Psychosocial Interventions for Bipolar II Disorder

Psychoeducation consists of structured sessions that focus on empowering individuals to better understand their bipolar illness, recognize and manage symptoms, and adhere to pharmacotherapy. It can be administered individually or in a group format, or recently, remotely through a telephone, smartphone, or web-platform (see discussion of “Technology-Assisted Interventions” below). Psychoeducation can be administered as a stand-alone treatment or combined with strategies from other evidence-based interventions.

We identified five studies with face-to-face individual (23, 24) or group (21, 25, 26) psychoeducation as the active intervention. One group (24) studied psychoeducation in combination with cognitive-behavioral therapy (CBT). Individuals with bipolar II disorder comprised 17%–53% of the sample. Follow-up lasted one to eight years. Three studies reported results by bipolar subtype (21, 23, 25) and are summarized below.

Colom and colleagues compared group psychoeducation with an unstructured support group among participants with bipolar I and II disorder, all of whom were receiving pharmacotherapy and usual outpatient psychiatric care (25). Group psychoeducation was a manualized, structured program of 21 sessions developed by Colom and Vieta (27). Their program targeted treatment compliance, illness awareness, early detection of prodromal symptoms, and lifestyle regularity. At the two- and five-year follow-ups, assignment to group psychoeducation was associated with significantly lower relapse rates (25, 28). In a follow-up report analyzing data from the bipolar II subset only, at the five-year follow-up, group psychoeducation was associated with significant advantages over the support group (19): fewer participants with one or more episodes of recurrence (62.5% versus 100%), fewer days with symptoms of hypomania or depression (10.5% versus 47%), and higher levels of functioning. Colom and colleagues suggested that psychoeducation derives its effect from improved functioning, possibly attributable to the power of psychoeducation to reduce time depressed (versus hypomanic). Accordingly, they proposed that group psychoeducation may be improved for bipolar II disorder if modified to place more emphasis on depression, including subsyndromal and atypical symptoms, comorbid anxiety, and physical health care.

Parikh and colleagues randomly assigned individuals to either six weeks of group psychoeducation or 20 weeks of individual CBT as an adjunctive to naturalistic pharmacotherapy (21). Group psychoeducation was a manualized, structured program of six sessions designed to teach illness recognition and coping strategies and assist with creation of an explicit care plan to address triggers for mania and depression. Individual CBT included traditional CBT techniques in addition to an emphasis on understanding the diagnosis and course of bipolar disorder, personal warning signs, and a “relapse drill” of actions to reduce relapse. After 72 weeks, there were no treatment group effects for the primary outcome, mood burden over time, suggesting brief group psychoeducation may be as effective as a full course of individual CBT. Among those with bipolar II disorder, only one participant spent more than 50% of the time ill. Almost 18% spent no time ill, and most (76%) spent less than 25% of the time ill. Subsyndromal symptoms, particularly depressive type, accounted for as much as 23% of the mood symptoms experienced by individuals with bipolar II disorder, compared with only 17% of individuals with bipolar I disorder. Investigators concluded that combination pharmacotherapy and psychosocial interventions, whether individual or group, result in favorable outcomes for both bipolar I and II disorders.

In the third study, Kallestad and colleagues compared the effectiveness of individual and group psychoeducation (23). Individual psychoeducation was a three-session intervention based on a psychoeducation workbook from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The workbook included information about bipolar disorder, importance of medication adherence, schedule management, dysfunctional cognitions, communication skills, and preventing mood episodes. Group psychoeducation was a 10-session manualized treatment based on Colom and Vieta’s model (27). Although there were no significant group differences, there was a significant interaction between group and diagnosis. Compared with individuals with bipolar I disorder, individuals with bipolar II disorder benefited less from either intervention and fared significantly worse with individual psychoeducation than with group psychoeducation. Those with bipolar II disorder had significantly earlier admissions to the hospital and higher rates of comorbid substance use, another factor that was significantly and independently associated with earlier hospital admission. Kallestad and colleagues hypothesized that the poor outcomes associated with bipolar II disorder may be related to the high frequency of substance use, treatment-refractory depressive symptoms, and overall illness instability in the bipolar II population. They concluded that psychoeducation might need to be adapted specifically to meet the needs of those with bipolar II disorder.

In aggregate, it appears that psychoeducation is a helpful treatment to prevent recurrence of mood episodes for individuals with bipolar II disorder in the maintenance phase. There is no information about this treatment as an acute intervention for bipolar II disorder. For this population, psychoeducation may be most potent in a group format and when administered early in the course of illness (26). Given its prominent focus on disease recognition and management, psychoeducation may benefit from modification to increase its salience for those with bipolar II disorder. For instance, bipolar I and II disorders differ in presentation (e.g., mania and psychotic features), course (29), and illness management (9). It may be particularly helpful to emphasize the recognition and management of subthreshold symptoms, especially depressive in nature, unstable course of the illness, and comorbid substance use.

