorder (e.g., Kessler, Rubinow, Holmes, Abelson, & Zhao, 1997 ), but more recent work has since validated it against the SCID ( Kessler et al., 2006 ). The SCID and the SADS both provide interview probes, symptom thresholds, and information about exclusion criteria (i.e., medical or pharmacological conditions that may induce mania). They differ, however, in the criteria they were designed to assess. The SCID is designed to help assess diagnoses according to the DSM-IV , whereas the SADS is designed to assess diagnoses according to the Research Diagnostic Criteria (RDC). RDC criteria are stricter in that psychotic symptoms are more likely to yield a diagnosis of schizoaffective disorder than would be applied in the DSM-IV criteria; within the DSM-IV criteria, psychotic symptoms must be present for at least two weeks outside of episode to be considered evidence of schizoaffective disorder. Further details about these measures are provided next. We begin by describing the measures and their psychometric characteristics for assessing bipolar I disorder. We then turn toward some specific issues that complicate the assessment of milder forms of bipolar disorder. Table 1 summarizes some of the well-supported measures for the diagnosis of bipolar disorder.

Summary of Validated Bipolar Disorder Assessment Tools for Diagnosis

The SCID ( Spitzer, Williams, Gibbon, & First, 1992 ) is recommended as a routine part of clinical intake procedures. The SCID is a semistructured interview that is divided into modules to cover different diagnoses. The modular design allows for the interview to be easily tailored to capture relevant diagnoses for a given research or clinical situation. Each SCID module contains probes to cover each of the core symptoms, and interviewers can use clinical judgment in gathering supplemental information if probes do not provide sufficient information for reliable symptom assessment. A clinician’s version is available through American Psychiatric Publishing ( First, Spitzer, Gibbon, & Williams, 1997 ). The SCID, and more specifically its bipolar disorder module, demonstrated good interrater reliability both in a large international multisite trial ( Williams et al., 1992 ) and in at least 10 other major trials ( Rogers, Jackson, & Cashel, 2001 ). In patient samples, reliability for current and lifetime diagnoses of bipolar disorder has been adequate to excellent, ranging from .64 to .92; establishing reliability for the SCID in community samples is more difficult due to low base rates of the disorder ( Williams et al., 1992 ). Compared to other structured interviews including the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI), and to clinicians not using a structured interview, diagnoses of bipolar disorder based on the SCID appear substantially more reliable. Results of one study indicated that the percentage of agreements with the gold standard were higher for the SCID as compared to standard clinician interviews ( Basco et al., 2000 ). In a sample of twins, diagnoses of bipolar disorder made using the SCID showed similar concordance rates between monozygotic and dizygotic twins compared to traditional twin studies using standard diagnostic interviews ( Kieseppä, et al., 2004 ).

The SADS ( Endicott & Spitzer, 1978 ) was designed to assess a broad range of Axis I diagnoses. For each diagnosis, the probes focus on the symptoms for the most recent episode and then capture a broad overview of past episodes. The reliability and validity of the SADS has been established across 21 studies (see Rogers, Jackson, & Cashel, 2001 , for a review). The SADS has demonstrated good to excellent reliability for both symptoms and diagnoses ( Andreasen et al., 1981 ). Specifically, mania diagnoses have achieved good interrater reliability and achieved good test–retest reliability over 5 to 10 years among adults ( Coryell et al., 1995 ; Rice et al., 1986 ). SADS diagnoses of bipolar disorder correlate robustly with other measures of mania ( Secunda et al., 1985 ), and the SADS appears to validly capture diagnoses across different cultural and ethnic groups within the United States ( Vernon & Roberts, 1982 ).

Diagnostic Assessment of Bipolar II Disorder in Adults

Hypomania is unique among DSM syndromes, in that by definition it does not cause any functional impairment. Perhaps because of this quality, the presence of at least one major depressive episode is also required to achieve a diagnosis of bipolar II disorder. This presents a unique diagnostic challenge: the hypomanic episodes that separate bipolar II disorder from unipolar depression are by definition of only limited severity, making this a hard diagnosis to reliably detect. Complicating this picture is the fact that there are important disagreements in the field regarding the best criteria for hypomanic episodes. For instance, current DSM criteria require three or four symptoms, in addition to elevated or irritable mood, lasting at least four days. In contrast, RDC criteria only require three symptoms lasting two days. Given this uncertainty and relative lack of severity of hypomania, it is not surprising that the accurate assessment of bipolar II disorder is more difficult to achieve than bipolar I disorder.

Given that hypomania is almost always accompanied by less distress than depressive episodes, one might be tempted to focus on detecting depression. There is evidence, however, that the diagnosis of hypomania (and hence, bipolar II disorder) is important above and beyond the detection of depression. Diagnoses of bipolar II disorder are accompanied by increased mood lability ( Akiskal et al., 1995 ) and a family history of bipolar II disorder ( Rice et al., 1986 ). In addition, at least three studies have demonstrated that people with bipolar II disorder are at a higher risk for suicide than are those with bipolar I disorder or unipolar depression ( Dunner, 1996 ). It is possible that the low mood of depression, combined with the impulsivity of hypomania, may be especially likely to lead to suicide attempts. In addition to suicide risk, the misdiagnosis of bipolar II disorder can have harmful pharmacological implications. The prescription of antidepressants, which is likely if bipolar II disorder is misdiagnosed as unipolar depression, may cause or exacerbate manic symptoms ( Ghaemi et al., 2001 ). Thus, identification of bipolar II disorder may be pivotal in administering effective treatments.

The above-described difficulties in assessing hypomanic symptoms have manifested in low reliability for the SADS in detecting bipolar II disorder ( Andreasen et al., 1981 ), even when interviewers rate the same tapes ( Keller et al., 1981 ). Some research groups have achieved better estimates, however ( Simpson et al., 2002 ; Spitzer & Endicott, 1978 ). Beyond the inconsistent estimates of interrater reliability, test–retest reliability over six months to two years likewise has been low for bipolar II disorder and cyclothymic disorder alike (Andreasen et al.; Rice et al., 1986 ). In one study, only 40% of participants with bipolar II disorder according to the SADS at baseline experienced any manic or hypomanic episodes over the ensuing 10 years ( Coryell et al., 1995 ). This lack of ability to accurately detect bipolar II disorder is not limited to the SADS. In one study, a SCID interview missed one third of bipolar II cases identified by expert clinical interview ( Dunner & Tay, 1993 ; Simpson et al., 2002 ). In sum, the best available diagnostic interviews are limited in their psychometric characteristics for the diagnosis of bipolar II disorder.

These difficulties have led some researchers to suggest that interviews aimed at detecting bipolar II disorder should start with questions about behavioral activation and increases in goal-directed behaviors rather than mood ( Akiskal & Benazzi, 2005 ). Although promising, such approaches have not yet been fully validated.

In sum, a set of issues mars diagnosis of bipolar II disorder. Persons who meet criteria for bipolar II disorder may be at high risk for suicidality, and they may experience a worsening of manic symptoms if prescribed antidepressants. On the other hand, available tools do not detect bipolar II disorder reliably. Thus a major goal for ongoing research is to develop ways to reliably capture diagnoses of bipolar II disorder.

Self Report Measures

The most reliable and valid way to obtain a diagnosis of bipolar disorder is through a structured interview with a trained clinician ( Akiskal, 2002 ). Nonetheless, given the time commitment involved in conducting structured interviews, several self-report measures have been developed to help clinicians identify persons most likely to meet criteria for bipolar disorders. It should be emphasized that these measures do not provide diagnostic accuracy, but, rather, might help identify people who should warrant more careful diagnostic interviews.

The General Behavior Inventory (GBI) was designed to cover the core symptoms of bipolar disorder, including both depressive and manic symptoms ( Depue et al., 1981 ). Different versions range from 52 to 73 items (e.g., Depue et al., 1981 ; Depue & Klein, 1988 ; Mallon, Klein, Bornstein, & Slater, 1986 ). Items on each version assess symptom intensity, duration, and frequency on a scale ranging from 1 (“never or hardly ever”) to 4 (“very often or almost constantly”). Although the GBI has the most robust psychometric properties of the available self-report screeners, the multiple versions make generalizations regarding psychometric properties difficult.

The full 73-item version of the GBI has demonstrated excellent internal consistency and adequate test–retest reliability. It has demonstrated sensitivity to bipolar disorder of approximately 75% and specificity greater than 97% ( Depue & Klein, 1988 ; Depue et al., 1989 ; Klein, Dickstein, Taylor, & Harding, 1989 ; Mallon et al., 1986 ) in clinical and nonclinical samples. Cutoff scores, however, have not been consistent across studies, further limiting the generalizability of the scale. At present, the GBI appears to be a useful screening tool for bipolar disorder, but future research to establish norms and cutoffs would increase its utility.

Another screening tool is the Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000 ). The first 13 items of the MDQ ask about the DSM-IV manic symptoms using a yes–no format. To achieve a positive screen, seven items must be endorsed. Additional items assess if the identified symptoms co-occurred and caused at least moderate impairment. The MDQ has attained adequate internal consistency ( Hirschfeld et al., 2000 ; Isometsä et al., 2003 ), fair one-month test–retest reliability, and fair sensitivity (.73 to .90) in distinguishing between bipolar and unipolar disorder in clinical samples ( Weber Rouget et al., 2005 ). In addition, at least one recent study has demonstrated that high MDQ scores are associated with greater impairment and suicidal ideation in a primary care setting ( Das et al., 2005 ). Nonetheless, specificity has been low in some studies (.47 to .90; Hirschfeld et al., 2000 , 2003 ; Isometsä et al., 2003 ; Miller et al., 2004 ; Weber Rouget et al., 2005 ) and the sensitivity in a community sample was only .28 ( Hirschfeld et al., 2003 ).

A review of the content of MDQ items may help clarify why the scale has achieved better performance in inpatient settings than in community settings. Several of the items appear to capture common experiences in community samples. For example, in one study, as many as 90% of college students endorsed items such as “Have you ever had a time when you were not your usual self and you felt much more self-confident than usual?” ( Miller, Johnson, & Carver, 2008 ). These items may be less commonly endorsed by persons with schizophrenia and other severe psychopathology, explaining why the scale may appear more beneficial in an inpatient setting than in a community sampling. Hence, the MDQ may be a potentially useful tool in clinical settings to screen for bipolar disorder among those with severe psychopathology, but may be less helpful in community settings.

