Archives of Psychiatry and , 2007; 3 : 35–41

The role of psychoeducation in the complex treatment of

Bartosz Grabski, Grzegorz Mączka, Dominika Dudek

Summary The importance of psychosocial interventions in bipolar disorder has recently been recognized. Apart from cognitive-behavioural therapy, interpersonal and social rhythm therapy, and family-focused therapy, psych- oeducation plays a central role in psychological approach. In our review paper we present evidence sup- porting the efficacy of psychoeducation, the topics to be addressed in a psychoeducational program and its postulated mechanisms of action as well as side-effects.

bipolar disorder / psychoeducation / psychotherapy

INTRODUCTION Since its effectiveness in enhancing treatment adherence and improvement of long-term out- As Colom and Lam notice [1], there has been a come in several medical conditions (cardiac ill- noticeable paradigm shift in the treatment of bi- ness, diabetes, asthma), psychoeducation can be polar disorder (BD), switching from an exclusive- viewed as a key element of a good medical prac- ly pharmacological approach, to a combined yet tice. As Colom and Lam put in: “psychoeduca- hierarchical model in which pharmacotherapy tion covers a fundamental right of our patients: plays a central role, and psychological interven- the right to be informed about their illness” [1]. tions help cover the gap that exists between the- oretical efficacy and “real world” effectiveness . Several multimodal psychotherapeutic inter- Psychoeducation – the review of evidence ventions have been developed for BD, such as family-focused therapy (FFT), interpersonal and Psychoeducation for patients social rhythm therapy (IPSRT), and cognitive-be- havioural therapy (CBT). All these treatment ap- Harvey and Peet (1991) explored the effect of a proaches encompass patient psychoeducation brief educational program on lithium adherence. (PE). More recent research has also began to ad- Sixty clinic attendees were allocated to the inter- dress the efficacy of PE as a stand-alone treat- ventional group or to usual treatment. The inter- ment for BD, and manual-based standardized vention consisted of a simple 12-minute video- PE interventions have now been developed [2, taped lecture with graphic illustrations of how 3, 4]. lithium is used to treat affective disorder. This was complimented with an illustrated transcript. Bartosz Grabski1, Grzegorz Mączkaą, Dominika Dudeką1,2: 1De- Patients also received a visit two weeks later to partment of Adult Psychiatry, University Hospital, Cracow; 2Chair discuss any particular difficulties they were hav- of Psychiatry, Collegium Medium, Jagiellonian University, Cracow; Correspondence address: Bartosz Grabski, Department of Adult ing with lithium. Six weeks after the intervention Psychiatry CMUJ, 21a Kopernika St., 31–501 Cracow, Poland; the education group, compared to usual treat- E-mail: [email protected] ment, showed a reduction in their self-report- 36 B. Grabski et al. ed missed doses of lithium, which just failed to study measured only adherence to psychother- reach statistical significance, p=0.07). The signif- apy with good results after treatment. The in- icant between-group differences in plasma lith- crease in knowledge of BD was also observed. ium levels were not observed [5]. In 1999, Perry et al conducted the randomized Another early study by van Gent and Zwart controlled trial of efficacy of teaching patients (1991) compared 14 bipolar patients attending with BP to identify early symptoms of relapse psychoeducation sessions with 12 controls. Fol- and obtain treatment. 69 bipolar patients re- lowing the sessions and 6 months later, the psy- ceived 7 to 12 individual treatment sessions from choeducated patients showed more knowledge a research plus routine care or rou- of the disease, medication and social strategies tine care alone. Teaching patients to recognize [6]. early symptoms of manic relapse and seek ear- In another later study van Gent (2000) showed ly treatment was associated with longer time to a significant decrease of non-compliant behav- first manic relapse and improvements in social iour and hospitalizations amongst psychoedu- functioning and employment [10]. cated patients [7]. Colom (2003) conducted the first large-scale In 1980 Seltzer, Roncari, and Garfinkel conduct- randomized controlled trial of psychoeducation ed an elaborate inpatient education study. 44 pa- in bipolar disorder. They allocated 120 euthym- tients with , 16 patients with bipo- ic bipolar subjects receiving standard treatments lar disorder, and 7 with major depression were to either 21 sessions of a structured group psy- placed in either education groups or no-educa- choeducation program, or to equivalent number tion control group. The patients were provided of sessions of an unstructured support group at- with nine lectures on their diagnosis, course of tended by the same therapist who delivered the treatment, medication, side effects, relapse, and psychotherapy intervention. At two-year follow- importance of social support. Five months later, up, the psychoeducation intervention compared the non-compliance rate for educational group with the control treatment was associated with a members was 9%, while the non-compliance significant reduction in total number of relaps- rate for the control group was 66%. Compliance es and 36% of patients in the control group were was measured through pill counts or medication hospitalized compared with 8% in the psychoed- blood levels [8]. ucation group. The treatment tested in this study Altamura and Mauri (1985) and Youssel (1983) combined 3 interventions that have shown some also tested the effectiveness of patient educa- efficacy individually: early detection of prodro- tion in improving treatment compliance in de- mal symptoms, enhancement of treatment com- pressed outpatients. Both studies indicated that pliance, and induction of lifestyle regularity and patients who received information about their was carried out in the Bipolar Disorders Program illness were more likely to follow the prescribed of the Hospital Clinic of Barcelona. The authors treatment regimen [8]. did not conduct separate comparisons for each Bauer [9] investigated a mixed psychoeduca- block of intervention, thus they could not con- tional and behaviour-oriented form of group clude whether there is only one useful part or psychotherapy, which was divided in two phase determine the major or minor efficacy of each group treatment. Each group consisted of 5 or 6 block [11]. patients and the sessions were highly structured. Interestingly, a recent subanalysis of the study Phase I was mostly psychoeducational and con- shows that psychoeducation may even be useful sisted of five weekly sessions. The sessions con- in those “difficult” patients fulfilling criteria for tained information about BP, early detection of a comorbid . It may be par- symptoms, and adaptive and maladaptive cop- ticularly important if we consider worse clinical ing strategies. Phase II was unstructured and the characteristics and poor outcome of comorbid bi- treatment was more flexible and adapted to indi- polar patients [12]. vidual needs. Moreover, there was a behaviour- Colom [13] have undertaken an additional al plan directed at improving social adaptation study to demonstrate that benefits of psychoedu- during which cognitive, behavioural or interper- cation are not mediated solely through enhanced sonal psychotherapy may have been used. The adherence. They conducted a randomized clini-

