Psychological Interventions For Bipolar Disorder Research Articles

Active components and mechanisms of action of psychological interventions in bipolar disorder: A systematic literature review.

The efficacy of psychological interventions for bipolar disorder (BD) is well established, but much remains unknown about how change occurs. The primary objective of this exploratory study was to audit what is known about active components and mechanisms of action of psychological interventions for BD. We conducted a systematic review (PROSPERO CRD42022323276). Two independent reviewers screened references from four databases and extracted data from eligible studies. We included four component studies, six studies with mediation analyses and 26 studies presenting subjective experiences of how psychological interventions bring change. Ten mediators were examined across six studies, with only one putative mediator, medication adherence, tested in more than one study. Some initial support for mediation of varied outcomes by control over thoughts, positive non-verbal behaviour, self-esteem, post-trauma growth and medication adherence. Some preliminary support was found in two components, human support and IPT. Studies exploring participant experiences of therapeutic change enumerated a range of potential active components, mechanisms of action and contextual factors potentially warranting investigation in future research. However, the evidence base for active components and mechanisms of action in psychological interventions for BD is unsatisfactory. Findings were inconsistent, studies homogenous with significant methodological limitations and statistical approaches failed to meet quality criteria. Preliminary identification of potential components and mechanisms via qualitative analyses and the insights emerging from this review will inform future research aimed at investigating how psychological interventions work in BD.

A pilot randomised controlled trial to assess the feasibility and acceptability of recovery-focused therapy for older adults with bipolar disorder.

Despite increasing evidence for the effectiveness of individual psychological interventions for bipolar disorder, research on older adults is lacking. We report the first randomised controlled trial of psychological therapy designed specifically for older adults with bipolar disorder. To evaluate the feasibility and acceptability of recovery-focused therapy, designed in collaboration with older people living with bipolar disorder. A parallel, two-armed, randomised controlled trial comparing treatment as usual with up to 14 sessions of recovery-focused therapy plus treatment as usual, for older adults with bipolar disorder. Thirty-nine participants (67% female, mean age 67 years) were recruited over a 17-month period. Feasibility and acceptability of recruitment, retention (>80% observer-rated outcomes at both 24 and 48 weeks) and intervention processes were demonstrated. The majority of participants started therapy when offered, adhered to the intervention (68% attended all sessions and 89% attended six or more sessions) and reported positive benefits. Clinical assessment measures provide evidence of a signal for effectiveness on a range of outcomes including mood symptoms, time to relapse and functioning. No trial-related serious adverse events were identified. Recovery-focused therapy is feasible, acceptable and has the potential to improve a range of outcomes for people living with bipolar disorder in later life. A large-scale trial is warranted to provide a reliable estimate of its clinical and cost-effectiveness.

Is cognitive behaviour therapy applicable to individuals diagnosed with bipolar depression or suboptimal mood stabilizer treatment: a secondary analysis of a large pragmatic effectiveness trial

BackgroundEfficacy trials of medications and/or psychological interventions for bipolar disorders (BD) aim to recruit homogenous samples of patients who are euthymic and such populations show high levels of adherence to the treatments offered. This study describes a secondary analysis of a large-scale multi-centre pragmatic effectiveness randomized controlled trial (RCT) of cognitive behaviour therapy plus treatment as usual (CBT) or treatment as usual alone (TAU) and explores outcomes in individuals who were: (i) recruited in depressive episodes, or (ii) receiving suboptimal doses of or no mood stabilizers (MS).MethodsData were extract on two separate subsamples (out of 253 RCT participants). Sample 1 comprised 67 individuals in a depressive episode (CBT: 34; TAU: 33); Sample 2 comprised 39 individuals receiving suboptimal MS treatment (CBT: 19; TAU: 20). Survival analyses (adjusted for confounding variables) were used to explore recovery in Sample 1 and relapse in Sample 2.ResultsIn Sample 1 (individuals with depression), Cox proportional hazards regression model revealed that the median time to recovery was significantly shorter in the CBT group (10 weeks; 95% confidence intervals (CI) 8, 17) compared to the TAU group (17 weeks; 95% CI 9, 30) [Adjusted Hazard Ratio (HR) 1.89; 95% CI 1.04, 3.4; p < 0.035]. In Sample 2 (suboptimal MS), the median time to any relapse was significantly longer in the CBT group compared to the TAU group (~ 35 versus ~ 20 weeks; Adjusted HR 2.01; 95% CI 1.01, 3.96; p < 0.05) with the difference in survival time to first depressive relapse also reaching statistical significance (X2 = 14.23, df 6, p 0.027).ConclusionsAdjunctive use of CBT appears to have benefits for individuals diagnosed with BD who are highly representative of the patients seen in routine clinical practice, but often excluded from efficacy RCTs. However, as this is a secondary analysis of 42% of the original RCT sample, it is important to replicate these findings in independent larger scale studies specifically designed for purpose.

