Psychotherapy for bipolar disorder

Psychotherapy for bipolar disorder J Scott The British Journal of Psychiatry 1995 167: 581-588 Access the most recent version at doi:10.1192/bjp.167.5.581

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Review Article

British Journalof Psychiatry (1995), 167,581—588

Psychotherapy forBipolar Disorder JAN SCOTT Background.Psychosocialfactorsmaycontribute25—30% to the outcomevariancein bipolar disorders.Sufferershave identifiedbenefitsfrom psychotherapy,but biologicalmodelsand treatmentsdominatethe researchagenda.The authorreviewsresearchon psychosocialissues and interventionsin this disorder.

Method.Researchon adjustmentto the disorder,interpersonal stressorsandobstaclesto treatment compliancewere locatedby computerisedsearchesand the author's knowledge of the literature.All publishedoutcomestudiesof psychosocialinterventionsin bipolardisorder are reviewed. Results.There is an inadequatedatabaseon psychosocialfactorsassociatedwith onset and maintenanceof bipolardisorder.While the outcome studiesavailableare methodologically inadequate,the accumulatedevidencesuggeststhat psychosocialinterventionsmay have significantbenefits for bipolarsufferersand their families. Conclusions.Giventhe significantassociatedmorbidityand mortality, there is a clear need for more systematicclinicalmanagementthat addressespsychosocialas well as biological aspectsof bipolardisorder.The author identifiesappropriateresearchstrategiesto improve knowledgeof effective psychosocialinterventions.

It is estimated that an adult developing bipolar disorder (BD) in his/her mid-20s effectively loses 9 years of life, 12 years of normal health and 14 years of work activity. In addition, the suicide-related mortality and the psychosocial consequences for ‘¿significant others' identify BD as a significantpublic health problem (Prien & Potter, 1990). The firstline treatment for BD remains pharmacotherapy, and the advent of lithium and other drugs have undoubtedly improved the quality of life for many individuals. However, Joyce (1992) noted that, even under optimal research conditions, prophylaxis will protect fewer than 50°lo of patients with BD against further episodes. Given the increasing interest in the use of psychotherapy in treatment-resistantdepressive and schizophrenic disorders, it seems surprising that such initiatives have not been applied more systematically to individuals with BD. This paper highlights the reasons why such approaches may have been ignored, emphasises why they should now be used, and identifies potential avenues for future research. Why have psychologicalapproachesbeen

overlooked? There appear to be three reasons why clinicians have been reluctant to employ psychosocial interventions: firstly, aetiological models which highlight the strong genetic and biological correlates of BD have dominated the researchagenda; secondly, it was long believed that patients with BD made a full inter episode recovery; and thirdly, psychoanalysts have

historically expressed greater ambivalence about the suitability of psychotherapy for manic—depressive patients compared with patients with other severe disorders. The latter is probably the most important influence. Fromm-Reichmann wrote that in com parison with individuals with schizophrenia, bipolar patients were poor candidates for psychotherapy becausethey lackedintrospection,weretoo dependent and were likely to discover and then play on the therapist's ‘¿Achilles' heel'. Yalom suggested that the inclusion of a bipolar patient in a therapy group was “¿one of the worst calamities―that could occur. Although others argued strongly for the importance of psychological treatments (e.g. Benson, 1975), the relative lack of empirical support for such developments (no large-scale, randomised, control trial has ever been published) meant that clinicians received little encouragement or advice on how to incorporate such approaches into treatment. The discouraging views on psychotherapy with bipolar patients were mainly published in the pre lithium era. As such, reticence about trying to cure acute mania with a talking therapy is easily under stood. However, the holistic approach advocated in modern practice encourages the integration of biomedical and psychosocial models of disorder. The treatment of acute mania rightly focuses initially on pharmacotherapy, but when the mental state is stabilised then the devastating impact of the episode on the individual and his/her family clearly needs addressing. Even if the patient was functioning well premorbidly,or apparentlymakes a full inter-episode

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recovery, he/she will need help in coming to terms with having a chronic and recurrent disorder. Also, Goodwin & Jamison (1990) have argued that as establishing ‘¿control' of biological factors is essential to the effective management of BD, it is vital to understand and overcome psychological barriersto compliance with pharmacotherapy. Psychosocialissues in BD There are a number of problems related to BD and compliance where psychosocial therapies could have a role but have so far been underused.