Other scales appear helpful in nonclinical samples, but do not have enough data regarding their usefulness as screening tools in clinical settings. The Hypomanic Personality Scale (HPS; Eckblad & Chapman, 1986 ) predicted the development of manic episodes at 13-year follow-up in undergraduates ( Kwapil et al., 2000 ). To date, the HPS has only been studied in one clinical sample, achieving a positive predictive value of .82 and a negative predictive value of .67, and achieving a point-biserial correlation of .56 with bipolar I diagnosis ( Kwapil, 2008 ). The Bipolar Spectrum Diagnostic Scale ( Ghaemi et al., 2005 ) and the Mood Spectrum Self-Reports ( Dell’Osso et al., 2002 ) have only been examined in a single study each, and two Hypomania Checklists ( Angst et al., 2005 ; Hantouche et al., 2006 ) have only been examined in Europe and China (e.g., Meyer et al., 2007 ; Vieta et al., 2007 ). The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego—Autoquestionnaire version (TEMPS-A; Akiskal & Akiskal, 2005 ) is a measure of temperament rather than manic or hypomanic episodes per se. Although the four-factor structure that includes dysthymic, cyclothymic, hyperthymic, and irritable temperaments has been examined in several countries and languages and psychometrically validated in clinical populations, research has not directly established the usefulness of this measure as a screen for bipolar spectrum disorders (e.g., Akiskal et al., 2005 ; Karam et al., 2007 ; Kesebir et al., 2005 ; Matsumoto et al., 2005 ; Mendlowicz, Jean-Louis, Kelsoe, & Akiskal, 2005 ; Sandor et al., 2006 ; Vazquez et al., 2007 ). At least one study, however, has demonstrated that the cyclothymic subscale of the TEMPS-A can prospectively predict bipolar spectrum diagnoses among clinically depressed children and adolescents over a two-year period ( Kochman et al., 2005 ). Although initial studies indicate that these scales demonstrate good psychometric properties, more research is needed to determine their usefulness as screening measures.

Summary of Assessment Tools for Diagnosis

Overall, the SCID and the SADS are the most common means of diagnosing bipolar disorder in adults. With excellent psychometric characteristics for the assessment of bipolar I disorder, they fare less well in assessing bipolar II disorder. This may be due to issues related to the definition of hypomania.

As a diagnostic screening tool, the scale with the best support is the GBI, as it has consistently demonstrated sensitivity of approximately .75 and specificity above .97. Readers should be cautious, however, because multiple versions of the scale exist, and cutoffs for a positive screen have not been firmly established. The MDQ has been helpful in clinical populations, but suffers from poor discriminatory power in community settings. Other promising scales require more psychometric development. When using self-report scales as screening tools, several broader issues must be kept in mind. First, the usefulness of a screening tool will vary depending on the prevalence of a disorder in the population of interest ( Phelps & Ghaemi, 2006 ). Second, few studies provide direct comparisons of psychometric characteristics of the different measures. Third, there are several ways to report on a screener’s usefulness, including sensitivity and specificity, positive and negative predictive values, area under the curve, and point-biserial correlations with diagnosis ( Kraemer, 1992 ). Not all studies on the detection of bipolar disorder report all of these results, limiting the ability to compare studies or measures. Furthermore, sensitivity and specificity are commonly reported, but these indices may be dependent on sample characteristics. Fourth, authors have often modified the diagnostic interviews used as a reference standard to capture milder forms of bipolar spectrum disorder, yet limited information about these modifications is available. Each of these issues makes comparisons between measures complex.

ASSESSMENT OF SYMPTOM SEVERITY

The most common approach to measuring the severity of manic symptoms has been clinician-rated interviews. The Young Mania Rating Scale (YMRS) and Bech-Rafaelsen Mania Rating Scale (MAS) are two of the most widely used clinician-rated scales for assessing symptom severity. These scales have been commonly used to track changes in symptoms over time as treatment progresses. We briefly review these two scales, as well as the Schedule for Affective Disorders and Schizophrenia—Change version (SADS-C) mania subscale. There has been growing recognition, though, of the need to track both clinician and patient perspectives on the course of treatment, and so we discuss available symptom severity measures that rely on self-report. Some research has focused on measures useful for case conceptualization and treatment planning, but this literature is not covered in detail here: interested readers are referred to other reviews (e.g., Johnson, Miller, & Eisner, 2008 ). Table 2 summarizes some of the well-supported measures for assessing symptom severity in bipolar disorder.

Summary of Validated Bipolar Disorder Assessment Tools for Symptom Severity

The YMRS ( Young, Biggs, Ziegler, & Meyer, 1978 ) is a 15- to 30-min interview designed to be conducted by a trained clinician. It was originally developed and tested within an inpatient population based on semi-structured interview and observation during an eight-hour period. Today, the YMRS combines the patient’s report of manic symptoms over the previous two days as well as the clinician’s observations during the interview. It consists of 11 items covering the “core symptoms of the manic phase”: mood, motor activity, interest in sex, sleep, irritability, speech, flight of ideas, grandiosity, aggressive behavior, appearance, and an item regarding patient insight ( Carlson & Goodwin, 1973 ; Winokur, Clayton, & Reich, 1969 ). It should be noted that item 8, Bizarre Content, combines the assessment of the manic symptom of grandiosity with other psychotic symptoms, including hyperreligiousity, paranoia, ideas of reference, delusions, and hallucinations. The YMRS does not account for other DSM criteria of mania, including distractibility, increases in goal-directed activity, or excessive involvement in pleasurable activities with a high potential for painful consequences. A factor analysis of the YMRS revealed a thought disturbance factor, an overactive/aggressive behavior factor, and a factor tapping elevated mood and psychomotor symptoms ( Double, 1990 ).

Seven items are rated on a severity scale ranging from 0 to 4, and four items are rated on a scale of 0 to 8. Four core symptoms (irritability, speech, bizarre content, and disruptive–aggressive behavior) are double-weighted to account for poor cooperation from severely ill patients. Although the weighting may make rating more complex, it has not been shown to affect the reliability, validity, or sensitivity of the scale. The YMRS has demonstrated excellent psychometric properties, including a high inter-rater reliability for total scores (intraclass correlation = .93) and for individual item scores (intraclass correlation = .66 to .92), as well as high correlations with other mania rating scales ( Young et al., 1978 ). Scores also statistically differentiate patients before and after two weeks of treatment. The YMRS has primarily been used to assess manic symptoms in treatment trials and was the primary measure of mania in the Systematic Treatment Enhancement Program for Bipolar Disorder study, the largest study to date on the effectiveness of treatments for bipolar disorder ( Sachs et al., 2003 ).

The MAS ( Bech et al., 1979 ) is a clinician-rated instrument that is similar in format to the YMRS. The 11 items of the MAS are rated on a five-point scale (ranging from 0 “not present” to 4 “severe”) and cover classic manic symptoms such as elevated mood, irritability, sleep, increased activity, talkativeness, flight of ideas, self-esteem, noise level, and sexual interest. Like the YMRS, it has achieved excellent internal consistency and interrater reliability, as well as strong correlations with more exhaustive measures of manic symptoms ( Bech, 1988 ; Bech, Bolwig, Kramp, & Rafaelsen, 1979 ; Licht & Jensen, 1997 ). It has been widely used in treatment and basic research (e.g., Bech, 2002 ; Johnson et al., 2008 ; Malkoff-Schwartz et al., 1998 ). Scores on the MAS reliably differentiate placebo and treatment groups, as well as detect changes in symptoms associated with treatment ( Bech, 2002 ).

The SADS-C ( Spitzer & Endicott, 1978 ) mania subscale is a five-item interview that assesses current severity of manic symptoms. Items are rated on a six-point scale that includes behavioral anchors. Good interrater reliability has been established in a range of settings with the exception of a sample of patients referred for emergency evaluation (intraclass correlation = .63 for mania; Rogers, Jackson, Salekin, & Neumann, 2003 ). Expected elevations on the scale have been seen in a bipolar sample compared to patients with other psychiatric disorders, as have robust correlations with another interview to assess manic severity, the MAS (r = .89; Johnson, Magaro, & Stern, 1986 ). Support for the scale in factor analytic studies has been mixed. One study found that all items loaded onto a single factor distinct from dysphoria, insomnia, and psychosis ( Rogers et al., 2003 ). However, less factor analytic support was obtained in a study that examined the item loadings for the SADS-C and a nurse observation scale for mania ( Swann et al., 2001 ).

Two self-report measures of symptom severity have strong psychometric support: the Altman Self-Rating Mania (ASRM) Scale and the Self-Rating Mania Inventory (SRMI). We will also discuss other measures under development.

The ASRM scale ( Altman, Hedeker, Peterson, & Davis, 1997 ) is a five-item scale that assesses mood, self-confidence, sleep disturbance, speech, and activity level over the past week. Items are scored on a 0 (absent) to 4 (present nearly all the time) scale, with total scores ranging from 0 to 20. Although the brevity can be an advantage, the scale covers fewer symptoms than other mania scales. Normative data for the ASRM have been gathered across major diagnostic groups ( Altman et al., 1997 ; Altman, Hedeker, Peterson, & Davis, 2001 ).

The ASRM has demonstrated good psychometric properties. A cutoff score of 5.5 is recommended, as it has shown an optimal combination of sensitivity and specificity (85% and 86%, respectively). The ASRM also shows good sensitivity to treatment, with an average decrease of five points after discharge from the hospital ( Altman et al., 2001 ). Finally, the ASRM demonstrated adequate internal consistency and concurrent validity when compared to SADS-based diagnoses, the YMRS ( Young et al., 1978 ), and the Clinician-Administered Rating Scale for Mania ( Altman et al., 1994 , 1997 , 2001 ). It should be noted that both of the published validation studies for the ASRM were conducted by the same research group. On the other hand, the scale has been shown to demonstrate expected correlations with psychological constructs related to mania, such as poor regulation of positive emotions ( Feldman, Joormann, & Johnson, 2008 ).

The Self-Report Manic Inventory (SRMI; Braunig, Shugar, & Kruger, 1996 ; Shugar, Schertzer, Toner, & Di Gasbarro, 1992 ) is a 47-item true–false inventory that assesses increased energy, increased spending, increased sexual drive, increased verbosity, elation, irritability, racing thoughts and decreased concentration, grandiosity, and paranoid or psychotic experiences during the past week, and includes an item that addresses insight. Normative data have been reported in three small studies of inpatients, and these studies each provided estimates of good internal consistency ( Altman et al., 2001 ; Braunig et al., 1996 ; Shugar et al., 1992 ). In two studies, the SRMI was found to have good discriminant validity, differentiating people with bipolar disorder from those with other psychopathology ( Braunig et al., 1996 ; Shugar et al., 1992 ). However, another study found the SRMI to have low concurrent validity as compared to the ASRM ( Altman et al., 2001 ). The scale appears sensitive to change in symptoms. It may not be well suited for inpatient assessment, however, because seven of the SRMI items describe behaviors that would not be possible within a hospital setting ( Altman et al., 2001 ).

The Internal State Scale (ISS; Bauer et al., 1991 ) is a 17-item scale that discriminates mood state and tracks manic and depressive symptoms. There are four empirically derived subscales: Activation, Well-Being, Perceived Conflict, and Depression Index. The Activation subscale (five items) assesses racing thoughts and behavioral activation, specifically feeling restless, sped-up, overactive, and impulsive. These items appear to capture general arousal more than symptoms of mania. Still, the Activation correlates well with other measures of mania ( Bauer, Vojta, Kinosian, Altshuler, & Glick, 2000 ). The overall scale has demonstrated correlations with other measures of mania ranging from .21 to .60 and rates of correct classification ranging from .55 to .78 ( Altman et al., 2001 ; Bauer et al., 1991 ; Bauer et al., 2000 ; Cooke, Krüger, & Shugar, 1996 ). The measure is sensitive to symptom decreases during treatment ( Altman et al., 2001 ; Bauer et al., 1991 ; Cooke et al., 1996 ). Despite these strengths, the ISS scale has a low sensitivity to manic symptoms at the time of hospitalization ( Altman et al., 2001 ). In addition, scoring algorithms vary substantially across studies, as do means and standard deviations of score distributions ( Altman et al., 2001 ; Bauer et al., 1991 ; Cooke et al., 1996 ). Thus, the ISS is not currently recommended.