Management of cognitive impairment in bipolar disorder: a systematic review of randomized controlled trials.

Cognitive impairment is common in bipolar disorder and is emerging as a therapeutic target to enhance quality of life and function. A systematic search was conducted on PubMed, PsycInfo, Cochrane, clinicaltrials.gov, and Embase databases for blinded or open-label randomized controlled trials evaluating the pro-cognitive effects of pharmacological, neurostimulation, or psychological interventions for bipolar disorder. Twenty-two trials were identified, evaluating a total of 16 different pro-cognitive interventions. The methodological quality of the identified trials were assessed using the Cochrane Risk of Bias tool. Currently, no intervention (i.e., pharmacologic, neurostimulation, cognitive remediation) has demonstrated robust and independent pro-cognitive effects in adults with bipolar disorder. Findings are preliminary and methodological limitations limit the interpretation of results. Methodological considerations including, but not limited to, the enrichment with populations with pre-treatment cognitive impairment, as well as the inclusion of individuals who are in remission are encouraged. Future trials may also consider targeting interventions to specific cognitive subgroups and the use of biomarkers of cognitive function.

Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration.

BackgroundSelf-monitoring of symptoms is a cornerstone of psychological interventions in bipolar disorder (BD), but individuals with lived experience also value tracking holistic outcomes, such as quality of life (QoL). Importantly, self-monitoring is not always experienced positively by people with BD and may have lower than expected rates of engagement. Therefore, before progressing into QoL tracking tools, it is important to explore user perspectives to identify possible risks and benefits, optimal methods to support engagement, and possible avenues to integrate QoL self-monitoring practices into clinical work.ObjectiveThis study aimed to conduct a qualitative exploration of how individuals with BD engaged with a Web-based version of a BD-specific QoL self-monitoring instrument, the QoL tool.MethodsA total of 43 individuals with BD engaged with a self-management intervention with an optional Web-based QoL self-assessment tool as part of an overarching mixed method study. Individuals were later interviewed about personal experiences of engagement with the intervention, including experiences of gauging their own QoL. A thematic analysis was used to identify salient aspects of the experience of QoL self-monitoring in BD.ResultsIn total, 4 categories describing people’s experiences of QoL self-monitoring were identified: (1) breadth of QoL monitoring, (2) highlighting the positive, (3) connecting self-monitoring to action, and (4) self-directed patterns of use.ConclusionsThe findings of this research generate novel insights into ways in which individuals with BD experience the Web-based QoL self-assessment tool. The value of tracking the breadth of domains was an overarching aspect, facilitating the identification of both areas of strength and life domains in need of intervention. Importantly, monitoring QoL appeared to have an inherently therapeutic quality, through validating flourishing areas and reinforcing self-management efforts. This contrasts the evidence suggesting that symptom tracking may be distressing because of its focus on negative experiences and positions QoL as a valuable adjunctive target of observation in BD. Flexibility and personalization of use of the QoL tool were key to engagement, informing considerations for health care providers wishing to support self-monitoring and future research into Web- or mobile phone–based apps.

Beyond Pharmacotherapy for Bipolar Disorder: The Role of Adjunctive Psychological Treatments

Recent years have seen increased research attention to psychological interventions as adjuncts to medication treatment of bipolar disorder (BD). Adjunctive psychological treatments are recommended in all major clinical guidelines for BD, and we now know that evidence-based treatment involves both pharmacotherapy and psychological therapy. We provide an overview of what is known about psychological interventions for BD, including the existing evidence base, core content elements of therapy, and emerging innovations. An overarching theme is the patient as a motivated agent in his or her own well-being; we emphasize recovery-oriented treatment goals, self-management approaches, and digital platforms to improve access to these empowering activities. Mental health professionals are encouraged to support their patients' participation in evidence-based psychological therapies as part of a holistic approach to managing BD. [ Psychiatr Ann. 2019;49(9):399–404.]