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 The role of psychoeducation in the complex treatment of bipolar disorder 37 cal trial using the same 21-session program, but Psychoeducation for patients’ families included only 50 bipolar I patients who fulfilled criteria for being considered as treatment com- Most patients’ families will have questions pliant Positive results were seen and the effect about the symptoms, the treatment, and the size was similar to the Archives’ study as were prognosis for the future. Educating family mem- the results. At the end of the 2 year follow-up bers about bipolar disorder serves two functions. 60% of the psychoeducated patients versus 92% First, it helps the family members cope with their of subjects in the control group fulfilled criteria own pain and suffering and prepares them for for recurrence. Also time to relapse was longer difficult times to come. Second, it enlists them as for psychoducated patients and they had a sig- active participants in the treatment process. As nificantly lower number of total recurrences and always, it is necessary to tailor the involvement number of depressive episodes. of significant others to the special needs of each Group psychoeducation may also act as the individual and to seek patients’ permission be- “mood-stabilizer stabilizer” by enhancing the fore communicating any clinical information to levels and stability of serum lithium levels [14]. their family members [8]. Preliminary data also suggest that group psy- Miklowitz carried out a randomized study choeducation may be associated with an in- among 101 bipolar patients who were stabilized crease in the reported quality of life (QoL), both on maintenance drug therapy and were rand- in terms of general satisfaction and in relation to omized to receive either 21 sessions of family-fo- levels of physical functioning [2]. cused psychoeducational treatment or two fam- The summary of the studies on psychoeduca- ily education sessions and follow-up crisis man- tion is presented in Tab. 1. agement. After a 2 year follow-up, patients who received the longer psychoeducational treatment had fewer relapses, longer times to relapse, sig- nificantly lower non-adherence rate than pa- tients assigned to the shorter intervention group [15, 16].