Kahn (1990) highlights the special problem of ‘¿dual vulnerability' in individuals with early-onset BD. He argues that mood instability or other prodromal symptoms preceding onset of the disorder may negatively influence interactions with people at home. A vicious cycle develops where the suboptimal environment created then adversely affects the individual's personality development which further damages interpersonal interactions even before the first illness episode occurs. Goodwin & Jamison (1990) also argue that early-onset BD may arrest or interrupt the completion of ‘¿developmental tasks' that normally lead to independence and leaving home.

Problems related to the disorder

Premorbid personality and coping skills may predict an individual's reaction to the diagnosis. Other psychosocial problems in BD may relate to actual or anticipated losses, or the nature and severity of the illness and its impact on relationships.

Loss

Individuals with BD may experience significant distress or relapse if concrete or abstract losses are not acknowledged and addressed. Financial and employment problems are cited by 70% of patients and their partners as the most frequent long-term Adjustment problems difficulties (Targum et al, 1981). In the first year after A comprehensive review of premorbid personality by a manic episode, Harrow et al (1990) reported that Goodwin & Jamison (1990) suggests that individuals 23°lo of patients were continuously unemployed, and with BD are more similar to, than different from, 36°lo showed a clear decline from their premorbid ‘¿normal' controls. Although remitted bipolar patients level of functioning at work. Loss of self-esteem may show lower rates of personality disorder (23°lo) than result from the loss of status. Relationships may be remitted unipolar patients (35°lo),adjustment after lost because of irrevocabledamage done by aberrant discharge is significantly worse, with 60% of BD behaviour during a manic episode. These losses are cases exhibiting functional impairment (Harrow et often accompanied by feelings of guilt. Overall, the al,1990).Persistent affective symptoms accountfor apparent lack of control over life undermines any about half the cases of poor adjustment. belief in self-efficacy and may lead to demoralisation, The reasons why others with BD show such deficits particularly if recurrencesoccur when the patient is are less certain as robust premorbid predictors of complying with medication (Kahn, 1990). adjustment are lacking. What is clear is that calm As well as real current losses, anticipated losses acceptance of the diagnosis and full compliance may also lead the patient to give up hope for the with treatment are exceptional. Goodwin & Jamison future. Detection of hopelessness is important as it (1990) state that on discovering that the illness is is a key variablein determiningwhethersuicidalideas chronic, recurrent and potentially life-threatening, are acted upon. Inquiring about the meaning of the predictable reactions are denial, anger, ambivalence illness often reveals that patients now view themselves and anxiety. All these responses can have adverse asdefective (Rush,1988; Goodwin& Jamison, 1990) effects if they become protracted. Joyce (1992) noted and express anxieties about the potential loss of that readmnissioncan be predicted by illnessbehaviour, actual or hoped for relationships, or ambivalence with those who fail to recognise or respond to about the advisability of having children. Younger evolving symptoms or who are less accepting of drugs people become more hopeless as they gradually having a worse outcome. Resentment and frustration realise that they may never achieve career or other may impair relationships with the family, social goals, or attain autonomy. network and professionals trying to offer treatment. Goodwin & Jamison (1990) also highlight losses Bipolar patients with high levels of anxiety often relatedto treatment, but stipulate that realisticlosses use inappropriate strategies to try to avoid relapses, must be distinguished from unrealistic losses (where such as excessive self-monitoring and extreme the disorder or the treatment are inappropriately restrictions on their lifestyle. The perceived stigma blamed for all past and currentdifficulties). Realistic of the diagnosis may also adversely affect self-image losses may include reduced energy, productivity and lead to social avoidance. and sexual activity. The loss of creativity associated

