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Bipolar Disorder in Young People: A Psychological Intervention Manual

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Craig A. Macneil, Melissa K. Hasty, Philippe Conus, et al. New York, NY; Cambridge University Press; 2009; ISBN 978-0-521-71936-0; pp 186; $55 (paperback).

Bipolar disorder (BD) in children and adolescents has received, for various reasons, a lot of attention in the scientific and lay press lately. Many have rightfully questioned the increase in the number of children and adolescents diagnosed with this disorder. The potential role of new medications approved for this disorder and the marketing push by their makers has been widely debated. The widespread use of the new anti-psychotics in BD especially in young individuals brought another serious element into this debate—the possible long-term adverse effects of these medications such as metabolic syndrome and diabetes mellitus. Last but not least, part of this debate is the proposal of a new DSM-V diagnostic category of “temper dysregulation disorder with dysphoria.” This category should supposedly help to alleviate the overdiagnosing of BD in children and adolescents, which, according to some, is much less frequent than generally thought.

Somehow lost in this entire debate remains the new developments in the management of BD in young individuals—the host of psychological interventions that have been found effective in BD, either alone or in combination with medications. The use of these interventions in young individuals is the focus of a new volume by Australian and European authors, Bipolar disorder in young people: A psychological intervention manual.

The book contains a preface, introduction, 9 chapters, and 13 appendices. As the authors point out, this is the first book summarizing a manualized psychological intervention for people in adolescence and early adulthood who are experiencing BD (p vii). The introduction notes that most BD patients relapse after 5 years of treatment despite good medication adherence (p ix). Psychological interventions clearly seem to help in preventing relapse and aid in adherence to medications. However, while the efficacy of psychological interventions in BD has been studied and well documented, many studies tend to exclude people under the age 18 (p x). This slender volume summarizes and manualizes the available information in this area in combination with the authors’ experience “of working with a naturalistic, ‘real world’ population of young people who are experiencing their first episode of mania and who previously had little, if any, contact with a mental health service.” After summarizing key information about BD in young people in the first chapter, this manual describes 8 modules addressing key areas commonly experienced when working with this population (p vii)—assessment and engagement; psychoeducation and adaptation; medication adherence; targeted cognitive-behavioral interventions; social rhythm regulation; family work; comorbid issues (substance abuse, alcohol and other disorders); and relapse prevention, including identification of early warning signs.

The first chapter has clinically important and relevant points, such as the fact that BD has one of the highest lifetime risks for suicide associated with any psychiatric disorder, and it has been demonstrated that receiving treatment is associated with lower suicide and mortality rates (pp 2-3). This chapter also succinctly summarizes some characteristics of young people with BD and opportunities for early psychological intervention following the first episode (ie, early intervention may prevent suicide and may prevent secondary morbidity; it may help prevent breakdowns in relationships; and it may help prevent relapse). The second chapter reviews issues such as diagnostic difficulties in BD (40% of persons with BD are initially misdiagnosed with unipolar depression), elements of psychological assessment of patients with this disorder, and characteristics of a positive therapeutic relationship (therapist and patient factors). The third chapter discusses several important issues such as insight and the ways in which young persons may adapt to the diagnosis of BD. I found the discussion of challenges to insight in the early phase of BD quite useful—examples include the experience of mania and hypomania can seem counter-intuitive to the concept of disorder or that posttraumatic stress resulting from involuntary hospitalization may be distressing and threatening to the sense of invulnerability. This chapter also reviews psychoeducation, functional recovery, and working to enhance psychological adaptation and reduce stigma, guilt, and shame, including the concept of posttraumatic growth.

The following chapter is an excellent overview of medication adherence. The reasons for poor medication adherence in BD are numerous and challenging, ie, stigma of long-term medication use, comorbid disorders, the fact that mania is pleasurable, side effects of medication, impulsivity, and rebellion. Factors that may assist medication adherence include understanding the reasons for nonadherence, recognizing that adherence is not a polarizing concept, identification of the right medication and dose, good psychoeducation, good therapeutic relationship, work with the family, motivational interviewing, and establishing routines and cues. Medication adherence also should be strongly encouraged when the patient is asymptomatic. The fifth chapter is a solid introduction to cognitive-behavioral interventions in BD with focus on a phase-specific intervention. The sixth chapter focuses on a relatively new element of psychological interventions in BD—social rhythm regulation and stabilization, including interventions such as life event charting, sleep hygiene, sports, and diet. The seventh chapter deals with relationships and family work. The eighth chapter discusses the high degree of comorbidity in BD, namely anxiety disorders, abuse, posttraumatic stress disorder (PTSD), and alcohol and illicit substance use. The last chapter informs the reader about the identification of early warning signs, prevention of relapse and termination of therapy. It includes a good example of a comprehensive “goodbye letter.” All chapters include good clinical examples and conclusions summarizing each chapter in a bullet form.

One should not forget the 13 appendices: 1. Guide for people with bipolar disorder (definition, symptoms, treatment etc.); 2. What can I do to help a person with bipolar disorder?—A handout for family members and friends; 3. The bucket metaphor; 4. The repertory grids; 5. Views of bipolar disorder questionnaire; 6. Medication attitudes matrix; 7. Blank CBT formulation; 8. Weekly activity schedule; 9. Mood monitoring chart; 10. Responsibility pie; 11. Attitude to relapse questionnaire; 12. Relapse prevention plan; and 13. Checklist of interventions completed.

This volume is a great addition to the BD literature. It is useful, practical, clinically oriented, and well organized. It presents refreshing views (mostly Australian) and an optimistic outlook of psychological intervention for BD in young individuals. I believe that every clinician treating young patients suffering from BD will find this book useful. As the authors point out, “bipolar disorder can have a significant effect on adolescent development and has traditionally been associated with poor outcomes, both symptomatically and in terms of psychosocial functioning” (p vii). The message of this volume is that this could be, at least partially, changed, and the negative impact of BD on development and future functioning could be alleviated. This is a positive message and the manual is definitely a good buy.