Psychological interventions for bipolar disorder in low- and middle-income countries: systematic review.

Adjunctive psychological interventions for bipolar disorder have demonstrated better efficacy in preventing or delaying relapse and improving outcomes compared with pharmacotherapy alone. To evaluate the efficacy of psychological interventions for bipolar disorder in low- and middle-income countries. A systematic review was conducted using PubMed, PsycINFO, Medline, EMBASE, Cochrane database for systematic review, Cochrane central register of controlled trials, Latin America and Caribbean Center on Health Science Literature and African Journals Online databases with no restriction of language or year of publication. Methodological heterogeneity of studies precluded meta-analysis. A total of 18 adjunctive studies were identified: psychoeducation (n=14), family intervention (n=1), group cognitive-behavioural therapy (CBT) (n=2) and group mindfulness-based cognitive therapy (MBCT) (n=1). In total, 16 of the 18 studies were from upper-middle-income countries and none from low-income countries. All used mental health specialists or experienced therapists to deliver the intervention. Most of the studies have moderately high risk of bias. Psychoeducation improved treatment adherence, knowledge of and attitudes towards bipolar disorder and quality of life, and led to decreased relapse rates and hospital admissions. Family psychoeducation prevented relapse, decreased hospital admissions and improved medication adherence. CBT reduced both depressive and manic symptoms. MBCT reduced emotional dysregulation. Adjunctive psychological interventions alongside pharmacotherapy appear to improve the clinical outcome and quality of life of people with bipolar disorder in middle-income countries. Further studies are required to investigate contextual adaptation and the role of non-specialists in the provision of psychological interventions to ensure scalability and the efficacy of these interventions in low-income country settings. None.

A mania-related memory bias is associated with risk for relapse in bipolar disorder,

ObjectivePrevious work has shown that neuropsychological performance can predict outcome of psychotherapy. The present paper explores whether an affective bias in verbal memory is associated with recurrence of mood episodes in patients with Bipolar Disorder (BD). Method76 euthymic adult patients with BD were randomly assigned to either 9 months of Cognitive Behavioral Therapy (CBT) or Support Therapy (ST), and followed up for 2 years after completing therapy. At baseline, affective learning memory (Emotional Auditory Verbal Learning Test; EMO-AVLT) and other measures were assessed. Recurrence of a mood episode was the primary outcome. ResultsThe survival analyses revealed that the interaction between therapy condition, more specifically ST, and a recognition bias in favor of mania-related, but not depression-related words predicted recurrence of mania. Recurrence of depression was predicted by neither affective memory bias nor their interaction with treatment. ConclusionsA mania-related memory bias emerged as a predictor of mania recurrence, specifically in an unstructured setting such as ST. Perhaps mania-related schemata are more salient or more easily activated in those at high risk for recurrence. Interventions targeting patients’ insight into their internal states as potential indicators of prodromal manic symptoms could be the key to improve the outcome of psychological interventions in BD. Additional research in the role of cognitive factors in relapse prevention is warranted.