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with ‘¿highs' has negative consequences for some individuals. Interpersonal

relationships

Unlike the extensive literature on unipolar depressive disorders, there are less data on the effect of BD on marital and family relationships, or the effects of these relationships on the prognosis of the disorder. Frank et al(1981) found that marital adjustment in couples where one spouse suffered from BD was similar to that in matched control couples where both spouses were mentally healthy. Other studies report less favourable outcomes, with significantly higher divorce and separation rates and expressed conflict in the marriages of bipolar patients compared with unipolar patients and community controls. Brodie & Leff (1971) reported that divorce in bipolar patients (which occurred in 57% of their sample) was always instigated after the first manic episode. Bipolar patients are also reported to have fewer confiding relationships than control subjects. Targum et al (1981) noted that 53°lo of healthy spouses said that they would not have married their bipolar partner, and 47% said that they would not have had children had they known the disorder would occur. Patients tended to underestimate the impact of the disorder on their relationships. Overall, healthy spouses regard the problems associated with the disorder as more severe and the effects of treatment as more beneficial than their bipolar partners. Bipolar individuals and their healthy spouses agree that depression is easier to cope with and accept than mania as the spouse tends to be sympathetic and perceive the disorder as beyond the patient's control (Targum et al, 1981). The threat of violence and poor judgement, particularlywith respectto interpersonal interactions and financial extravagance, tend to dominate concerns about mania. Healthy spouses often regard the behaviour of someone with hypomania as deliberate and spiteful. Interestingly, Hooley et al (1987) demonstrated that marital adjustment in spouses of patients who suffer more florid manic episodes is actually better than in spouses of patients with less severe symptoms. This may be because these extreme types of behaviour are more readily accepted as uncontrollable (Goodwin & Jamison, 1990). The literature on the parenting skills of bipolar patients is sparse. Suggestions that parent—child bonding may be disruptedby lack of consistent care, or that mothers with BD are less attentive to their children's needs, come from small, mainly descriptive studies and it is difficult to extrapolate to other samples.

DISORDER

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The influence of interpersonal relationships on BD outcome must also be considered. In a study of 23 bipolar patients, Miklowitz et al (1988) found that intrafamilial levels of expressed emotion (EE) and affective style (AS)predict thelikelihood ofrelapse over 9 months' follow-up. Social adjustment after discharge was also predicted by AS profile. The most striking finding in this study was a relapse rate of 94% if either EE level was high or AS profile was

negative regardless of treatment regime, medication compliance, baseline symptoms, illness history or demography. If the AS profile was benign and EE level low, the relapse rate was only 17°lo. High relapse rates and symptom exacerbation despite adequate lithium prophylaxis have also been noted in bipolar patients reporting stress related to marital disharmony or experiencing other interpersonal events. Problems relating to compliance Data on medicationcompliancein bipolarcases relate mainly to lithium. Information on carbamazepine and other drugs is generally lacking, although non adherence rates for carbamazepine (38%) tend to be lower than rates for lithium treatment (51%) (Goodwin & Jamison, 1990). Up to 75% of relapses in bipolar disorder may be associated with non-compliance. Prevalence and patterns of non-compliance Reported non-compliance rates for lithium prophy laxis vary between 20—50%,with about one in five patients failing to comply despite a good therapeutic outcome. Goodwin & Jamison (1990) make a plea for more research, commenting that, unlike non response (which has been extensively examined), non compliance should be reversible through good clinical management and a therapeutic relationship which facilitates the discussion of adherence problems. Complianceis rarelyall or nothing. Fullcompliance and total non-compliance are the most overt types of behaviour, but intermittent and late patterns are reported. The prevalence of intermittent compliance is high: 47% of bipolar patients discontinue lithium against medical advice on at least one occasion and 34% discontinue on two or more occasions. Some individuals describe a cyclical pattern of strict compliance immediately after an illness episode, followed by reducing compliance, leading to non compliance if they remain symptom free. This behaviour pattern is reinforced by the fact that side effects disappear early, often leading to the patient feeling better, while the reappearance of symptoms is delayed and not always associated with non compliance in the patient's mind (Rush, 1988).

