Elizabeth taught me how to cope with bipolar disorder—she was my psychiatrist until I moved from England to the United States in 1989. I’d like to think it was because she took a special interest in me, but maybe she just got tired of me turning up on her doorstep every 12 months or so in a raging manic episode.
At the time, my method of coping with bipolar disorder was to ignore it, an excellent method except for one drawback—it didn’t work. Every year or two, I’d spend several weeks in full-blown mania, sometimes followed by depression, and then six months of withdrawal in the inevitable “morning-after” recovery that follows mania.
So Elizabeth taught me how to cope. It was her job. But, how many psychiatrists go beyond prescribing medication to the other part—teaching us how to cope? It took a while to get the hang of it. Like learning to ride a bicycle, I fell off a few times. Eventually I got really good at it, and in the past 10 years, I haven’t had a full-blown manic episode. (I’m still taking my medications.)
Many people have a story like mine. Many have learned to cope. Recently, scientists have begun to investigate the effectiveness of teaching people how to cope with bipolar disorder. What they have discovered is very exciting. They found that it really works, that it really works well, and that it really works well without any side effects.
Warning: science content
I watch the TV show MythBusters on the Discovery channel. They apply vaguely scientific methods to explore the truth of popular myths. Whenever there is serious science content, they flash a warning on the screen. Likewise here, there’s a bit of science content. But the bottom line is a three or four times improvement in staying well for those of us who have bipolar disorder and with no annoying side effects. That’s worth suffering some science!
To test the effectiveness of a new treatment for a disease, scientific comparisons are made. Typically, the treatment is a new drug. However, in the following studies (all of which were conducted between 1999 and 2003), the treatments being tested are different ways of teaching people how to cope with bipolar disorder.
All four studies about learning to cope use a similar method. A large group of patients is recruited and each patient is randomly assigned to one of two groups. One group receives the treatment being tested and the other group receives some other form of treatment. When a drug is being tested, the other form of treatment is frequently a placebo—a pill with no active ingredients. As far as possible, everything except the treatment under study is kept the same for both groups.
Treatment is given for a period of time and the progress of all patients is measured. The scientists taking the measurements do not know which patients are receiving the active treatment and which are in the comparison group, thus preventing bias from creeping into the results.
Illness self management
Teaching people how to cope with a Long-term illness is often called illness self-management. (For mental illnesses, it is also called “psychoeducation.”) The major ingredients of illness self management for mental illnesses include:
• medication compliance
• early identification of warning signs
• relapse prevention
• coping strategies for dealing with persistent symptoms
• improvement of illness awareness
This is what Elizabeth taught me, and these ingredients lie at the core of the therapies investigated in the following four studies: early symptom detection, family-focused therapy, cognitive therapy, and group education. The difference between the studies is where the emphasis is placed on the core ingredients and the additional elements included in the recipe. In all of the studies, therapies were given in addition to the patient’s usual medication regime.
Treatments on trial
Early symptom detection
• teaching people how to identify early symptoms of relapse and to seek prompt treatment in seven to 12 individual sessions given by a research psychologist with little previous clinical experience
Sixty-nine patients who had bipolar disorder and had had a relapse during the previous year participated (mostly bipolar type I).
After 18 months, the group that received the education avoided manic episodes nearly four times longer than the group that received treatment as usual (an average of 65 weeks against 17 weeks). The number of people who stayed free of mania was also better: only nine got sick compared to 20 from the other group. There was no effect on episodes of depression, but overall social functioning and employment were significantly improved. (Reference: A. Perry et al., BMJ [British Medical Journal], January 1999)
• 21 sessions for patients and their caregivers in their homes by a therapist with the first seven sessions on these illness self-management basics: medication compliance, early identification of warning signs, and strategies for relapse prevention
• communication enhancement training sessions to teach skills for active listening, giving feedback, and requesting changes in behavior
• problem-solving training to help identify family problems and select solutions
Of the 101 participants, most had bipolar I and had recently had an episode. The therapy group was compared to a less intensive crisis management strategy consisting of two sessions of family education plus crisis intervention sessions as needed.