Self-Monitoring Tools

Continuous monitoring of symptoms and functioning is pivotal for people suffering from chronic, recurrent conditions like bipolar disorder (e.g., Horn et al., 2002 ; Schärer, Hartweg, Hoern, et al., 2002 ). Such frequent monitoring, however, can be expensive both economically and in terms of clinicians’ time. In addition, there is increasing consensus regarding the benefits of a collaborative care model for bipolar disorder, in which patients play an active role in managing their illness ( Bauer et al., 2006a , 2006b ; Sajatovic et al., 2005 ). Enlisting patients’ input can have numerous benefits, including reduced costs, higher patient investment in treatment, and higher validity than clinician observations alone. These benefits may be especially relevant for longitudinal data with high variability, such as may be seen with rapid-cycling patients ( Lam & Wong, 2005 ). In addition to the tracking of bipolar symptoms such as sleep disturbance and mood, self-monitoring may also provide broader information regarding important issues such as medication adherence and psychosocial functioning. These facts have led to a growing literature supporting the use of self-monitoring tools for bipolar disorder. For instance, the NIMH prospective Life-Chart Method (NIMH-LCM-p) can provide detailed information regarding rapid fluctuations in mood ( Denicoff et al., 2000 , 2002 ).

Frequent monitoring of bipolar symptoms can produce so much data that entering and organizing it into a useful format may be incredibly time-consuming. In response to this, some research has focused on the use of palmtop computers and other electronic formats for self-monitoring. Examples include a palmtop version of the NIMH-LCM ( Schärer, Hartweg, Valerius, et al., 2002 ) as well as ChronoRecord software, the latter of which has shown significant correlations with the YMRS ( Bauer et al., 2008 ).

Most of the research in support of self-monitoring in bipolar disorder should be considered preliminary, but promising. In addition to the methods described above, many clients find it helpful to create their own self-monitoring forms or to complete brief checklists to track their progress over time. Many consumer-oriented websites, such as that maintained by the Depression and Bipolar Support Alliance, provide such forms. To increase awareness of symptoms, these self-monitoring forms can be compared to clinician-rated interviews. This is an important area for future study, and it is the hope of the authors that self-monitoring methods continue to be refined and validated for bipolar disorder.

Summary of Symptom Severity Measures

At least two interview measures (the YMRS and MAS), as well as some self-report measures (e.g., the Altman and SRMI), have received psychometric support. Self-report measures can be completed quickly, but brevity and ease of use may also result in reduced precision. Self-monitoring may also be useful to help increase awareness about symptoms and to track progress over time, but further research is required in this domain.

CONCLUSIONS AND FUTURE DIRECTIONS

This article has summarized assessment tools for screening, diagnosis, and symptom monitoring within bipolar disorder. We would note that there are many important aspects of assessment in bipolar disorder that we have not addressed. Although the symptom severity and diagnostic scales covered above predominately address manic symptoms, we urge readers to evaluate a broader range of outcomes, including depression, quality of life, and social functioning. People with bipolar disorder experience at least some depressive symptoms at least one-third of the weeks in a year ( Judd et al., 2002 ; Keck & McElroy, 2003 ), and these subsyndromal depressive symptoms can be associated with substantial impairment across a variety of domains ( Altshuler et al., 2006 ). High risk for suicide has been documented during depression within bipolar disorder ( Angst et al., 2005 ); thus it will also be important to assess for depressive symptoms and suicidality. To date, there is strong evidence that bipolar and unipolar depressive symptoms are relatively similar ( Johnson & Kizer, 2002 ), so applying the well-validated measures of depression from the unipolar literature is a reasonable strategy. Patients report that improvement in quality of life is a more important treatment goal to them than are specific symptoms, highlighting the importance of this oft-ignored domain ( Michalak, Yatham, Kolesar, & Lam, 2006 ). Whereas measures of these constructs have been developed for other disorders such as depression and schizophrenia, this is a realm that remains largely untapped for bipolar disorder, with at least one exception (e.g., Michalak et al., 2006 ). In addition, there is some debate regarding the ultimate treatment goals for bipolar disorder. Given the high base rates of subsyndromal symptoms, complete recovery may be an unrealistic goal, or require levels of medication that would lead to intolerable side effects ( Sachs & Rush, 2003 ). Proper care must take individual needs into account, but to date little research has directly addressed this issue. Overall, it is highly recommended that researchers and clinicians pay attention to issues that extend far beyond the level of mania. For those who seek a more detailed review of assessment measures for bipolar disorder or psychiatric conditions more generally, the authors recommend comprehensive books such as the Handbook of Psychiatric Measures ( Rush, First, & Blacker, 2008 ).

Returning to the focus of this article, though, the good news is that well-validated tools exist for the assessment of mania in adults. Reliable and valid measures are available for the diagnosis of bipolar I disorder, and indeed, the psychometric characteristics of these tools are as good as those seen for most Axis I disorders. Similarly, scales are available to measure symptoms using both interviewer and client perspectives.

On the other hand, much work remains to be done in this domain. A first goal would be the refinement of diagnostic measures for bipolar II disorder and other milder forms of bipolar disorder. Ideally, research and dialogue in the near future will help to establish accepted standards for defining hypomanic episodes. A second major goal is the refinement of screening tools. With the possible exception of the GBI, no self-report measure has consistently achieved acceptable levels of sensitivity and specificity within community samples, and conclusions regarding the GBI are limited by the existence of several different versions and cutoffs. One might expect that the most pressing need would be for screening tools that were viable for community or outpatient screening, as by the time a person is hospitalized, symptoms may be so extreme as to be easily diagnosed. A third major goal is more systematic research on how to integrate clinician and self-report ratings of symptom severity, especially in the face of potentially impaired insight for those with bipolar disorder ( Ghaemi, Boiman, & Goodwin, 2000 ). Intriguingly, although researchers have now begun to examine the relative weight to give ratings from different informants in understanding juvenile bipolar disorder ( Findling et al., 2002 ), such research has not been conducted in adult bipolar disorder. Rather, researchers focused on adult bipolar disorder have often failed to take into account patient perspectives on severity. We are hopeful that future research will continue to refine this field, and that this review has illuminated research challenges to be tackled.

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15 C15 Assessment Tools

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Bipolar disorders are difficult to diagnose and treat, despite their global prevalence and pervasiveness. With the proper tools, however, clinicians and researchers alike are able to detect bipolar disorders in their patients and establish the proper treatment plans. Knowing the prevalence of bipolar disorders and other common diagnoses in a specific setting, gathering predictive information before the first visit, and screening patients with efficient, low-cost assessment options are a few of the ways that clinicians can be better prepared to detect bipolar disorders in their patients. Further, assessment should not halt once a diagnosis is established; brief, recurring measures to collect data about a patient’s current state throughout treatment offer important information about symptoms, progress, and how a treatment plan can be tailored to meet a client’s ongoing needs. This chapter equips clinicians and researchers with the tools to confidently diagnose their patients with bipolar disorders, suggesting tips to establish diagnostic hypotheses as well as specific assessments for both adults and youths for whom the diagnosis seems likely. Technology in particular offers the opportunity to access low-cost assessment options and administer ongoing measures to ensure that clinicians continue to meet their patients’ needs throughout the treatment process.

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Bipolar Disorder

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Bipolar disorder, also known as bipolar affective disorder, is one of the top 10 leading causes of disability worldwide. Bipolar disorder is characterized by chronically occurring episodes of mania or hypomania alternating with depression and is often misdiagnosed initially. Treatment involves pharmacotherapy and psychosocial interventions, but mood relapse and incomplete response occur, particularly with depression. Continual reevaluation and treatment modification are commonly required during the long-term care of patients with bipolar disorder. Management of comorbid psychiatric and chronic medical conditions may also be necessary. This activity reviews the etiology, classification, evaluation, management, and prognosis of bipolar affective disorder, and it also highlights the role of the interprofessional team in managing and improving care for patients with this condition.

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This activity has been designed to meet the educational needs of physicians, physician associates, nurses, pharmacists, nurse practitioners, and social workers.

Learning Objectives

Recognize patterns of symptoms suggestive of bipolar disorder, its various subtypes, and related disorders.

Implement evidence-based management of bipolar disorder based on current published guidelines.

Select individualized pharmacotherapy plans and adjunct therapies for bipolar disorder and comorbidities.

Describe the necessity of an interprofessional holistic team approach that integrates psychiatric and medical healthcare in caring for patients with bipolar disorder to help achieve the best possible outcomes.

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Bipolar Disorder: Biopsychopharmacosocial Approach Essay

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Steven is a forty-three-year-old American male that has lived alone in his house for more than ten years. He has a longstanding diagnosis of bipolar disorder which was diagnosed in the patient fifteen years ago. The individual has been admitted to several mental health rehabilitation centers after the episodes of severe depression and the related suicidal thoughts and one attempt. Steven is divorced, and his condition was among the causes of the split with his wife. The analysis of Steven’s case is based on Clark and Clarke’s (2014) biopsychopharmacosocial (BPPS) approach to psychiatric nursing, which entails the promotion of patient-centered care and planning by exploring the relevant areas of influence.

The physical health of Steven requires the management of a range of comorbidities. Over a decade ago, he was diagnosed with liver disease, which runs in his family. However, his lifestyle and unhealthy dietary choices have certainly contributed to the diagnosis. It is crucial to managing Steven’s liver damage because of the possibility to result in scarring and subsequent liver failure, which is a life-threatening condition (Osna et al., 2017). To manage the condition, Steven has been prescribed medications, but he has often failed to take them because his psychological health was debilitating.

Psychological

The patient’s mental health negatively influences his quality of life. Specific triggers for both manic and depressive symptoms include prolonged alcohol use, loneliness, and stressful events. The patient’s bipolar disorder is characterized by the prevalent occurrence of depressive features with a less lasting presence of ‘low’ episodes (Bobo, 2017). Steven’s bipolar disorder-related depressive symptoms manifest through the decreased appetite to the point of not eating anything for several days. The patient has also experienced extreme fatigue and low energy alongside feelings of hopelessness, despair, guilt, and worthlessness (Koenders et al., 2020). At present, Steven has been prescribed the atypical antipsychotic lurasidone (Latuda) in combination with Lithium to treat his symptoms of bipolar depression (Ostacher et al., 2017).