4.4 INTERNET-BASED INTERVENTIONS FOR BIPOLAR DISORDER

BackgroundAdjunctive psychological interventions as an add-on to pharmacological treatment in serious mental illnesses have shown to further improve long-term outcome, especially in the case of Bipolar Disorder and first episode psychosis. Among them, psychoeducational programs have a well-established evidence of efficacy and cost-efficiency. However, there are several limitations restricting the broad implementation of these psychological treatments, out of which the most important one is related to a tremendous gap between availability and demand. Therefore, there is an emerging interest to explore new approaches to deliver this kind of treatments tailored to individual needs and in a continuous way (e.g. all year long) from any location while maintaining their efficacy at a low cost. The high availability of Internet connected devices as well as it’s user-friendly interfaces could be a potential and feasible window to expand and extend psychoeducational programs in Bipolar disorder and other serious mental illnesses. The main objective of this presentation will be: 1. to review the available internet-based psychological interventions for bipolar disorder, 2. to present the SIMPLe project development, studies protocols, results from a feasibility study and an open study, and finally, 3. to provide some insights and perspectives into the future of the field.MethodsA systematic-review of the literature was undertook to review the available internet-based psychological interventions for bipolar disorder and provide a critical appraisal of the studies and platforms included. A feasibility pilot study was conducted to test the first version of the SIMPLe app in which retention, acceptability and satisfaction were assessed in a group of subsequent samples of bipolar patients using the app, pre and post intervention questionnaires and assessments were conducted during face to face interviews. Regarding the open trial (i.e. OpenSIMPLe), a similar approach was adopted, but involving patients from all around the world and using online questionnaires.ResultsDuring the systematic review we identified over 251 potential entries matching the search criteria and after a thorough manual review, 29 publications pertaining to 12 different projects, specifically focusing on psychological interventions for bipolar patients through diverse Internet-based methods, were selected. In the feasibility study, 51 participants were initially enrolled in the study, 36 (74%) remained actively using the application after 3 months. The whole sample interacted with the application a mean of 77 days (SD=26.2). Over 86% of the participants agreed that the experience using the application was satisfactory. So far, the OpenSIMPLe trial have enrolled more than 300 participants, preliminary results show levels of satisfaction beyond 80%, although a retention of only 5% after 6 months was calculated from servers registries.DiscussionConsidering the high rates of retention and compliance reported, they represent a potential highly feasible and acceptable method of delivering this kind of interventions to bipolar patients. The results of the feasibility study confirms that this particular intervention is feasible and represent a satisfactory and acceptable instrument for the self-management of bipolar disorder as an add-on to the usual treatment but future clinical trials must still probe its efficacy. Moreover, preliminary results from the OpenSIMPLe study shows that is feasible to extend this intervention to many people at a low cost. Present and future technologies employing passive data collection and weareables could improve the personalization and accuracy of these interventions.

Improving functional outcome in bipolar disorder: A pilot study on metacognitive training.

Effective group psychological interventions in bipolar disorder are rare. In this study, we present "metacognitive training (MCT) for bipolar disorder"-an adaption of a group intervention that has proven effective in other severe psychiatric disorders. MCT is a structured, interactive approach that addresses cognitive biases, social cognition, and self-esteem. In this pilot study, we investigated psychosocial functioning as primary outcome measure, as well as the feasibility of MCT and its acceptance among bipolar patients. Thirty-four outpatients with bipolar disorder were recruited. Inclusion criteria were euthymia and psychosocial functioning with a score >11 assessed by the Functional Assessment Short Test. The subjects received eight weekly MCT sessions. Before and after the intervention, psychosocial functioning, quality of life (QoL), and patient views were assessed. Patients improved significantly in global psychosocial functioning, with a large effect size from baseline to post-treatment. Over the intervention period, patient QoL improved significantly in terms of their physical health, however not for other QoL subdomains. Treatment adherence was 80%, and patients' appraisal of the training was positive. As this study lacks a control group, it is not possible to ascertain whether the positive treatment effects are attributable to MCT. Additionally, it is unclear whether gains in psychosocial functioning would have been maintained long term. This pilot trial conclusively shows that MCT is feasible and provides preliminary evidence for both the acceptance and efficacy of MCT. Further studies with larger samples and control condition will be necessary to build on these findings.

Pilot study of a culturally adapted psychoeducation (CaPE) intervention for bipolar disorder in Pakistan

BackgroundDespite the use of maintenance medication, recurrence rates in bipolar affective disorder (BPAD) are high. To date, there are no clinical trials that have investigated the use of psychological interventions in bipolar disorder in Pakistan.AimThe purpose of the study was to assess the feasibility and acceptability of a culturally adapted bipolar psychoeducation programme (CaPE) in Pakistan.MethodsThirty-four euthymic bipolar I and II outpatients were randomized to either 12 weekly sessions of individual psychoeducation plus Treatment As Usual (Intervention) or Treatment As Usual (TAU) (Control). Outcomes were assessed using the Young Mania Rating Scale (YMRS), Beck Depression Inventory (BDI), EuroQoL (EQ-5D), Bipolar Knowledge and Attitudes and Questionnaire (BKAQ), and a self-reported measure of medication adherence (Morisky Medication Adherence Scale-4 items, MMAS-4). Effect sizes were derived from baseline adjusted standardized regression coefficients.ResultsRetention in the study was good, 80% of patients in the TAU follow-up assessment and 100% of patients in the CaPE group attended all 12 sessions. Patient satisfaction was higher in the CaPE group relative to control (ES = 1.41). Further, there were large effect sizes shown for CaPE versus TAU for medication adherence (MMAS-4: ES = 0.81), knowledge and attitudes towards bipolar (BKAQ: ES = 0.68), mania (YMRS: ES = 1.18), depression (BDI: ES = 1.17) and quality of life measures (EQ-5D: ES ⇒ 0.88).ConclusionsCulturally adapted psychoeducation intervention is acceptable and feasible, and can be effective in improving mood symptoms and knowledge and attitudes to BPAD when compared with TAU. Larger scale studies are needed to confirm our findings.Trial registration. Clinicaltrials.gov identifier NCT02210390