Table 1. Summary of psychoeducation studies (modified [9])

Authors / Study design Mode/Intervention Subjects/ Sessions Follow-up Results year control Harvey Controlled Group/Videotaped lecture 30/30 1 (12min 6, 12 and −Knowledge and atti- and Peet and illustrated transcript video) 24 weeks tude to lithium (1991) [5] on lithium usage Van Gent Controlled Group 14/12 5 6 and 12 −−Knowledge and atti- (1991) [6] months tude to treatment Bauer et Open trial Group 29/10 8 months Post-trial −Knowledge of BD al. (1998) [in:9] Perry et Controlled Individual/ Teaching to 34/35 7–12 6 12, 18 −Time to first manic re- al (1999) recognize early symp- months lapse, social functioning, [10] toms of mania employment Colom Randomized, single- Group 60/60 22 2 years, ¯Relapses and recur- (2003) blinded, clinical trial monthly rences [11] Miklow- Randomized Family 31/70 21 2 years ¯Relapses and non-ad- itz et al. herence (2003) −Time to relapse [16]

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 38 B. Grabski et al.

The development of family psychoeducation and client collaborate together to reach a shared for children with bipolar disorder (multifamily understanding of the most appropriate way to psychoeducation groups; MFPG and individu- help that individual, and differences of opinion al family psychoeducation; IFP) is also under- should be acknowledged and respected. way [17]. Scott and Tacchi proposed an abbreviated mod- el of cognitive therapy, called “concordance ther- apy (CCT)” based on the principles of “concord- Topics to be addressed in a psychoeducational ance”, which was designed specifically to over- program come barriers to adherence with lithium proph- ylaxis. Current psychological therapies in bipolar disor- CCT uses the ‘Cognitive Representation of Ill- der (e.g. PE and CBT) appear all to include four ness’ model, which describes how an individual key components: 1. information about the disor- constructs an internal representation of what is der (psychoeducation in a narrow sense), 2. in- happening to them when he or she experiences ducing lifestyle regularity (including reduction any physical or psychological symptoms. in substance use), 3. enhancing medication ad- It suggests that, no matter what the nature of herence, 4. early recognition and management the symptoms, most people organize their think- of symptoms of relapse ing around five key themes. These are: 1. What Psychoeducation of bipolar patients should in- is it? (identity), 2. Why has it happened? (cause), clude information about high recurrence rates 3. How long will it last; will it recur? (timeline), associated with the illness, drugs and their po- 4. What effects will it have? (consequences), 5. tential side-effects, early detection of prodrom- What can I do to make it go away? (cure/con- al symptoms and their management, the impor- trol). tance of avoiding illicit substances and alcohol, They will then make some attempt to cope the importance of maintaining routines, stress with symptoms and after assessing the coping management and some concrete information strategy they will then continue to use or modi- about issues such as pregnancy and bipolar dis- fy it accordingly. order, suicide risk, stigma, and social problems The model suggests that individuals who per- related to the illness. ceive coherence between their concrete experi- One of the main targets of psychoeducation ences of symptoms, the meaning they have at- concerns the enhancement of treatment adher- tached to them, and the explanation given to ence, which is usually very poor in bipolar pa- them by significant other (including health pro- tients, even when euthymic [1, 18]. fessionals) are more probably to engage with The results of the BEAM survey by Paolo health services or adhere with the treatments Morselli [19] have shown that issues tradition- offered. ally considered as the main source of non-ad- The CCT reported by Scott and Tacchi com- herence and addressed by psychiatrist, i.e. side- prised seven 30-minute sessions with a psychia- effects concerned as few as 3% of the patients, trist who was also an expert in cognitive therapy. whilst patients view ‘feeling dependant’ as the The goal of the sessions was to agree to a treat- most frequent (22.7%) reason for non-compli- ment regime that was acceptable, understand- ance. Thus, as Colom and Vieta concluded “in- able and manageable to an individual with BP formation is never enough to improve treatment and coherent with the individual’s cognitive rep- compliance” and other psychoeducational inter- resentation of the illness (individual’s percep- ventions for compliance enhancement, such as tions of the identity, cause, course, consequenc- the Concordance model by Scott [20], should be es and possibilities for cure or control). developed and promoted. The table 2 summa- Laboratory results demonstrated statistical- rizes the results of the BEAM survey. ly significant increases in serum plasma lithium A cornerstone of the philosophy of concord- levels although only four of the 10 subjects com- ance is that each individual is a rational consum- pleted all seven half-hour therapy sessions and er who makes choices that ‘makes sense to them’. homework tasks. The small sample size and the This philosophy also assumes that the clinician open character of the study require much fur-

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 The role of psychoeducation in the complex treatment of bipolar disorder 39

Table 3. Sessions of the psychoeducation program by Barce- Table 2. Concerns about medication (the BEAM survey) [18] lona group [11].