The manic episodes in Steven’s case are characterized by racing thoughts, increased agitation and activity, as well as the decreased need for sleep to the point of not sleeping for forty-eight hours and more (WHO, 2019). In addition, the patient reported having poor decision-making during his manic episodes. Steven also reported distorted sleeping patterns as one of the most consistent and long-term symptoms of bipolar disorder (Gold & Sylvia, 2016). Disruptions in his sleep have been directly associated with either high or low episodes. When Steven experiences manic episodes, his sleep patterns change to the opposite. The extreme levels of energy and racing thoughts make it difficult for him to fall asleep to the point that he has to take medication that would allow him to have some sleep.

Steven has been known to be harmful toward himself during depressive bipolar disorder episodes. During a severe ‘low,’ Steve drank a bottle of vodka and got to a high floor in his apartment complex, and stood on the ledge of a balcony for several minutes before his neighbor noticed him and pulled him from the dangerous spot. Such behavior is troubling because individuals with BD are at high risk for suicide, especially if their condition remains untreated (Dome, Rihmer, & Gonda, 2019).

The patient has had some experience with receiving mental health services acutely. He was admitted to a mental health ward after attempting to jump off a balcony during a depressive episode. Steven was prescribed medication and referred to a mental health specialist, but he failed to continue his care on a long-term basis because the manic episode gave him the sense of confidence that he was fine, even when he was not. However, without consistent support, therapy, and medication, Steven finds himself spiraling into severe depression after a manic episode and the related comorbidities (Post, 2020).

Pharmacological

From the pharmacological perspective, Steven has shown several side effects from the prescribed medication. During the first years after the initial diagnosis of bipolar disorder, Steven has been prescribed an antidepressant (Lexapro) to manage his ongoing depressive symptoms. However, there have been limited results with the prescription because of its varied effectiveness for bipolar depression (Jelen & Young, 2020). Lexapro was a mistake in prescription in Steven’s case because the medication is recommended not to be given as a monotherapy option in individuals with bipolar (Yamaguchi et al., 2018). Taking antidepressants for several years has resulted in Steven developing more pronounced and severe episodes of mania.

After the failure with taking antidepressants, Steven was prescribed a mood stabilizer Lithobid, 300 mg per day. After taking Lithium for some time, Steven realized that the medication was more effective in treating his manic episodes rather than depressive ones (Gitlin, 2016). This resulted in the furthering of the depressive symptoms and increased suicidal ideation, which led to a suicide attempt by trying to jump from a balcony of his apartment building. After being admitted to an acute psychiatric facility, Steven received an adjusted medication prescription which included a combination of a mood stabilizer and an atypical antipsychotic drug.

Over time, Steven has found it more challenging to manage his condition with medication. Lithium has taken a toll on Steven in terms of his physical health as it has resulted in persistent headaches, dizziness, appetite changes, hand tremors, as well as occasional nausea and vomiting (Ortiz & Alda, 2010). The prescription of lithium in Steven’s case has been problematic because of his liver disease. As Carrier et al. (2016) and Culpepper (2014) found in patients with advanced chronic liver diseases, the prescription of specific psychiatric treatments should be avoided. The fact that Steven has already had liver disease before being diagnosed with bipolar I disorder should be considered in the further recommendations concerning his treatment.

Before being diagnosed with bipolar disorder, Steven had frequently used alcohol as a means of coping with his depressive state. He did not understand that he was experiencing a bipolar ‘low’ and considered his feelings sadness and anxiety and wanted to numb them with the help of alcohol (Johnson, 2018). When Steven was in an elevated mood, he felt that alcohol would help him stay active and excited. However, overusing alcohol during the periods of ‘highs’ led to Steven falling back into a depressive state quickly (WHO, 2019). Taking medicines for bipolar disorder with alcohol can exacerbate adverse side effects such as dizziness, the impairment of memory, confusion, as well as increased risks for falls and injury (Anderson, 2019).

Steve currently lives alone and has lived alone for quite some time because of the divorce. He does not hold any aggression toward his former wife and blames all bad events on himself and his inability to take the situation under control. He has no siblings and very few friends, spending most of his time at home. The social isolation has caused some issues in his mental state and the worsening of depressive symptoms because there is no one there to offer help or support. Steve’s former wife calls him occasionally to remind him to take his medication.

Being on his own and having a weak support system makes Steve consider suicide during his depressive episodes. COVID-19 and the associated lockdown orders have reduced the social interaction Steven gets further, creating conditions of extreme isolation for him. As Pfefferbaum and North (2020) note, the pandemic has had substantial negative effects on people’s mental health overall, with those most vulnerable affected especially strongly. Due to lacking social support, the patient sees alcohol use as the answer to loneliness and as a way to uplift one’s spirits (Brooks et al., 2017). He quit his office job and has worked remotely since the symptoms have become debilitating. However, being alone at home meant that Steven had less structure in his life, which reduced stress and social responsibility; however, it furthered his depressive episodes (Dome et al., 2019).

Critique of the BPPS Model

While the BPPS model has found widespread adoption in healthcare, it has some substantial issues that its critics frequently highlight. One position aims to expand the model, with its adherents stating that its lack of a spiritual domain reduces its effectiveness. They claim that, since one’s spirituality substantially affects their beliefs on matters such as hope or suicide, it has to be explicitly included in the analysis. The opposite perspective is outlined by Huda (2019), with its proponents criticizing the nonscientific nature of the BPPS model. They state that it is poorly defined, complicating analytic understanding through the introduction of vaguely related perspectives and their equal consideration, which in practice is not always substantiated. As a result, it is possible for the model’s user to become distracted by minor facts and misunderstand the patient’s condition.

Mental State Examination

• Level of consciousness: normal.
• Appearance and General Behavior: the patient looks older than their stated age due to the poor visible condition of their skin. He is unkempt, likely due to his tendency not to leave his house and generally antisocial patterns of behavior. The patient’s clothing is subdued and dirty, his posture is kyphotic, and his gaze is furtive.
• Speech and Motor Activity: no problems with output or articulation, no signs of mania being shown currently. Movement is slow and non-spontaneous, likely as a result of the patient experiencing a “low” at the moment.
• Affect and Mood: affect is restrained, with the patient showing limited emotional responses. The overall mood is negative and dysphoric in its overall nature, indicative of a depressive condition.
• Thought and Perception: the patient does not exhibit signs of a thought disorder. His ideas appear to be realistic and rooted in events he has experienced. His concerns are realistic, though his condition sometimes elevates them to irrational levels.
• Attitude and Insight: the patient demonstrates a highly pessimistic attitude, claiming that he has already tried all he could and that it has not helped. This experience also leads him to demonstrate signs of helplessness and surrender to his condition. He views the illness as nonpsychiatric, considering it the result of his failures in life as well as alcoholism.
• Examiner’s Reaction: examiner felt that the patient was not particularly unusual, exhibiting the standard signs of depression. With that said, they expect that the patient may show a different response if examined during a manic episode.
• Attention: the patient has somewhat diminished reaction speed and ability to memorize sequences of letters. However, the abnormality is not large and can be attributed to his alcohol abuse.
• Language: no visible issues. The patient has passed both speaking and comprehension tests without much difficulty.
• Memory: the patient has complained of memory loss episodes, mostly related to alcohol binge drinking. Other than that, their short- and long-term retention appear to be at levels that are close to optimal.
• Constructional Ability and Praxis: while the patient is experiencing tremors, they do not impede him from performing learned motor acts. They do not suffer from a constructional inability or other mental impediments in this regard, either.
• Abstract Reasoning: the patient is experiencing few to no issues with his abstract reasoning. Tests have shown that it is functioning normally, and the patient’s overall presentation supports this conclusion.

Care Plan Commentary

Steven’s case calls for a comprehensive and rigorous overhaul of the. The plan is patient-focused and was developed through collaboration with Steven who identified his needs in terms of his areas of influence (Gliedt et al., 2017). It also follows guidelines by the National Institute of Health and Cares Excellence (2016), which demand adherence to person-centered and recovery-focused care in all aspects of nurse training and work. The nurse acted as the liaison between the patient and the various medical professionals whose aid was required. The BPPS model used for exploring Steven’s case has provided valuable data about Steven’s prior interactions (Gliedt et al., 2017). The adverse interactions between the four areas of influence contributed to the deterioration of his psychological health as well as increased alcohol use (Carrier et al., 2016). The care plan has been made accessible and provided to Steven in both printed and digital formats (NMC, 2020). Evidence-based interventions that address the mental health issue go beyond the psychological component and also help patients deal with stigmatization and discrimination (O’Donnell et al., 2018). Drawing from the evidence provided by Smith et al. (2013), the care plan will rely on regular patient-provider relationships, with an ongoing review and assessment leading to changes if necessary. Steven has a clear understanding of the services provided to him by his healthcare team, which is essential for care continuity and patient education (NMC, 2020).

Evidence-based management of liver disease implemented is a biological intervention that includes BCAA-rich supplementation, abstinence from consuming alcohol, corticosteroid therapy, and adherence to a strict dietary regimen (Fukui et al., 2016). Steven is set to undergo regular screenings with the assigned nurse, which will liaise with an interdisciplinary team that also includes his psychotherapist, a pharmacologist, a dietician, and a social worker. The pharmacologist will review Steven’s prescriptions and adjust them if necessary (Carrier et al., 2016). The nurse will structure their interventions around therapeutic engagement, following practices such as active listening and regular devotion of time.

The role of Steven’s nurse caretaker is the regular monitoring of his vital signs, introducing monitoring charts for food and fluid intake. Steven will be subjected to the NEWS tool to monitor changes in his health. Specifically, the tool will monitor respiratory rate, oxygen saturation, body temperature, systolic blood pressure, heart rate, and BPM. The nurse will also regularly schedule liver function test screenings for the patient and attend them with Steven. In collaboration with the nurse, a dietician will develop a plan of nutrition. EBP recommendations for a liver disease-specific diet include a decreased intake of carbohydrates and high-fat foods, adequate hydration, as well as tobacco and alcohol abstinence (Arab et al., 2014). Smoking and alcohol cessation interventions will also be carried out.

A significant issue in Steven’s treatment is that he struggles with following his medication schedule despite having a monitor and with lithium level assessments. To that end, the nurse caretaker will help him develop a system that will enable him to take his medication regularly and consistently. They will educate him about the side effects and interactions of all the drugs he is currently taking or will be prescribed. Per “Lexapro side effects” (2020), the drug can commonly cause “diarrhea, drowsiness, ejaculatory disorder, headache, insomnia, nausea, and delayed ejaculation.” Lithobid, on the other hand, can result in a broad range of effects, such as fainting, thirst, weight gain, acne, diarrhea, and others, but they are less common (“Lithobid side effects,” 2020). The two drugs also interact with each other, increasing the risk of an irregular heart rhythm, and the side effects of both are exacerbated by alcohol intake (“Drug interaction report,” n.d.). Hence, Steven needs to reevaluate his drug and alcohol intake practices with the nurse caretaker’s help.