What are People's Experiences of a Novel Cognitive Behavioural Therapy for Bipolar Disorders? A Qualitative Investigation with Participants on the TEAMS Trial.

This is the first paper to qualitatively explore people's experiences of individual psychotherapy for bipolar disorders. It highlights elements of psychotherapy described as particularly helpful or unhelpful and the clinical changes viewed as most impactful. Participants reported benefitting in a number of ways from TEAMS therapy. They valued learning to reappraise and problem-solve situations and manage moods. Participants identified TEAMS techniques as helpful, such as exploring advantages and disadvantages of moods, and building healthy self-states.

Unexplored areas of psychotherapy in bipolar disorder.

Several psychological interventions-including group psychoeducation, family-focused psychoeducation, and interpersonal social-rhythm therapy-have demonstrated prophylactic efficacy as an adjunct to medication in bipolar disorders (BDs). The field of psychological interventions for BD has experienced impressive progress over the last 15 years. Certain unexplored areas, however, require further research in order to establish the full potential of psychological interventions for BD. Such research should focus, among other things, on cognitive impairment associated with BD, BD in the elderly, comorbid anxiety disorders and other comorbidities, the treatment of BD in pregnant women, and the improvement of patients' overall physical health.

Clinical and demographic features associated with the detection of early warning signs in bipolar disorder

AimThe detection of early warning signs is a major component of many psychological interventions for assisting in the management of bipolar disorder. The aim of this study was to assess whether the ability to detect early warning signs was associated with clinical and demographic characteristics in a bipolar disorder clinic sample. MethodTwo-hundred-and-one participants with DSM-IV bipolar I or II disorder aged over 18 years of age were recruited through a specialized bipolar disorder clinic. Participants were administered a structured interview by psychiatrists asking participants about any early warning signs, and features of the phenomenology, course and treatment of bipolar disorder. ResultsParticipants were significantly more likely to recognise both hypo/manic and depressive early warning signs rather than only one type of mood episode. The ability to detect signs of both hypo/mania and depression was greater in younger participants. The ability to detect signs of depression was associated with more prior depressive episodes and a lesser likelihood of prior hospitalisations whilst a history of mixed mood was associated with a greater likelihood of detecting depressive symptoms. The ability to recognise signs of hypo/mania was greater in those reporting a history of visual hallucinations (during depressive and/or manic episodes). LimitationsCross-sectional design and previous experience with psychotherapy was not assessed. ConclusionThese findings provide useful clinical data pertinent to psychological interventions for bipolar disorder. Longitudinal studies are needed to further examine how the ability to recognise early warning signs may be associated with longer term outcome.

Thought suppression in patients with bipolar disorder.

Suppression of negative thoughts has been observed under experimental conditions among patients with major depressive disorder (MDD) but has never been examined among patients with bipolar disorder (BD). Patients with BD (n = 36), patients with MDD (n = 20), and healthy controls (n = 20) completed a task that required unscrambling 6-word strings into 5-word sentences, leaving out 1 word. The extra word allowed the sentences to be completed in a negative, neutral, or “hyperpositive” (manic/goal-oriented) way. Participants completed the sentences under conditions of cognitive load (rehearsing a 6-digit number), reward (a bell tone), load and reward, or neither load nor reward. We hypothesized that patients with BD would engage in more active suppression of negative and hyperpositive thoughts than would controls, as revealed by their unscrambling more word strings into negative or hyperpositive sentences. Under conditions of load or reward and in the absence of either load or reward, patients with BD unscrambled more negative sentences than did controls. Under conditions of reward, patients with BD unscrambled more negative sentences than did patients with MDD. Patients with BD also reported more use of negative thought suppression than did controls. These group differences in negative biases were no longer significant when current mood states were controlled. Finally, the groups did not differ in the proportion of hyperpositive sentence completions in any condition. Thought suppression may provide a critical locus for psychological interventions in BD.