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Late compliance (where early drug refusal is later replaced by adherence) is of interest as it highlights the critical need to identify and tackle denial. It appears that some individuals initially reject both the diagnosis and the medication. With time, evidence of disorder and the negative consequences of untreatedepisodes lead to the development of insight and gradual acceptance of the rationale for medication (Goodwin & Jamison, 1990). Risk factors for non-compliance

Several studies identify that lithium compliance rates are increased in those with a stable social network, those who perceive the symptoms as severe and treatment as effective, and those with obsessional personality traits (Goodwin & Jamison, 1990). The most common factors associated with lithium non compliance are younger age, male gender, experience of fewer illness episodes and previous history of treatment non-adherence. Non-compliance rates are particularly high during the first year of lithium treatment and in those who have persistent elevated mood, a history of grandiosity or who complain of missing ‘¿highs'. The latter is noteworthy as patient surveys suggest that fear of depression is a stronger motivating factor for compliance than fear of mania. Drug side-effects undoubtedly account for a significant proportion of cases of non-compliance, although psychiatrists may rate side-effects as a more important cause of non-compliance than patients (Jamison & Akiskal, 1983). Clinicians and sufferers also differ in their views of which side-effects are most problematic and which lead to non-adherence (Jamison et al, 1979). It is reportedthat 75°lo of side effects regarded by psychiatrists as most important are somatic symptoms, while 80°loof side-effects regarded by patients as most worrying are cognitive changes such as mental confusion and memory problems (Jamison&Akiskal, 1983).One explanation for this disparity is that clinicians and patients disagree about whether a particular feature is a side effect or a symptom. However, a review of patient reports of somatic side-effects found that although certain complications (such as excessive thirst) occur more frequently, the side-effects they found least acceptable and most likely to lead to non-compliance were weight gain and tremor (Goodwin & Jamison, 1990). These findings clearly have implications for how doctors and patients communicate about treatment. Only a small literature exists on individual attitudes towards lithium treatment (Cochran & Gitlin, 1988; Rush, 1988; Peet & Harvey, 1991). Recurringthemes are a greater risk of non-compliance in individuals

who dislike having their moods ‘¿controlled' by medication and see the disorder and the need to receive long-term pharmacotherapy as a personal weakness. They often express the view that if they simply tried harder then relapses would not occur. In a study of 48 out-patients, Cochran & Gitlin (1988) demonstrated that both individual attitudes and social influences (namely what significant others expect an individual to do) modify lithium compliance. Aetiological theories and treatment advice ofrelatives who suffer frommentaldisorder strongly influence patient beliefs, and the quality of the doctor—patientrelationship also significantly affects compliance. If the patient perceived the psychiatristas ambivalent about the treatmentor the patient was not motivated to do as expected, he/she was less likely to comply. A control trial of 60 lithium clinic attenders also demonstrated that those offered an educational programmeshowed improved knowledge and more favourable attitudes towards pharmacotherapyand better medication compliance than those receiving standard treatments alone (Peet & Harvey, 1991). Outcome studies There are a number of descriptive articles on the use of psychosocial interventions in BD, but few publications address outcome, and empirical treat ment studies are rare. The available research is reviewed; none was undertaken in Britain. Individual therapy