Steven has experienced a variety of lithobid side effects, which were exacerbated both by his alcohol intake and by his liver disease. Most commonly, he has had headaches, felt dizzy, and experienced hand tremors, and more rarely, he has had nausea and vomited. Since Lithobid is not recommended for his state (Carrier et al., 2016), Steven should stop taking the drug. The levels in Steven’s blood will be monitored, and the prescriptions will be regularly discussed with the pharmacist, the psychiatrist, and other nurses. It will be replaced with a more suitable pharmacological intervention should this replacement (as opposed to the removal of the drug’s intake) be necessary. The replacement drugs will be screened for side effects and interactions and adjusted in the case their usage is not acceptable. Mwebe (2018) also recommends the usage of the Glasgow Antipsychotic Side Effect Scale (GASS). Steven will also learn about the common side effects of each medication he is taking and the coping methods to use should they arise.

The nurse will carry out patient-provider meetings once every two weeks to identify the effectiveness of the sequence of therapeutic interventions and prioritize the steps based on Steven’s feedback (Smith et al., 2013). Both face-to-face and web-based CBT will be implemented to address Steven’s depression and suicidal thoughts, prevent their onset, avoid ED visits and hospitalizations linked to suicidal attempts, and decrease the medical risks of self-injurious acts (Brodsky, Spruch-Feiner, & Stanley, 2018). In addition, the CBT Readiness Assessment Tool was used, resulting in a score of 7 (based on the Likert scale between 0 and 10), indicating Steven’s higher than average level of readiness (Trusz et al., 2011).

Another significant issue Steven has is that, until recently, he did not understand the condition that he had, which resulted in him misjudging his depressive episodes and coming close to suicide as a result. To prevent the emergence of similar issues in the future, Steven will have to undergo education about his symptoms and triggers. It will be continuous and enable him to see the negative effects of his excessive alcohol intake. He will learn how to recognize the early signs of an incoming episode so that it does not take him by surprise. He will also learn the appropriate responses, such as calling the appropriate number (learning which will be part of the intervention). In addition, the patient and the caretaker will review the strategies and medications that have been successful in the past. This information can be included in Steven’s advance care plan so that his helpers know what actions to take to manage his crisis even if they are not experienced in caring for him (Nizette, O’Brien, & Evans, 2016). As a result, he will be prepared for his condition and be able to mitigate the effects of the episodes, reducing the negative effects they have on his life. Johnson (2018) also recommends the usage of a bipolar diary for the patient to document his moods. In doing so, he will be able to understand the qualities each of his moods has and control themselves better.

Examples of numbers that Steven can call for support in crises include his nurse caretaker, care coordinator, friends, family, and local crisis management hotlines. The nurse will work with Steven to develop a collaborative crisis plan per National Institute for Health and Care Excellence (2020) recommendations. Additionally, the training will focus on identifying Steven’s strengths that will let him overcome his issues internally. Per the recommendations by Kvam et al. (2016), it will recommend that he engage in exercise to help deal with his depression. The role of the nurse caretaker in this effort is to help the patient achieve personal growth and capitalize on their strengths to achieve partial or full independence (Hercelinskyj & Alexander, 2020). One example of an approach that can help Steven learn how to manage his condition is CBT, which will help him identify misconceptions and problematic thinking patterns in which he engages during critical situations. The nurse can refer Steven to a qualified therapist to perform this procedure.

Finally, the intervention will focus on Steven’s troubled sleep patterns. The nurse caretaker believes that the reason for this problem is that his daily life practices are not conducive to healthy sleep, with a variety of problematic behaviors compounding to result in serious sleep issues. Hence, he will undergo sleep hygiene education to inform him of what factors may cause him to have difficulty going to sleep and how he may address them. Per Pandi-Perumal, Narasimhan, and Kramer (2017), this learning consists of studying practices that affect sleep, such as alcohol consumption in the evening, and a review of current issues and ways to fix them with the physician. Through this holistic assessment, the patient and the caretaker will develop a comprehensive plan for addressing the former’s problems that will be integrated into the broader treatment program. Steven’s sleeping patterns will also be monitored to determine his progress in overcoming the issue, with additional reviews and interventions taking place if the current intervention is unsuccessful.

Because the patient indicated that his support system was weak, the emphasis of the nurse’s agenda is regularly reviewing Steven’s daily life in society (NMC, 2020). As suggested by Naylor et al. (2016), the integrated health approach will help individuals like Steven to improve their social, mental, and physical wellness. Evidence-based intervention for increasing social support to the patient includes reducing Steven’s social isolation through him engaging in community groups, extending social support outreach by engaging in work and hobbies, as well as facilitating self-development (O’Rourke, Collins, & Sidani, 2018). Specific hobbies that Steve will undertake include painting, yoga, and meditation. The latter two have the potential of improving his physical health and being complementary to the established mental health improvement plan (Kaushik et al., 2020).

Cognitive Behavioral Therapy Critique

The plan is extensive and likely to take a substantial time to implement, over which Steven’s progress will have to be carefully monitored. The patient will have to educate himself extensively, and the nurse will need to monitor him and act as a liaison to the other team members. There is a risk that they will not be able to devote enough time to the patient and that issues will go unnoticed. Crises are also problematic, as, without constant oversight, the patient will not necessarily be able to manage the episode alone. With that said, this plan combines mental health treatment and society reintegration best, which is why it was formulated in this form. CBT should also be approached carefully, as Townend et al. (2017) highlight its recent apparent loss of effectiveness. Steven’s readiness to engage in it is also in question, and Wenzel (2017) recommends the use of motivational interviewing before engaging in CBT. CBT is also not holistic, focusing excessively on mental processes and ignoring the social, biological, and environmental factors.

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Clark, L., & Clarke, T. (2014). Realizing nursing: A multimodal biopsychopharmacosocial approach to psychiatric nursing. Journal of Psychiatric and Mental Health Nursing, 21 (6), 564-571. Web.

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Gliedt, J., Schneider, M., Evans, M., King, J., & Eubanks Jr., J. (2017). The biopsychosocial model and chiropractic: A commentary with recommendations for the chiropractic profession. Chiropractic & Manual Therapies, 25 (16). Web.

Gold, A. K., & Sylvia, L. G. (2016). The role of sleep in bipolar disorder. Nature and Science of Sleep, 8 , 207-214. Web.

Hercelinskyj, G., Alexander, L. (2019). Mental health nursing: Applying theory to practice . Melbourne, Australia: Cengage Learning Australia.

Huda, A. S. (2019). The medical model in mental health: An explanation and evaluation . Oxford University Press.

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Johnson, J. (2018). How does alcohol affect bipolar disorder? Web.

Johnson, S. L. (2017). Therapist’s guide to clinical intervention: The 1-2-3’s of treatment planning (3 rd ed.). Elsevier Science.

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Appendix A: Plan of Care

Identified needs.

• Mental health needs: establish mental health at a manageable level for the patient as related to his bipolar disorder diagnosis;
• Physical health needs: manage physical comorbidities associated with bipolar medication side effects as well as the long-term diagnoses of liver disease;
• Behavioral needs: managing depression and mania as well as suicidal thoughts, prevent self-harm.
• Self-care needs: establish a cohesive self-care plan that includes dietary and lifestyle changes, smoking cessation, and mild physical activity;
• Social needs: improve socialization with friends, family, and members of the community.

SMART Goals

• Mental Health SMART Goal: To help reach a stable mental health baseline with holistic and pharmacological treatment and improve life quality despite Steven’s diagnosis.
• Physical Health SMART Goal: To enable Steven to reach the desired quality of physical health through appropriate diet and lifestyle choices, medication, and alcohol abstinence.
• Behavioral Health SMART Goal: To help Steve live with his diagnoses safely and without risks by teaching preventive measures and holistic practices for balanced behavior.
• Self-care SMART Goal: To help Steven act in his personal care, healthy lifestyle choices, and self-development.
• Social SMART Goal: To enable socialization and interactions with the outside environment by promoting independence and the strengthening of relationships.

Actions/Interventions

Mental Health (psychological)

• Closely monitor whether the patient takes the prescribed medication for the management of his bipolar diagnosis;
• Schedule therapy appointments beforehand so that Steven has a clear idea of his schedule; explain the importance of attending them regularly;
• Use frequent follow-ups and calls with Steven to facilitate close communication and monitoring of the patient’s status;
• Reduce the severity of Steven’s depressive episodes by allowing him to express his feelings and discover his triggers independently.
• Encourage Steven to participate in activities he likes and promote his integration into a social network.

Medications (pharmacological)

• Review the medications Steven is taking, determine their side effects, contraindications, and interactions.
• Replace any potentially dangerous medications with safer alternatives.
• Provide Steven with help purchasing the medications and learning how to use them.
• Establish a medication schedule and help Steven adhere to it.

Physical Health (biological)

• Ensure that the patient takes the necessary medication for managing his liver disease;
• Schedule follow-up appointments every six months to screen Steven’s liver for any further damage associated with prescription medication for bipolar disorder;
• Encourage reduction and the subsequent cessation of alcohol to improve liver health as well as prevent adverse interactions between BD medication and Steven’s liver condition.
• Discuss Steven’s attitude to eating and take his weight regularly. Consult with a psychiatrist and a dietician to monitor Steven; use food and fluid charts.

Behavior (psychological)

• Healthcare team to differentiate between Steven’s manic and depressive symptoms to understand the influence on the patient;
• Persistent and longstanding periods of depression should be monitored carefully to prevent suicidal thoughts, self-harm, as well as suicidal attempts;
• Encourage Steven to find a creative outlet in order to put his struggles in a positive direction;
• Facilitate holistic practices such as meditation, yoga, and other practices of mindfulness.
• Educate Steven about sleep hygiene and develop a plan for overcoming his issues.

Self-Care (psychological)

• Help Steven develop a personalized and comprehensive self-care plan that involves a sleeping schedule, a diet and exercise program, and a schedule of taking prescription medication.
• Remind Steven of the regular therapy visits as well as any other check-ups and follow-ups.
• Ensure that Steven follows the plans and reports any challenges in compliance with his physician.
• Educate Steven about his symptoms and how to manage them by giving him crisis and GP numbers.
• Help Steven find value in social interactions by enabling him to communicate with people more and share his struggles with others;
• Enable participation in support groups for individuals with mental health diagnoses
• Encourage reconnecting with old friends, colleagues, and family members to establish a robust support system.

Contingency Plan for a Crisis

• It is recommended to implement the following steps in case of a crisis relapse associated with a suicide attempt during a depressive episode.
• Control correct and appropriate administration of medication for bipolar disorder;
• Get the patient under the surveillance of healthcare specialists or in a designated mental health setting;
• Refer to a therapeutic professional, such as psychologist and psychiatrist;
• If mental health continues deteriorating, consider admitting Steven to an inpatient facility for continuous monitoring and therapeutic processes.