CBT, administered individually or in a group format, focuses on identifying and changing maladaptive thoughts, beliefs, and behaviors that contribute to psychiatric symptoms (30). When tailored for bipolar disorder, CBT typically incorporates strategies such as management of sleep and routines, attention to medication adherence, and psychoeducation about bipolar disorder (31). This section includes variants of CBT such as cognitive therapy and mindfulness-based cognitive therapy (MBCT).

We identified three studies with face-to-face individual CBT (21, 32, 33) and three studies with group CBT (34–36) as the active intervention. Individuals with bipolar II disorder comprised 21% to 37% of the sample. Follow-up lasted one to two years. Three studies reported results by bipolar subtype (21, 32, 33). One study was described in the psychoeducation section and is not repeated here (21).

Miklowitz and colleagues reported bipolar II disorder outcomes from STEP-BD, a multi-site project that compared the efficacy of three individual psychotherapies—CBT, family-focused therapy (FFT), and interpersonal and social rhythm therapy (IPSRT)—with a three-session psychoeducation control intervention as treatments for acute bipolar depression (32). All participants were receiving pharmacotherapy. For the control condition, participants received a STEP-BD psychoeducation videotape and workbook, and sessions focused on review of these materials (content previously described in the psychoeducation section). CBT sessions included psychoeducation, life events scheduling, cognitive restructuring, problem-solving training, relapse prevention, and interventions for comorbidities, if applicable. FFT sessions included psychoeducation, strategies to foster the development of a common understanding between patients and relatives about the index episode, medication adherence, role of stress, relapse prevention, communication enhancement, and problem solving. IPSRT is discussed in detail in the IPSRT section. Briefly, IPSRT sessions included psychoeducation and a focus on interpersonal relationships with behavioral interventions to modify social rhythms. After controlling for site, family involvement, and bipolar subtype, assignment to any one of the three intensive psychotherapies was associated with significantly higher rates of recovery (64% versus 52%), shorter time to recovery (median=113±78.2 days versus 146±80.0 days), and greater improvement in functioning. Bipolar subtype did not alter the effect of interventions on these outcomes, suggesting that CBT, FFT, and IPSRT were comparably efficacious for participants with bipolar I or II disorder.

Meyer and Hautzinger compared CBT to supportive therapy (ST) (33). In the ST condition, therapists provided emotional support and general advice. CBT included psychoeducation, relapse prevention, cognitive and behavioral strategies for depression and mania, and training in communication skills and/or problem solving. No significant differences were observed between groups in relapse rates or mood symptoms, although assignment to CBT was associated with a trend for preventing any mood episode. Bipolar subtype was a nonspecific predictor of outcomes: those with bipolar II had a higher risk of recurrence and increased risk for depressive relapse. That is, CBT and ST were both less effective for the management of bipolar II than for bipolar I disorder.

On the basis of these RCTs, CBT and its variants appear to be efficacious for acute bipolar II depression and may also prevent recurrence—although one study suggested that those with bipolar II disorder had worse outcomes relative to bipolar I disorder. It seems likely that CBT may need some subtype-specific modifications. Like psychoeducation, CBT may be more beneficial with greater emphasis on the recognition and management of subthreshold symptoms. It may also be important to focus more on dysfunctional thoughts, beliefs, and behaviors acquired during years of living with an untreated and unrecognized illness.

IPSRT is a manualized treatment that addresses interpersonal problems and disrupted social rhythms (37). Social rhythms are those daily activities—such as time of getting out of bed, first contact with another person, start of daily activity, dinner, and time to go to bed—that are thought to exert an effect on underlying biological rhythms. IPSRT rests on an “instability model” that defines three interconnected pathways to bipolar recurrences: stressful life events, medication nonadherence, and social rhythm disruption. IPSRT helps individuals identify and manage symptoms, link mood to life events, mourn the loss of the healthy self, resolve a primary interpersonal problem area (role transitions, role disputes, interpersonal deficits, or grief), maintain a regular daily rhythm, and predict and problem-solve potential precipitants of rhythm dysregulation. IPSRT typically is administered individually but can be provided in a group format.

We identified four studies with face-to-face individual IPSRT as the active intervention (16, 18, 22, 32). Individuals with bipolar II disorder comprised 17% to 100% of the sample. Follow-up lasted three months to three years. Three studies provided results for participants with bipolar II disorder (16, 18, 32); one was discussed in the CBT section and is not repeated here (32). To date, the following two reports are the only RCTs to include samples exclusively composed of participants with bipolar II disorder.

Swartz and colleagues compared IPSRT to quetiapine for bipolar II depression among unmedicated participants (18). Over 12 weeks, both groups experienced improvements in depressive and manic symptoms, and there were no significant differences between groups. In a follow-up study, Swartz and colleagues compared IPSRT plus placebo to IPSRT plus quetiapine for bipolar II depression (16). IPSRT plus quetiapine was associated with significantly faster improvements in depression and manic symptoms, albeit with more side effects than with IPSRT alone. Side effects of IPSRT plus quetiapine included significantly higher body mass index over time and dry mouth. Response rates did not differ between groups.