Erratum to: A Critical Update on Psychological Interventions for Bipolar Disorders

Erratum to: A Critical Update on Psychological Interventions for Bipolar Disorders

A critical update on psychological interventions for bipolar disorders

Although pharmacotherapy is the mainstay of treatment for bipolar disorder, the combination of evidence-based psychological interventions and drug treatment enhances overall effectiveness, mostly by further protecting patients from relapse/recurrence. In recent years, well-designed controlled studies have added weight to evidence favoring specific psychotherapy modalities for bipolar disorders. However, critical issues that may limit the benefits of psychotherapy in day-to-day clinical practice have emerged. In this article, we critically examine the effectiveness of psychosocial approaches to bipolar illness by reviewing the literature, which has been substantially enriched during the past 5 years. Recent studies further support the fact that psychoeducation and cognitive-behavioral therapy are effective in bipolar disorder, especially the early stages. Family interventions based on a psychoeducational model are also effective. Intensive psychotherapies may be more effective than short, managed care-based ones. Group psychoeducation seems to have long-lasting effects and to be cost-effective. Future studies should focus on neurobiological markers of response to psychotherapy and tailor interventions to specific subtypes.

S11-04 Psychological treatments and prevention in bipolar disorder - recent developments

This contribution provides a systematic review on recent developments in psychological interventions for bipolar disorder. The main focus of research to date has investigated the role of different psychotherapeutic approaches (cognitive behavioural therapy, family focused therapy, interpersonal and social rhythm therapy, psychoeducation) as an adjunct to pharmacotherapy for remission and relapse prevention. The review will assess efficacy and effectiveness of these interventions, their common ingredients, limitations and predictors of outcome. It will further explore the potential role of psychological interventions for primary prevention of bipolar disorders in high risk children and adolescents. Suggestions will be made for future work in these areas.

Actigraphic assessment of circadian activity and sleep patterns in bipolar disorder

Theoretical accounts and psychological interventions for bipolar disorder indicate that disruption of circadian rhythms is important, both in affective episodes and as a vulnerability factor in subsyndromal periods. This study aims at assessing both circadian activity and sleep patterns using actigraphy within a bipolar sample experiencing low levels of subsyndromal symptoms. It is hypothesized that such participants will display circadian activity disruption in spite of low levels of symptoms. This study employed a mixed design with cross-sectional assessment of mood and week-long (7-day) recording of actigraphy data. All clinical participants were psychiatric outpatients within a UK NHS Hospital. Nineteen bipolar patients and 19 age- and gender-matched controls wore an actigraph for 7 days to obtain sleep and circadian activity data. SCID was used to confirm DSM-IV diagnostic status. Self-report measures of mood were obtained from both groups. Bipolar patients were found to have less stable and more variable circadian activity patterns than controls. Regression analysis indicated that variability alone was a significant independent predictor of diagnostic group. There was evidence from raw activity data that bipolar patients were also less active than controls. These differences were not associated with levels of subsyndromal symptoms. Bipolar patients did not differ from controls on any of the sleep indices used. Circadian activity disruption is apparent in bipolar patients even when not acutely ill. This finding is not associated with the presence of sleep disturbance. Should such patterns be replicated interventions to address both circadian instability and individual attributions for the effects of such instability are likely to be relevant to successful psychological interventions.

Psychological interventions in bipolar disorder: From wishful thinking to an evidence-based approach.

We aimed to examine the historical and current relevance of psychosocial approaches to bipolar illness by conducting a systematic review of prospective studies assessing the effectiveness of psychological interventions for bipolar disorder. A systematic literature search was conducted using EMBASE, MedLine and PsychLIT and reference sections of papers were scrutinized for further relevant reports. Only four trials met the criteria of a prospective study and achieved the necessary methodological standards. The studies showed benefits for patients in terms of relapse prevention and the reduction of hospitalization rates. Psychoeducation (delivered in groups or as part of a family intervention) and cognitive behavioural therapy were also found to be effective prophylactic treatments for bipolar disorder in medicated patients. Other interventions do not appear to be supported by sufficient evidence. Psychological approaches, and particularly psychoeducation and cognitive-behavioural therapies, are evidence-based prophylactic therapies for bipolar patients receiving pharmacotherapy. They should be used as adjuncts to medication where possible in the prevention of bipolar disorder.