Anecdotal reports of the benefits of individual therapy for bipolar patients can be found in the psychoanalytic and cognitive-behavioural literature. The largest case series was published by Benson (1975) who described a 41-month, open, follow-up study. Twenty-four out of 31 patients (21 women) who received psychotherapy in addition to lithium maintenance treatment were reported to have a good clinical outcome. Cochran's (1984) study of the impact of six sessions of individual cognitive therapy on lithium compliance and clinical outcome in bipolar out patients is the only one to include a control group. Twenty-eight patients with BD who were newly referred to a lithium clinic were randomly assigned to cognitive therapy or ‘¿treatment as usual'. On subjective and observer ratings (including serum lithium levels), compliance was significantly better at6-weekand6-monthfollow-up intheintervention group. Only three subjects assigned to cognitive therapy (21°lo) as opposed to eight (57%) control

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FOR

subjects discontinued lithium against medical advice, and admission rates were significantly lower in the cognitive therapy group. Couples and group therapy

BIPOLAR

DISORDER

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Finally, Wulsin et al(1988) described a long-term group run monthly at a CMHC for 22 bipolar out patients (12 women) over 4 years. Unlike the other studies, the group focused on interpersonal relation ships, and the prescribing of lithium was done solely outside this setting. Reductions in admission were reported, but the drop-out rate was 55°lo.

Davenport and colleagues (1977) described the use of psychodynamic ‘¿couples group therapy' (n = 12) and retrospectively contrasted this approach with Family therapy lithium clinic attendance (n=11) and community mental health centre (CMHC) follow-up (n = 42). Fitzgerald (1972) noted his clinical impressions of the Individuals were not randomly allocated to the benefits of family therapy for a consecutive series different treatments, but all those included in the of 25 bipolar patients. Others describe general study had been admitted for mania 2—10years benefits from this approach, but more systematic previously and had an intact marriage at the time data are provided by Glick and colleagues (1994). of discharge. At follow-up, the ‘¿couples group Ina cross-national studyof24in-patients withsevere therapy' patients werefunctioning significantly better affective illnesses, patients who received individual in terms of social and family adjustment and and family psychoeducation showed better resolution reported no readmissions or marital failures. The of the index episode and better global outcome CMHC group had the worst outcome (16 12—18months after discharge. readmissions; 10 marital failures; 3 suicides), but the A further large-scale, randomised, controlled trial differences between these patients and lithium clinic using an in-patient family intervention(IFI) has been attenders were non-significant. Treatment modality undertaken by the above research group (Spencer et was the only predictor of outcome identified. al, 1988; Clarkin et a!, 1990). This study looked at No controlled trials of group therapy (combined outcome 18 months after discharge in 169 in-patients with lithium treatment) exist, but four open studies who received six sessions of IFI during their hospital have been published. Shakir et al (1979) and later stay. The results for the 50 cases of affective Vollunar et a! (1981) reported on a therapy group for disorders were reported separately (Clarkin et a!, 15 lithium-responsive, bipolar patients (13 men) which 1990). The data on 21 bipolar subjects (14 women) ran for a number of years. Shakir and colleagues within this group represent the only randomised identified significant ‘¿before and after' changes in control study of psychological treatments undertaken patient functioning in the 2 years before and 2 years in BD. Twelve subjects were allocated to IFI and nine after the introduction of group therapy. Before to the control intervention (the usual in-patient therapy, ten patients had a history of poor compliance treatmentprogramme).Drop-out ratesand treatment and admissions, the group spent an average of 16 after discharge did not differ significantly between weeks a year in hospital, and only five individuals the two groups. The immediate and long-term were in regular employment. After about 51 weeks' outcome data demonstrated that, in comparison to attendance ata ‘¿Yalom-style' group,onlythree indi all other groups, female bipolar IFI patients showed viduals were admitted over the next 2 years, the significantly better social, family, leisure, work and average length ofin-patient stay was3weeksperyear, role performance and significantly improved family serum lithium levels and compliance rates were attitudes to treatment. Although the gains made by improvedand ten patientswerein continuousemploy female bipolar IFI subjects diminished with time, the ment. Volkmar and colleagues wrote that the shared results held even when other variables were controlled experience of BD and lithium treatment enhanced the for. Female bipolar patients benefited significantly therapy process, but highlightedthat it was not poss from IFI, whereas male bipolar patients and unipolar ible to distinguish the specificeffects of psychotherapy patients showed either no benefit or, in some cases, from the non-specific benefits of close follow-up. a negative effect. Kripke & Robinson (1985) describe a long-term Prien& Potter (1990) pointoutthatthere aretwo out-patient support group for 14 bipolar patients populations of bipolar patients to be considered (13men),eightof whom werestill attending the when providing family therapy: older bipolar group 12 years later. Anecdotal evaluation suggested patients with a spouse (and children); and young that problem-solving strategies were better received adults with early-onset BD who live with their nuclear than dynamic analysis. Perceived benefits were family. The latter group may benefit from an reduced rates of admission and enhanced social and adaptation of behavioural family therapy (BFT) previously advocated in schizophrenia by Falboon. A economic functioning.