At the end of the two-year study, three times as many patients in the therapy group stayed well compared to the other group (52 percent compared to 17 percent). On average, for patients who did get sick, those in the therapy group stayed well longer than the other group (74 weeks compared to 54 weeks). Also the therapy group showed reduced mood symptoms, particularly depression, and better medication adherence. (Reference: D. J. Miklowitz et al., Archives of General Psychiatry, September 2003)
Cognitive therapy focuses on patterns of thinking that lead to undesirable moods and on the beliefs behind these thought patterns. Patients are taught techniques to monitor, examine, and change these thought patterns. This study examined an enhanced form of cognitive therapy for bipolar patients.
The therapy was extended to add relapse prevention by:
• monitoring mood and detecting warning signs, and taking action to avoid full-blown episodes from developing with patients receiving 16 sessions
There were 103 participants who had bipolar I and who experienced frequent relapses despite being on mood stabilizers. The therapy group was compared to a group that received treatment as usual.
Therapy recipients spent three times fewer days in bipolar episodes than the other group (an average of 27 days compared to 88 days). The therapy cut the hospital admission rate in half—15 percent of patients in the therapy group were admitted compared to 33 percent for treatment as usual. The group that received cognitive therapy also exhibited significantly higher social functioning, fewer mood symptoms, and significantly less fluctuation in manic symptoms than the group that did not receive it. (Reference: D. Lam et al., Archives of General Psychiatry, February 2003)
The above studies investigated education therapies administered in individual sessions. The group education study is exciting because group sessions are much more cost-effective and thus more likely to become widely available.
• groups of eight to 12 participants with 21 sessions, each lasting 90 minutes
• each session consisted of a speech on a topic followed by a relevant exercise with these major topics: illness awareness, medication compliance, early detection of warning signs, and lifestyle regularity
There were 100 participants who had bipolar I and 20 who had bipolar II; all had been well for at least six months. The therapy group was compared to a group that attended unstructured group meetings for the same number of sessions, in the same size group with the same therapists. The only difference was that unstructured meetings contained no education component.
After two years, four times as many patients in the therapy group stayed completely well compared to the unstructured group (33 percent compared to eight percent). The therapy group spent three times fewer days in the hospital (an average of five days compared to 15 days). Also, the length of time before getting sick was significantly longer for the therapy group. (Reference: F. Colom et al., Archives of General Psychiatry, February 2003)
And the verdict …
The results are best summarized by this quote “… the usefulness of psychotherapy [teaching self-management] for improving outcome for bipolar patients is now unquestionable, especially for patients who have achieved a certain degree of remission from acute symptoms,” in a December 2004 paper by F. Colom, PhD, and E. Vieta, MD, PhD, in Bipolar Disorders.
In other words, it’s a free upgrade, a stay-out-of-hospital card, and scientifically tested. From my own experience, I know the improvement that learning illness self-management brought to my own quality of life. But that is just one anecdotal story. Now science has measured the improvement. After learning illness self-management, three or four times as many patients stayed well, and they spent much less time in the hospital than those on medication alone.
From good science to good sense
The same scientific method that brought us modern medications has shown that teaching wellness works for those of us who have bipolar disorder. By learning to manage our illness, we can stay well longer and visit the hospital less. There is no longer any question regarding the value of wellness education.
In the words of Drs. Colom and Vieta, “Psychoeducation, like every effective psychological intervention, is essentially based on common sense.” It is a joy and delight to see common sense making further inroads into the treatment of mental illness.
Peter Newman holds a PhD in computer science and works in Silicon Valley, California. He maintains a Web site on illness self-management for bipolar disorder at http://www.lucidinterval.org
SIDEBAR: Two learning programs
In these two free programs below, people who are successfully managing their own mental illness, teach others.
• NAMI (National Alliance on Mental Illness) offers the Peer-to-Peer Recovery Education Course, consisting of nine weekly sessions, of two hours each, led by trained peer mentors and based on the core ingredients of illness self-management (www.nami.org). The course is designed to motivate as much as to educate. You can teach someone what to do, but it is much more powerful to motivate them to do it.
•Wellness Recovery Action Plan (WRAP), offered by Mary Ellen Copeland, mental health recovery educator and author (www.mentalhealthrecovery.com), is a method of self-management consisting of eight sessions, of two hours each, led by two trained peer instructors.