Concerns about medication Content of the Psychoeducative Program (the BEAM survey) (Barcelona Bipolar Disorders Program) 1. Feel dependent 22.7% 1. Introduction 2. It is slavery 9.9% 2. What is bipolar illness? 3. I am a little afraid 9.5% 3. Causal and triggering factors 4. Fear of long-term side effects 6.7% 4. Symptoms (I): Mania and hypomania 5. Feel ashamed 4.6% 5. Symptoms (II): Depression and mixed episodes 6. It is unhealthy 4.0% 6. Course and outcome 7. Side effects 3.0% 7. Treatment (I): mood stabilizers 8. My physical condition 0.9% 8. Treatment (II): antimanic agents 9. Treatment is useless 0.8% 9. Treatment (III): antidepressants 10. Medication not really needed 0.6% 10. Serum levels: lithium, carbamazepine, and valproate 11. Got pregnant 0.4% 11. Pregnancy and genetic counseling 12. Psychopharmacology vs. alternative therapies 13. Risk associated with treatment withdrawal ther research, but suggest the need to individu- ally tailor psychoeducative interventions to in- 14. Alcohol and street drugs: risks in bipolar illness dividual needs of every patient [20]. 15. Early detections of manic and hypomanic symptoms Tables 3 and 4 show psychoeducational for- 16. Early detection of depressive and mixed episodes mats that have been delivered in the Barcelona Bipolar Disorders Program [11] and in a mood 17. What to do when a new phase is detected? disorders program in the University of British 18. Regularity Columbia Hospital in Vancouver [2]. The Barce- 19. Stress management techniques lona group proposed twenty one 90-min sessions 20. Problem-solving techniques under the direction of two trained . The group consisted of 8–12 patients. The con- 21. Final session tent followed a medical model with a directive style, encouraged participation and focused on the illness rather than on psychodynamic issues. symptoms and coping strategies to be imple- The experts from the British Columbia Hospital mented in case of recurrence, lifestyle regular- proposed a PE program delivered in eight 90- ity and risks associated with alcohol and street min sessions, on a weekly basis, with group sizes drugs abuse are also addressed. Active partici- varying between 6 and 20 participants. The ses- pation and sharing experiences are also encour- sions were led by a nurse, a social worker, and a aged. psychiatrist. Psychoeducation has become the standard part of the complex treatment of affective disorders How does psychoeducation work? in the depression treatment unit of Department of Adult Psychiatry in Cracow. It is conducted Vieta [21] suggests that psychoeducation can be in a group mode, in-patients, out-patients and fitted into the mood-stabilization paradigm de- their family members are encouraged to partici- veloped by Ketter and Calabrese [22] – compris- pate. The main topics include: information about ing stabilization from above (class “A”) or below causal and triggering factors of mood disorders, (class “B”) – by creating the “C” class mood-sta- their symptomatology, course and outcome, ba- bilizer, i.e. those that stabilize from the centre. sic principles of treatment, early recognition of This would be because psychoeducation seems

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 40 B. Grabski et al.

Table 4. Format of psychoeducation (Mood Disorder Clinic, risks and benefits of the planned interventions. University of British Columbia Hospital) [2] In the review article on psychoeducation and cognitive-behavioural therapy in bipolar disor- Session Topic of discussion der Gonzalez-Pinto et al. [9] revealed two ad- 1 Introduction: definitions and descriptions of bipo- verse events that must be taken into account and lar disorder (BD) measured when using in bipo- 2 Treatment modalities (I): medications and other lar disorder: increased use of antidepressants therapeutic interventions and increase in . Vieta stresses that psy- 3 Treatment modalities (II): continued choeducation may not be useful for all patients 4 Open group: open discussion (includes members with bipolar disorder. Specifically he points out, of previous groups) that for instance, some patients with obsessive- 5 Psychosocial factors: focus on the psychosocial compulsive personality features may become ex- impact of BD ceedingly concerned about detecting early pro- dromal symptoms, unnecessarily increasing the 6 Relationship factors: focus o the impact of BD on number of extra visits to their psychiatrists and interpersonal relationships receiving unjustified extra medication. Other pa- 7 Family factors: focus on impact of BD on the fam- tients may become too rigid about sleeping hab- ily (includes family members) its, missing social events or travel because they 8 Open group: open discussion (includes members feel they must adhere inflexibly to their regular of previous groups) sleep schedule [23]. Vieta also cites a recent con- trolled trial on the efficacy of CBT in bipolar dis- order, which suggests that patients who are still to work best when patient is euthymic, and pro- symptomatic and have a higher number of pre- vides little or no benefit over ‘A’ and ‘B’ mood vious episodes may become distressed by this stabilizers during an acute episode of mania or kind of intervention and may actually worsen depression. [23]. Moreover depressed patients may tend to The mechanism of action of the psychoeduca- absorb only the negative aspects of psychoedu- tion is unknown. Colom et al. [11] hypothesize cational information, and manic patients can be that teaching life regularity would play a main disruptive and may not absorb the information role in the prevention of depression, while the at all [24]. early detection of prodromal symptoms would be crucial to prevent mania. The above men- tioned replication of the Archives’ study con- CONCLUSIONS ducted by the Barcelona Bipolar Disorders Pro- gram included only 50 BD I patients considered One limitation of some of the studies examined as treatment compliant, which enabled to dem- is the lack of separate comparisons for each block onstrate, that the influence of psychoeducation of the intervention (early detection of prodromal goes beyond the simple-but indispensable- en- symptoms, enhancement treatment compliance hancement of treatment adherence [13]. and inducing lifestyle regularity). Another limi- tation of some studies on psychoeducation is in- sufficient information on how BD patients are Adverse effects of psychotherapy and “usually” treated. Also there is still lack of more psychoeducation other large-scale randomized controlled trials on psychoeducation. An old humorous clinical saying claims that Despite these limitations, psychological inter- “if you cannot get killed by something, you will ventions have proved their efficacy in bipolar not possibly get cured by it either”. To put it in disorder. Almost every intervention tested con- other words, as with the other active treatments tains important psychoeducative elements con- (e.g. pharmacotherapy), the psychoeducation- cerning both compliance enhancement and ear- al approach must be attentive to the develop- ly identification of prodromal signs, stresses the ment of adverse events and consider both the importance of lifestyle stability, and explores pa-