Risk Assessment

• History of suicidal ideation and attempts: therapy, community support groups, environmental safety controls, regular follow-ups, and check-ins;
• Increased alcohol use: replacement therapy, community support groups, a lifestyle and dietary change plan;
• Risks of liver disease exacerbation: encouraging a healthy lifestyle change, a cohesive diet plan, alcohol use cessation;
• Risks of physical exhaustion: facilitating a healthy sleeping schedule, the introduction of mild exercises;
• Loneliness and isolation: participating in social activities, creating a support network for him;
• Causing harm to others: therapy, ongoing monitoring of the mental state, improved quality of interactions with friends and relatives;
• Risk of injury: appropriate medication concordance.
• Liver disease exacerbation: implementing regular and effective screening for viral hepatitis and steatohepatitis; lifestyle and dietary adjustments;
• Absence of motivation and interest in life: encouraging taking up hobbies, engaging in volunteering, seeking community support, setting short-term goals.

BPPS Diagram

• The Psychosocial Context of Bipolar Disorder
• Bipolar Disorder and St. Augustine Florida
• Cognitive-Behavioral Therapy for Bipolar Disorder
• The United States Healthcare Intervention on Suicide Crisis
• Psychotherapeutic Drugs: Types and Usage Spectrum
• Anxiety and Depression in Hispanic Youth in Monmouth County
• Research-Based Psychoeducational Article Summaries
• Alternative to Incarceration (ATI), Treatment Court
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2022, July 2). Bipolar Disorder: Biopsychopharmacosocial Approach. https://ivypanda.com/essays/bipolar-disorder-biopsychopharmacosocial-approach/

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Bibliography

IvyPanda . "Bipolar Disorder: Biopsychopharmacosocial Approach." July 2, 2022. https://ivypanda.com/essays/bipolar-disorder-biopsychopharmacosocial-approach/.

Bipolar Disorder

Yes, i'm studying to be a social worker. yes, i have a mental illness..

I have a mental illness and I am studying to be a social worker.

Two distinct memories stand out as I write this: the day I was accepted into a prestigious school of social work — and the day I was diagnosed with bipolar 1  disorder. Now that I am half-way through my social work degree, I can see how those two pivotal moments in my life have collided to give me purpose and motivation to keep fighting — for my own wellness and for those who still feel silenced or marginalized.

• What is Bipolar disorder ?

It started off as a nuisance. It was March of 2017, and one night I couldn’t sleep. I didn’t think much of it, chalking it up to stress. Then I didn’t sleep the next night, or the night after that . By day three, I refused to go inside because of the paranoia I was experiencing, despite it being -20 degrees Celsius outside. I developed frostbite on my toes. I wandered around the vast city I lived in without sleep or food, talking nonsensically and rapidly to anyone who would listen. I vividly remember the fourth night of being awake. It was St. Patrick’s Day and I was sprawled outside Wendy’s with nothing but spilled, cold coffee to my name. I decided I should probably see a doctor. After a rapid assessment of my presentation, my doctor sent me to the ER for an assessment by a psychiatrist, who explained I was experiencing a manic episode requiring hospitalization, proceeding to diagnose me with bipolar 1 disorder. After resting my brain for a month in the hospital, I was placed on medication that leveled out my highs and lows to allow me to lead a fulfilling life with minimal symptoms. On my discharge date, I walked out of that hospital with new hope, a fresh perspective, a calm mind and the tools to manage my illness. I have never returned.

I then decided I wanted to be a social worker so I could be a light in someone’s darkness, mirroring the people who had been a light in my own distress. Three personal essays, two references, a resume and a list of volunteer and work experiences later, my application was mailed off — on the exact deadline to apply.

When a letter arrived in the mail, I assumed the worst. I didn’t even want to open it. When I did, the only word I saw was, “Congratulations!” before I started crying. I thought, how could someone like me, mentally ill with bipolar disorder , be accepted into such a rigorous program? I questioned whether I was deserving to have that seat or not. Surely, there were other people more qualified, right?

I am writing this exactly two years after receiving that piece of paper accepting me into their program. I was chosen for this profession, not because of my illness, but because my illness is not  correlated with my ability to be a good social worker. I am just as deserving to be in this program as any of my other hardworking classmates. I will soon be working in the field, dedicating my professional life to helping others.

If you have a mental illness and want to work in the helping field, please believe me when I say the following:

1. Despite the rampant stigma that somehow being mentally ill exempts you from being a health care provider, that is not true. I am proof that is not true. One of my favorite quotes is: “I love when people who have been through hell walk out of the flames carrying buckets of water for those still consumed by the fire.” Recovering from bipolar disorder felt like hell, yet those experiences have prepped me to be a caring, considerate social worker carrying those buckets of water for people behind me still in the fire. You cannot learn empathy from a book, but I certainly learned it through my experiences with bipolar . I am not grateful for this illness, but I am grateful for the lessons it has taught me.

2.  Living with a mental illness does not make you incompetent. It may even give you a leg up because you can understand, deeply, what it means to struggle. You can relate to clients/patients/customers in a way that will make them trust you, talk to you and have confidence in you.

3.  View your illness as a strength, not a weakness. Remember, it’s not a character flaw.

4.  If you have bipolar or any other mental illness , that is out of your control and not your fault. You can control making the choice to live your life passionately despite of, and because of, your illness.

Yes, I have bipolar disorder .

Yes, I was admitted to a psychiatric facility when I was sick. Yes, I take medication every day to regulate my mood. Yes, I see a psychiatrist.

Yes, I made the Dean’s list. Yes, I have been appointed to the School’s student committee. Yes, I volunteer with non-profits, work with people with disabilities and sit on a board of directors.

I will not be just a social worker. I will be an understanding, empathetic, passionate, mentally ill social worker.

And that is more than OK.

Whatever your dream is, never let the fear of accomplishing it with a mental illness hold you back. Your illness is part of you — take it with you, but do not let it dictate where you go.

We want to hear your story.

Do you want to share your story? Click here to find out how.

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POTS / living my best life / advocate

• Open access
• Published: 05 January 2024

Cognitive behavioural therapy for social anxiety disorder in people with bipolar disorder: a case series

• Barbara Pavlova 1 , 2 ,
• Emma Warnock-Parkes 3 , 4 ,
• Martin Alda 1 , 2 ,
• Rudolf Uher 1 , 2 &
• David M. Clark 3  

International Journal of Bipolar Disorders volume  12 , Article number:  1 ( 2024 ) Cite this article

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Social anxiety disorder increases the likelihood of unfavourable outcomes in people with bipolar disorder. Cognitive behavioural therapy (CBT) is the first-line treatment for social anxiety disorder. However, people with bipolar disorder have been excluded from the studies that this recommendation is based on. 

We completed a case series to obtain initial data on whether CBT is an acceptable, safe, and effective treatment for social anxiety disorder in people with bipolar disorder.

Eleven euthymic participants with bipolar disorder attended up to sixteen treatment and three follow-up sessions of CBT for social anxiety disorder. Participants attended on average 95% of the offered CBT sessions. No adverse events were reported. Participants’ mean score on the Social Phobia Inventory decreased from 46.5 (SD 6.6) before the treatment to 19.8 (SD 11.9) at the end of the sixteen-session intervention and further to 15.8 (SD 10.3) by the end of the 3-month follow-up. This degree of improvement is equivalent to the effect observed in studies of CBT for social anxiety disorder in people without severe mental illness.

Conclusions

This case series provides preliminary evidence that CBT is acceptable, safe, and effective for treating social anxiety disorder in people with bipolar disorder during euthymia. A randomized controlled trial is needed to confirm these findings, and to establish whether treatment for social anxiety disorder improves the course of bipolar disorder.

Introduction

Bipolar disorder affects 1–2% of the population (Merikangas et al. 2011 ; Clemente et al. 2015 ; Moreira et al. 2017 ; Humpston et al. 2021 ). Effective treatments are available (Yatham et al.  2018 ) but treatment outcomes are mixed. While some people with bipolar disorder return to their premorbid level of functioning, many experiencelongstanding functional impairment (MacQueen et al.  2001 ; Judd et al.  2008 ; Marwaha et al.  2013 ). A diagnosis of bipolar disorder shortens one’s life by almost 13 years (Chan et al.  2022 ).

One predictor of unfavourable course of illness in people with bipolar disorder is a comorbidity with anxiety disorders, which is associated with negative outcomes, including an overall higher severity of bipolar disorder (Pavlova et al.  2018 ), shorter time to relapse (Lorenzo-Luaces et al.  2018 ) and suicide attempts (Simon et al.  2007 ; Amuk and Patel  2020 ). This comorbidity is common. Almost a half of people with bipolar disorder meet diagnostic criteria for an anxiety disorder in their lifetime (Pavlova et al. 2015 ). This is not simply anxiety occurring during depressive episodes, because a third of individuals with bipolar disorder, still meet diagnostic criteria for an anxiety disorder during euthymia (Pavlova et al.  2017 ).

Social anxiety disorder is one of the most common anxiety comorbidities in people with bipolar disorder. 20% of people with bipolar disorder have a lifetime diagnosis of social anxiety disorder (Pavlova et al.  2015 ), and 10% of people with bipolar disorder still meet diagnostic criteria for social anxiety disorder when they are euthymic (Pavlova et al.  2017 ). Several investigations have linked social anxiety disorder with increased rates of suicidal ideation and behaviour (Perroud et al.  2007 ; Kocabas et al.  2019 ; Amuk and Patel  2020 ; Masi et al.  2021 ), as well as with substance use problems (Yapici Eser et al.  2018 ) in people with bipolar disorder. These associations were stronger for social anxiety disorder than for any other anxiety disorder (Perroud et al.  2007 ; Yapici Eser et al.  2018 ; Kocabas et al.  2019 ).

While a number of people with bipolar disorder need treatment for social anxiety disorder, the use of some of the treatments is problematic in this population. Antidepressants, specifically the selective serotonin reuptake inhibitors, are the main pharmacological treatment for anxiety (Baldwin et al.  2014 ; Katzman et al.  2014 ), including social anxiety disorder (Mayo-Wilson et al.  2014 ). However, they may destabilize mood in people with bipolar disorder, especially if used without a mood stabilizer (Viktorin et al.  2014 ; McGirr et al.  2016 ). Benzodiazepine use is associated with a risk of dependency and negative effects on cognition (Perlis et al.  2010 ; Cañada et al.  2021 ). The use of pharmacological treatments for social anxiety disorder is further complicated by the fact that many people with bipolar disorder are already on complex medication regimens. This makes the provision of psychological therapy especially important in this population.

The treatment of choice for social anxiety disorder is individual cognitive behavioural therapy (CBT) (Mayo-Wilson et al.  2014 ). Please see “ Materials and methods ” section for a detailed description of the treatment components. The evidence on the efficacy of CBT for social anxiety disorder in people with bipolar disorder is very limited. Bipolar disorder was an exclusion criterion for the studies that informed the recommendation of CBT as the first-line treatment for social anxiety disorder. A previous investigation of group CBT for social anxiety suggested that the magnitude of improvement is not impacted by the comorbid diagnosis of bipolar disorder (Fracalanza et al.  2014 ). A single case study reported that twenty-three weekly sessions of individual CBT combined with interpersonal psychotherapy led to a remission of social anxiety disorder in one man with bipolar disorder (Queen et al.  2015 ). However, there are no previous investigations of individual CBT for social anxiety in people with bipolar disorder. In addition, it has been highlighted that data on safety and acceptability of psychological treatments for anxiety in people with bipolar disorder are missing (Stratford et al.  2015 ). For example, as people with bipolar disorder spend around half of the time with various levels of mood impairment (Judd et al.  2002 ), mood worsening during a course of CBT is to be expected in some people. The question whether the treatment remains feasible for individuals even when they experience mood deterioration remains unanswered.

