Brief Versus Intensive Psychosocial Treatments for Bipolar Disorder: Time for Stepped Care?

To the Editor: Bipolar disorder presents major challenges: how to manage a complex disorder with finite resources and how to provide standardized treatment. In the June 2014 issue of the Journal, Miklowitz et al. (1) demonstrated that a brief psychoeducational intervention can be as effective as a much longer family-focused therapy involving highly trained therapists, replicating in adolescents what our previous adult studies discovered by comparing brief psychoeducation to cognitive-behavioral therapy (CBT) (2–3). Brief psychoeducation requires less staff training to provide and is more convenient for patients to complete. As noted by Simon and Ludman (4), centrally delivered psychosocial interventions offer advantages in standardization, cost, and access, often through telephone or Internet approaches. Weaving these studies and recommendations together, we now have additional support for a stepped-care approach to bipolar disorder, which we proposed earlier: a brief, perhaps centrally delivered psychoeducational intervention of three to six sessions that is offered to all patients with bipolar disorder, followed by selective use of high-intensity services such as CBT or family-focused therapy (5). Screening with tools to detect persistent dysfunctional assumptions or demonstrated family problems by the end of psychoeducational intervention can identify those individuals needing more services; in a similar fashion, additional testing could identify those in need of cognitive remediation or rehabilitation. But starting with the principle of simple, effective, and universal treatments first will help us all balance the need for treatment with inevitable fiscal constraints—and is in the spirit of the Affordable Care Act.