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 The role of psychoeducation in the complex treatment of bipolar disorder 41 tients’ beliefs about health and illness awareness. oeducation in bipolar patients with comorbid personality dis- Current treatment guidelines are already sug- orders. Bipolar Disord. 2004, 6: 294–298. gesting the use of psychotherapy in bipolar dis- 13. Colom F, Vieta E, Reinares M, Martinez-Aran A, Torrent C, order [25, 26]. The noticeable shift in approach to Goikolea JM, Gasto C. Psycheducation efficacy in bipolar dis- bipolar disorders in which specialized and val- orders: beyond compliance enhancement. J. Clin. Psychiatry idated psychological interventions (like psych- 2003, 64:1101–1105. oeducation) become a requirement rather than 14. Colom F, Vieta E, Sanchez-Moreno J, Martinez-Aran A, Rein- just an option is underway. ares M, Goikolea JM, Scott J. Stabilizing the stabilizer: group psychoeducation enhances the stability of serum lithium lev- els. Bipolar Disord. 2005, 7 (Suppl. 5): 32–36. REFERENCES 15. Miklowitz DJ, Simoneau TL, George EL et al. Family-focused treatment of bipolar disorder: 1-year effects of a psychoedu- 1. Colom F, Lam D. Psychoeducation: improving outcomes in bi- cational program in conjunction with pharmacotherapy. Biol. polar disorder. European Psychiatry 2005, 20, 359–364. Psychiatry 2000, 48: 582–592. 2. Michalak EE, Yatham LN, Wan DDC, Lam RW. Perceived qual- 16. Miklowitz DJ, George EL, Richards JA, Simoneau TL, Suddath ity of life in patients with bipolar disorder. Does group psy- RL. A randomized study of family-focused psychoeducation choeducation have an impact? Can. J. Psychiatry 2005, 50: and pharmacotherapy in the outpatient management of bi- 95–100. polar disorder. Arch. Gen. Psychiatry 2003, 60: 904–912. 3. Vieta E. The package of care for patients with bipolar depres- 17. Frisad MA, Gavazzi SM, Mackinaw-Koons B. Family psychoed- sion. J Clin Psychiatry 2005, 66 (Suppl. 5): 34–39. ucation: an adjunctive intervention for children with bipolar 4. Colom F, Vieta E. A perspective on the use of psychoeduca- disorder. Biol. Psychiatry 2003, 53: 1000–1008. tion, cognitive-behavioral therapy and interpersonal therapy 18. Tacchi M-J, Scott J. Improving adherence in Schizophrenia for bipolar patients. Bipolar Disord. 2004, 6: 480–486. and Bipolar Disorders. The Atrium, Southern Gate, Chiches- 5. Peet M, Harvey NS. Lithium maintenance: A standard edu- ter, West Sussex: John Wiley and Sons; 2005. cation program for patients. Br. J. Psych. 1991, 158: 197– 19. Morselli PL, Elgie R. The BEAM survey: Information on current 200. and past treatmemnt of bipolar disorder generated by a pa- 6. Van Gent E, Zwart FM. Psychoeducation of partners of bipo- tient questionnaire. Bipolar Disord. 2002, 4 (Suppl. 1): 131. lar-manic patients. J. Affect. Disord. 1991, 21: 15–18. 20. Scott J, Tacchi MJ. A pilot study of concordance therapy for in- 7. Van Gent EM. Follow-up study of 3 years group therapy with dividuals with bipolar disorders who are non-adherent with lithium treatment. Encephale 2000, 26: 76–79. lithium prophylaxis. Bipolar Disord. 2002, 4: 386–392. 8. Basco MR, Rush AJ. Cognitive-behavioral therapy for bipolar 21. Vieta E. Maintenance therapy for bipolar disorder: current disorder. New York: Guilford Press; 2005. and future management options. Expert Rev Neurotherapeu- tics 2004, 4 (Suppl. 2): 35–42. 9. Gonzalez-Pinto A, Gonzalez C, Enjuo S, Fernandez de Corres B, Lopez P, Palomo J, Gutierrez M, Mosquera F, Perez de He- 22. Ketter TA, Calabrese JR. Stabilization of mood from below ver- redia JL. Psychoeducation and cognitive-bahavioral therapy sus above baseline in bipolar disorder: a new nomenclature. in bipolar disorder: an update. Acta. Psychiatr. Scand. 2004, J. Clin. Psychiatry 2002, 63: 146–151. 109: 83–90. 23. Vieta E. Improving treatment adherence in bipolar disorder 10. Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised through psychoeducation. J. Clin. Psychiatry 2005, 66 (Sup- controlled trial of efficacy of teaching patients with bipolar pl. 1): 24–29. disorder to identify early symptoms of elapse and obtain treat- 24. Vieta E, Colom F. Psychological interventions in bipolar dis- ment. BMJ. 1999, 318: 149–153. order: from wishful thinking to an evidence-based approach. 11. Colom F, Vieta E, Martinez-Aran A, Reinares M, Goikolea JM, Acta Psychiatr. Sand. 2004, 110 (Suppl. 422): 34–38. Benabarre A, Torrent C, Comes M, Corbella B, Parramon G, 25. Calabrese JR, Kasper S, Johnson G, Tajima O, Vieta E, Yatham LN, Corominas J. A randomized trial on the efficacy of group psy- Young AH. International Consensus Group on Bipolar I Depression choeducation in the prophylaxis of recurrences in bipolar pa- Treatment Guidelines. J. Clin . Psychiatry 2004, 65: 571–579. tients whose disease is in remission. Arch. Gen. Psychiatry 26. Goodwin GM, Consensus Group of the British Association for Psy- 2003, 60: 402–407. chopharmacology. Evidence-based guidelines for treating bipo- 12. Colom F, Vieta E, Sanchez-Moreno J, Martinez-Aran A, Torrent lar disorder: a recommendations from the British Association for C, Reinares M, Goikolea JM, Benabarre A, Comes M. Psych- Psychopharacology. J. Psychopharmacol. 2003, 17: 149–173.

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 42 B. Grabski et al.

Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41