We completed a case series to (1) test the acceptability, safety, and efficacy of individual CBT for social anxiety in people who also have bipolar disorder, and to (2) identify any modifications to the standard CBT for social anxiety disorder that may be needed for individuals with bipolar disorder.

Materials and methods

Participants.

We recruited participants among the outpatients attending the Mood Disorders Program in Halifax, Nova Scotia, Canada. Participants were referred by their treating clinicians. All participants were previously diagnosed with bipolar I or bipolar II disorder and social anxiety disorder by their treating psychiatrists. We included participants with bipolar I or bipolar II disorder who were euthymic and had not changed their medication within the 4 weeks prior to study entry. Euthymia was defined as a score of 12 or less on the Montgomery–Åsberg Depression Rating Scale (Montgomery and Åsberg  1979 ) and 7 or less on the Young Mania Rating Scale (Young et al.  1978 ). We required the diagnosis of social anxiety disorder to be one of the main presenting complaints at the time of the assessment to justify the therapeutic focus on it. All diagnoses were confirmed using the Structured Clinical Interview for DSM-5 Disorders (SCID-5) (First et al.  2015 ). Exclusion criteria were a current diagnosis of a substance use disorder, cognitive impairment that would interfere with the delivery of CBT, being actively suicidal at the time of study entry, and not having a sufficient command of English. We also excluded individuals who were receiving psychological therapy or had a previous adequate course of CBT (at least eight sessions) for social anxiety disorder.

Prior to the study entry, a structured diagnostic assessment was conducted by a research nurse or research assistant using the SCID-5 and agreed in a consensus meeting with the first author (a licensed clinical psychologist). Eligible participants were offered sixteen sessions of CBT for social anxiety within 20 weeks followed by 3 monthly booster sessions. After the sixteenth session, participants met with a research nurse or assistant for the end-of-treatment assessment and then after 3 months for a follow-up assessment. While the standard number of sessions in trials is fourteen, we added two more sessions to allow dealing with depressive symptoms, which we anticipated to occur more frequently in people with bipolar disorder, or to address any social anxiety-related thoughts and images that may specifically occur in people with bipolar disorder.

We used the protocol for individual cognitive therapy for social anxiety disorder (Clark and Wells  1995 ; Clark et al.  2003 ,  2006 ) based on the model by Clark and Wells ( 1995 ).

The core components include (1) collaboratively developing a personalized cognitive model of social anxiety; (2) an experiential exercise to demonstrate the negative effects of self-focused attention and safety behaviors, i.e., the self-focused attention and safety behaviours experiment; (3) video and still photo feedback to update negative self-imagery; (4) attention training to practice externally focused attention; (5) behavioral experiments to test patients’ negative beliefs by dropping safety behaviors and focusing attention externally in social situations, and by purposefully displaying feared behaviors or signs of anxiety (decatastrophizing); and (6) developing a therapy blueprint. Additional treatment components include surveys to loosen beliefs alongside experiments; addressing anticipatory worry and post-event rumination; memory work (discrimination training and memory rescripting) to reduce the impact of early social trauma experiences; and additional techniques to address persistent negative self-beliefs and self-criticism. Video illustrations of all treatment techniques are available at www.oxcadatresources.com .

We were open to modifications that may be needed for people with bipolar disorder. All participants were treated by the first author, who is a clinical psychologist and a cognitive behavioural therapist registered with the Canadian Association of Cognitive and Behavioral Therapies (BP). She was supervised by a clinical psychologist and cognitive behavioural therapist registered with the British Association for Behavioural and Cognitive Psychotherapies (EW-P).

Primary outcomes

There were three primary outcomes: (1) Acceptability (defined as the percentage of offered sessions that were attended), (2) safety (defined as the number of severe adverse events related to the treatment, including inpatient admissions, suicide attempts, or other life-threatening events) and (3) the change of the total score on the Social Phobia Inventory (SPIN) (Connor et al.  2000 ).

While the magnitude of change on the SPIN was the main outcome, for descriptive reasons we also defined remission as a score of 19 or less (Connor et al.  2000 ). There have been various cut-offs for response on the SPIN. We will report the most stringent cut-off for a response, which is a decrease of at least 50% from baseline (Connor et al.  2000 ).

Secondary outcomes

The secondary outcomes included the total change on The Leibowitz Social Anxiety Scale, self-report version (LSAS) (Baker et al.  2002 ), the presence or absence of social anxiety diagnosis on the SCID (First et al.  2015 ), a change in mania severity assessed by the Young Mania Rating Scale (YMRS) (Young et al.  1978 ), and a change in depression severity measured by the Beck Depression Inventory II (BDI-II) (Beck et al.  1996 ) and the Montgomery and Åsberg Depression Rating Scale (MADRS) (Montgomery and Åsberg  1979 ).

Although the overall change on the LSAS was the main secondary outcome, for descriptive purposes we also provide information on the remission and response status on the LSAS. Remission was defined as a score of 30 or less (Rytwinski et al.  2009 ) and a response as at least a 31% decrease from the baseline (Leichsenring et al. 2013 ).

Eleven participants took part in the case series. Seven were females and four were males. All participants were outpatients. They ranged in age from nineteen to mid-forties. Eight were White, and three were Asian or Black. Six were in a full-time employment, one was in a part-time employment, three were unemployed, and one was a full-time student. Seven had bipolar I disorder and four had bipolar II disorder. Four had experienced psychotic symptoms during mania. All participants were receiving pharmacological treatment for bipolar disorder. Participants had on average 2.5 current comorbid psychiatric disorders in addition to bipolar disorder. Apart from social anxiety disorder (N = 11), the most common current comorbid psychiatric disorder was generalized anxiety disorder (N = 7), followed by obsessive compulsive disorder (N = 4), body dysmorphic disorder (N = 2), agoraphobia (N = 2), and eating disorders (N = 2).

Acceptability of CBT for social anxiety disorder in people with bipolar disorder

The participants attended 95% of the offered sessions. Ten participants attended all sixteen sessions and three follow-up appointments. One participant attended nine sessions and no follow-up appointments. This reflects a shorter course of treatment requested by the participant, who attended all research follow-ups. CBT for social anxiety disorder appears to be a highly acceptable treatment for individuals with comorbid bipolar and social anxiety disorder.

Safety of CBT for social anxiety disorder in people with bipolar disorder

No severe adverse events were reported during the treatment or the 3-month follow-up period. Specifically, there were no suicide attempts and no manic episodes.

Effect of CBT for social anxiety disorder in people with bipolar disorder

Primary outcome.

The average score on the SPIN decreased from 46.5 (SD 6.6) before the treatment to 19.8 (SD 11.9) at the end of the sixteen-session intervention and further to 15.8 (SD 10.3) by the end of the 3-month follow-up. Six participants achieved remission by the end of the treatment, one achieved response and four did not meet criteria for treatment response. By the end of the 3-month follow-up, eight individuals achieved remission, one achieved response and two remained non-responders (Fig.  1 ).

The score on the Social Phobia Inventory (SPIN) before treatment, after treatment and at a 3-month follow-up (FU3). The finer lines denoted as A to K show the SPIN scores of the individual participants. The thick black line is the SPIN average score of all eleven participants

Social anxiety

The average score on the LSAS halved from 87.9 (SD 21.3) at the beginning to 40.9 (SD 25.2) at the end of the treatment and further decreased to 37.1 (SD 21.8) by the end of the 3-month follow-up. At the end of the treatment, four participants were in remission, five achieved response and two did not respond based on the LSAS score. At the 3-month follow-up, there were six remitted participants, four who responded to treatment and one who did not respond to treatment (Fig.  2 ).

The score on the Leibowitz Social Anxiety Scale Self-Report (LSAS) before treatment, after treatment and at a 3-month follow-up (FU3). The finer lines denoted as A to K show the LSAS scores of the individual participants. The thick red line is the average LSAS score of all eleven participants

Ten out of eleven participants no longer met diagnostic criteria for social anxiety disorder at the end of the 3-month follow-up.

The average YMRS score remained low through the course of the study; 2.1 (SD 1.9) at the beginning of the treatment, 1.1 (SD 1.0) at the end of the treatment and 1.2 (SD 2.3) at the end of the 3-month follow-up period. No participant scored above the clinical cut-off during the course of the study.

The average score on MADRS (administered during every encounter) remained in the euthymia range and did not change during treatment; the average score was 5.9 (SD 3.6) at the beginning of the treatment, 5.8 (SD 3.7) at the end of the treatment and 5.1 (SD 4.2) at the end of the 3-month follow-up period. However, with participants’ MADRS scores ranging between 0 and 31 during the treatment, we observed interindividual differences in depression fluctuations. Please see “ Relationship between depressive symptoms and improvement in social anxiety ” section for more detail.

The average score on BDI-II halved from 12.3 (SD 8.2) at the beginning of the treatment to 6.4 (SD 6.6) at the end of the treatment. At the end of the 3-month follow-up period, the average BDI-II score was 7.6 (SD 8.2).

Relationship between depressive symptoms and improvement in social anxiety

Participants were euthymic at the time of joining the study. However, most participants (seven out of eleven) experienced clinical levels of depression (MADRS˃12) at some point during the treatment. Those who experienced elevated depressive symptoms during the treatment, improved on average by 23 points on the SPIN during the sixteen-session intervention, compared to a 33-point-improvement in the group of people without elevated depressive symptoms. However, at the end of the 3-month follow-up, participants who had experienced elevated depressive symptoms during the treatment improved by further 6 points reaching an overall improvement of 29 points from baseline. The average improvement in the group of participants without significant depressive symptoms during the treatment did not change between the end of treatment and the 3-month follow-up (33 points). Please see Fig.  3 .

Average score on the Social Phobia Inventory (SPIN) before treatment, after treatment and at a 3-month follow-up (FU3). The blue line is the average SPIN score of the four participants who remained euthymic throughout the treatment. The orange line is the average SPIN score of the seven participants who experienced clinical levels of depression during the treatment

Modifications of CBT for social anxiety disorder for people with bipolar disorder

Overall, the treatment did not differ from the standard protocol, including individualized conceptualization, attention and safety behaviours experiment, videofeedback, attention training, behavioural experiments, discrimination training of triggers for social anxiety, imagery rescripting, core belief work, and creating a blueprint. All participants received the core components of CBT for social anxiety disorder.

As is standard for CBT for social anxiety disorder, the focus was on experiential exercises. Participants completed behavioural experiments most sessions during treatment and for homework.

Below, we describe some aspects of CBT for social anxiety disorder that may be specific to people with bipolar disorder.

Impact of history of manic and hypomanic episodes on images, thought, and safety behaviors

The negative thoughts and self-images/impressions of some participants in this case series were influenced by their experiences during elevated mood episodes. One participant saw himself as looking “utterly mad” with huge bulging eyes, bright red complexion and saliva flowing from his mouth. Further questioning revealed that this was how he imagined he looked during his manic episode. His safety behaviour was to focus on his face and make sure it moved as little as possible. Another participant was sure that she was being irritating in contact with others. This was based on her experience of people acting irritated when they were unable to interrupt her during her hypomanic episode. Consequently, she avoided social situations as much as possible and when she could not avoid them, she tried to stay away from groups and remain silent. A third participant worried that she may say something offensive like she did during a manic episode. She spent a lot of time preparing “appropriate things to say”. All three participants responded well to interventions, including experiments with dropping safety behaviours to test their fears, feedback from others and videofeedback to update their negative self-images/impression, as well as stimulus discrimination to look for differences between the past manic episode and the present-day social situation.

Another common belief in the participants was “I am weird/different”. This was at least partly based on the participants’ experiences with severe mental illness. As has been emphasized before (Warnock-Parkes et al.  2022 ), these beliefs were addressed from the very beginning of treatment in behavioural experiments by comparing participants’ predictions with reading the feedback of others, observing their reactions, and watching themselves on the video. Dropping safety behaviours meant to hide this “weirdness” helped participants discover that these were unnecessary and frequently counterproductive. For example, one participant was extremely ashamed about delusional beliefs that she voiced during her manic episode and believed that everyone was able to tell what happened just by looking at her and seeing how “weird” she was. She was trying to blend in by not giving her opinions unless she knew that they were in line with other people’s views, letting others make choices for her, and staying in the background. Consequently, some people stopped asking for her opinions, which strengthened her belief that she was different and had nothing to add. When she started experimenting with voicing her opinions, others were accepting, interested, and started talking to her more. In addition, a decatastrophizing experiment when the participant explicitly disagreed with someone, not only helped her recognize that she was not treated as weird when she disagreed but also that this did not result in a manic episode.

In summary, working with the participants to help them drop their safety behaviours, which were intended to prevent them from appearing or becoming manic, was crucial. By dropping the safety behaviours, the participants were able to find out that that bipolar disorder was not visible to others and that mania could not be triggered by not monitoring themselves in social situations.

Dampening refers to attempts to decrease the intensity of a positive emotion. Some studies suggest that people with bipolar disorder engage in dampening more often than those without bipolar disorder, possibly because of a fear of mania (Dodd et al.  2019 ; Edge et al.  2013 ). They may also avoid rewarding activities in attempts to prevent mania (Edge et al.  2013 ).

During the treatment, dampening interferes with patients generating generalized positive alternative thoughts (such as “I’m likeable”) from their experiments and with keeping positive data logs. Several participants were worried that noticing positives about themselves may bring on mania. Some participants learned to mistrust any positive thoughts about themselves, because they learned that their grandiose thoughts during mania were inaccurate and led to embarrassment.

Stimulus discrimination was effective in helping participants distinguish between positive self-evaluation occurring during euthymia and overly positive self-impressions that participants experienced during elevated episodes. For example, one participant did not trust any positive thoughts about himself, because he felt he was tricked by his mind before, when he experienced grandiosity during mania. He was able to notice all the differences between the situation during his mania and receiving positive feedback when euthymic (for example, he was now sleeping eight hours per night, he was on effective medication, and he was in a stable job). Socratic questioning about mania triggers was followed by behavioural experiments testing whether writing down positive generalized beliefs about the self on experiment record sheets or keeping a more traditional positive data log would lead to an onset of mania. Work was done on distinguishing between episodes of mania/hypomania and euthymia and understanding the feared behaviours (e.g., saying something offensive) as a symptom of mania or hypomania. Later behavioural experiments with video feedback illustrated the point that the participants did not come across the way they feared. None of the participants experienced mania or hypomania during the treatment.

Misdiagnosis danger

A 19-year-old participant was referred for an assessment. One of the referral questions concerned a differential diagnosis between bipolar disorder and schizophrenia due to what appeared like negative symptoms (e.g., no discernable emotional expression, and minimal verbal utterances). Prior to the treatment, this participant experienced a severe manic episode with psychotic features and was hospitalized. Following her discharge, she developed depression and the apparent negative symptoms persevered even after other depressive symptoms improved. A possibility that the apparent negative symptoms were in fact symptoms of social anxiety was raised. During the treatment for social anxiety, it transpired that these were due to the use of safety behaviours (e.g., focusing on how she was coming across and not talking for the fear of being judged). Following the CBT for social anxiety, these symptoms were no longer present. The remission of social anxiety coincided with marked improvement in social and occupational functioning and the participant returned to higher education.

For some participants, a brief detour to depression treatment was used. This mainly focused on activity scheduling and using skills gained in the CBT for social anxiety disorder, including planning behavioural experiments and addressing self-criticism. Some thought records were also used.

Based on this case series, individual CBT for social anxiety delivered during euthymia is an acceptable, safe, and effective treatment for people with bipolar disorder.

Following the treatment, social anxiety in participants with bipolar disorder decreased as much as in samples of people without severe mental illness. The average decrease on the SPIN in our study was identical to that observed in individual CBT delivered in a recent study (Clark et al.  2022 ). Our secondary social anxiety outcome measure, LSAS, was used in most studies that evaluated individual CBT for social anxiety disorder in people without severe mental illness (Clark et al.  2003 ,  2006 ,  2022 ; Mörtberg et al.  2007 ; Goldin et al.  2012 ). The average change on the LSAS in these studies ranged between 29.6 and 52.7. The average change of 47.4 on the LSAS in the current sample of participants with bipolar disorder is at a higher end of this range. Moreover, in keeping with the findings in samples of people without bipolar disorder (Mörtberg et al.  2007 ; Goldin et al.  2012 ; Clark et al.  2022 ), the scores on the social anxiety measures continued to decrease during the follow-up period. At the end of the treatment, five participants were in remission based on the SPIN score and four participants were in remission based on the LSAS score. At the 3-month follow-up, these numbers increased to eight and six as measured by the SPIN and LSAS respectively. This suggests a good maintenance of treatment gains despite the clinical levels of depression that some participants experienced.

Our finding that individual CBT is effective in treating social anxiety in people with bipolar disorder is in line with previous findings on treatments for social anxiety disorder in people with unipolar depression; recent meta-analyses suggested that depressive symptoms or a depressive disorder diagnosis do not adversely affect outcomes of treatments for social anxiety disorder and that in individual CBT people with major depressive disorder may have outcomes superior to those without a mood disorder (Rozen and Aderka  2020 ).

We only recruited people who were not in a major mood episode at the beginning of the treatment, hence our study was not designed to evaluate the impact of CBT on depressive symptoms, which on average did not change. Despite recruiting only people outside a major mood episode, seven out of eleven participants developed clinical levels of depression during the study. By the end of the sixteen-session treatment, those who experienced depression during the study, improved less than those who remained euthymic. However, by the end of the 3-month follow-up, their treatment gains were comparable to the group who remained euthymic.

The negative association between anxiety and various unfavourable outcomes in people with bipolar disorder is well established (Simon et al.  2007 ; Lorenzo-Luaces et al.  2018 ; Pavlova et al.  2018 ). However, little is known about whether treating anxiety may improve the course of bipolar disorder itself. Among people with bipolar disorder, those with anxiety disorders are more likely to be treated with antidepressants or benzodiazepines (Simon et al.  2004 ). Treating their social anxiety disorder using individual CBT may simplify their pharmacological regimes and decrease the burden of medication side effects. Future studies should evaluate whether treating social anxiety improves inter-episode functioning and decreases the likelihood of mood episodes relapses.

Strengths and limitations

This is the first case series that describes the acceptability and efficacy of CBT for social anxiety in people with bipolar disorder during euthymia. We enrolled a similar number of men and women and of people with bipolar I disorder and bipolar II disorder.

It is well established that case series are prone to selection bias (Munn et al.  2020 ). While we recruited people consecutively, it is possible that participants who were referred by their clinicians and who volunteered to take part were those most likely to respond. Our participants were selected exclusively from a specialist clinic, so may have more severe and complex mood disorders than people with bipolar disorder in general. However, despite greater severity of mood disorders, treatment in specialized mood disorder programs is associated with better long-term outcomes (Kessing et al.  2013 ). It is not clear whether the findings would generalize to a population treated in a generalist setting.

Additionally, even though the research assessments were not conducted by the therapist, the researchers conducting the assessments were aware of the treatment the participants received. Therefore, we used a self-report measure as the main outcome.

Finally, due to the absence of a comparison group, we cannot exclude a possibility that the participants’ social anxiety would have improved regardless of the treatment. However, the fact that spontaneous remission of social anxiety is unusual in people with bipolar disorder (Pini et al.  2006 ) makes it unlikely.

The small sample size and the lack of a control group make our findings preliminary.

Future directions

CBT for social anxiety disorder in people with bipolar disorder needs to be tested in a randomized controlled trial. A trial with a longitudinal follow-up may elucidate not only whether CBT for social anxiety is effective in decreasing anxiety in people with bipolar disorder but could also test whether an improvement in social anxiety serves as a protective factor against future mood episodes.

Clinical implications

CBT for social anxiety appears to be safe and effective in people with bipolar disorder. It should be available to individuals with bipolar disorder, who also have social anxiety disorder.

Despite enrolling only euthymic participants with bipolar disorder, more than a half developed a transient clinical level of depressive symptoms during the treatment. It was possible to continue the effective treatment with every single participant experiencing depression. Based on this finding, it is likely that people with bipolar disorder presenting with mild to moderate depression are likely to benefit from CBT for social anxiety as long as social anxiety is the primary concern at the time of the enrollment.

Although the standard CBT protocol for social anxiety disorder can be offered to people with bipolar disorder, the treatment providers should be aware that past mood episodes may impact the presentation of social anxiety in people with bipolar disorder. For example, a fear of mania may lead to avoidance of reinforcing stimuli, and the content of social fears may be impacted by experiences from mood episodes.

CBT for social anxiety disorder in people with bipolar disorder appears safe, acceptable, and effective. Due to the lack of control group and the small sample size in the current investigation, a randomized controlled trial should evaluate CBT for social anxiety disorder in a larger group of people with bipolar disorder.

Availability of data and materials

The dataset used during the current study is available from the corresponding author on reasonable request.

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This work was supported by the Nova Scotia Health Research Fund (grants 1026578 and 1010913).

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BP conceived the study, provided the treatment, analyzed the results, and wrote the first draft of the manuscript. All authors contributed to the conception, design, and interpretation of data, as well as reviewing and approving of the final manuscript.

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Pavlova, B., Warnock-Parkes, E., Alda, M. et al. Cognitive behavioural therapy for social anxiety disorder in people with bipolar disorder: a case series. Int J Bipolar Disord 12 , 1 (2024). https://doi.org/10.1186/s40345-023-00321-8

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Received : 20 June 2023

Accepted : 27 November 2023

Published : 05 January 2024

DOI : https://doi.org/10.1186/s40345-023-00321-8

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• Bipolar disorder
• Social anxiety disorder
• Cognitive therapy