Based on three investigations, it appears that IPSRT, as a monotherapy or adjunctive treatment, is an efficacious treatment strategy for acute bipolar II depression. No data are available about its role in the maintenance phase. IPSRT monotherapy should be considered when individuals prefer, or need, a nonpharmacological modality. IPSRT has been modified for bipolar II disorder (38), with changes that include increased attention to the following: rationale for making changes to social rhythms, identification of mood states, regulation of levels of stimulation, management of grandiosity, addressing emotional dysregulation, and treating comorbid substance use.

Integrated care management (ICM) is a multicomponent population-based intervention designed to improve clinical care and outcomes (39). ICM is founded in integrated care models for chronic illness care and includes evidence-based strategies for case management and patient- and provider-level interventions. We identified two studies with face-to-face ICM as the active intervention (40, 41). Individuals with bipolar II disorder comprised 13% and 24% of the sample, and follow-up lasted three and two years, respectively. Neither report included results by subtype, and therefore the specific utility of ICM for managing bipolar II disorder is not clear.

Functional remediation (FR) is a neurocognitive intervention designed to target attention, memory, and executive functioning deficits associated with bipolar disorder (42). FR includes structured group sessions providing neurocognitive techniques, psychoeducation on cognition-related issues, and problem-solving to enhance functioning. We identified one RCT of FR detailed across two reports (42, 43), including one report that exclusively detailed outcomes for the patients in the bipolar II subgroup (17).

Torrent and colleagues compared FR, psychoeducation, and treatment as usual (TAU) as therapies for impaired functioning among participants with bipolar I and II disorders (42). Compared with TAU, FR was associated with significantly greater improvement in global psychosocial functioning. No differences were observed between FR and psychoeducation. In post-hoc analyses of the bipolar II subset, Solé and colleagues assessed treatment effects on global psychosocial functioning (17). They found a nonsignificant trend favoring FR with a significant treatment-by-time interaction: participants with bipolar II receiving FR showed significant reductions of subsyndromal depressive symptoms compared with those receiving psychoeducation.

On the basis of the Torrent et al. study (17, 42), FR appears to be a promising strategy to address impairments in psychosocial functioning for euthymic individuals with bipolar II. No data are available on the effects of this intervention during an acute mood episode. Like other interventions reviewed, FR may confer its advantages by reducing depressive symptoms which, in turn, leads to improved functioning.

Despite the strong rationale for psychotherapies in bipolar II disorder, barriers to their dissemination include limited availability of trained therapists and patient access to specialized mental health services (44). Adjunctive psychotherapies that utilize technology reduce this pressure. We identified seven studies evaluating technology-assisted interventions. One study compared an online intervention to in-person TAU (45). Two studies compared active online to control online interventions (46, 47). Three studies used a hybrid approach, combining an in-person intervention with an online component (48–50), and one study was a within-subject, pre- versus post-online intervention design (51, 52). Three interventions included elements of CBT (45–47). Psychoeducation and mood monitoring were central components of all interventions. Individuals with bipolar II disorder comprised 12% to 49% of the sample. Follow-up lasted three months to one year. We found no studies or subanalyses of outcomes for those with bipolar II disorder. Therefore, the specific utility of technology-assisted interventions for managing bipolar II disorder is unknown. Of note, because bipolar II disorder is a depression-predominant illness, Faurholt-Jepsen and colleagues’ findings (see Table 1) of worsening depressive symptoms associated with an in-person intervention with an online component may be particularly important to consider when developing technology-assisted interventions for individuals with this disorder (48).

We identified four studies that were not categorized elsewhere. One study examined face-to-face individual care (enhanced clinical intervention) in the context of a comprehensive care management program (53). A second trial compared group relapse prevention to TAU (54). A third study compared an integrated group model to group drug counseling for individuals with bipolar disorder and comorbid substance use disorders (55). The fourth was a pilot study comparing group dialectical behavior therapy to a wait-list control condition (56). Individuals with bipolar II disorder comprised 16% to 58% of the sample in these four studies, and follow-up lasted three months to two years. No report included results by subtype, and therefore their potential role in the management of bipolar II disorder is unclear.

In a prior review of this topic (57), we argued that several strategies are common to almost all of the empirically supported psychosocial interventions for bipolar disorder: 1) education about the illness, 2) education about medications, 3) careful review of medication side effects, 4) promotion of regular sleep-wake cycles, 5) daily mood monitoring, 6) discussion of prodromes and related approaches to relapse prevention, and 7) direct involvement of family members and significant others, or at a minimum, consideration of their role in the maintenance of wellness. These approaches are also relevant to psychotherapies for bipolar II disorder. In addition, the following set of strategies should be considered when treating an individual with bipolar II disorder: