Archives of Psychiatry and Psychotherapy, 2007; 3 : 35–41 The role of psychoeducation in the complex treatment of bipolar disorder 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- 3 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. 9 bipolar patients re- lowing the sessions and months later, the psy- ceived 7 to 12 individual treatment sessions from choeducated patients showed more knowledge a research psychologist plus routine care or rou- of the disease, medication and social strategies tine care alone. Teaching patients to recognize []. 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 schizophrenia, 1 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 %. Compliance es and 3% 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 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 personality disorder. 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. 0% 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