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pilot study of eight patients treated with lithium and BET suggested that the approach was well received by sufferers and their families (Miklowitz eta!, 1988) and, over 9 months, relapse rates in this group (13°lo) were significantly lower than those in a similar group of 23 patients who received lithium alone (70%).

schizophrenia about20 yearsago.Work on schizo

phrenia has since demonstrated an interaction between biological vulnerability and psychosocial dimensions, and the need for adjunctive psycho therapies is now accepted. Prien & Potter (1990) note that BD may disrupt the patient's family environment, reduce ability to cope with stress, impair social adjustment and lead to deficits similar to the negative Comment symptoms of defect states. Life events and intra Most of the studies reviewed are unsophisticated or familial stress have also been implicated in early inadequate in a number of ways: only a small number relapses. On the basis of these data, there are of recognised research toolsor definedoutcome implications for clinical practiceand future research. measures were used, and only two studies (Cochran, 1984; Clarkin eta!, 1990)randomly allocated patients Clinical implications to either a psychosocial or control treatment. These are the most comprehensive studies available, also Many clinicians employ psychosocial strategies in employing more clearly defined treatment modalities the management of BD. While flexibility of style (CT and IFI). However, the relatively small sample and techniques is often required to cope with sizes render the statistical power low and make fluctuating moods and other psychopathology, there definitive statements about outcome unwise. is some consistency in the descriptions of beneficial Some tentative conclusions can be drawn from the approaches (Rush, 1988; Goodwin & Jamison, 1990), researchers' observations. Individual therapy clearly and most clinicians reiterate the fmdings of the improved knowledge about BD and its treatmentand National Institute of Mental Health collaborative allowedsufferers to explorebeliefs aboutthese study on depression that systematic clinical manage issues in detail. Group process benefited from the ment in combination with pharmacotherapy is a homogeneousnatureof thesampleand,provided simple and effective strategy. Organising an agenda that individuals were engaged in the therapy, for follow-up appointments ensures coverage of all admissions did not unduly disrupt the proceedings. topics. Assume that compliance will become an issue Sharing knowledge about the disorder helped those for all patients at some point and create an who denied or underestimated problems to gain atmosphere in which ambivalence or obstacles can insight andawareness intotheir difficulties. Couples be anticipated, discussed and simple behavioural group therapy was helpful in educating spouses about techniquesintroduced (such as ‘¿pairing' tablet-taking the disorder, allowed exploration of patients' own with a routine activity) to facilitate adherence. attitudes and reduced stress. Similar benefits accrued Giventheimportance ofotherpeople's attitudes, from family therapy in both female in-patients (IFI) and research evidence thatsufferers underestimate and younger out-patients (BET). Older men may the impactof BD, then extending the psycho do well in individual or group formats. Possible educational approachisappropriate. Franketa! explanations are that the families of male bipolar (1985) reported that after patients and their families patients may be more critical than the families of attended a 1-day educational workshop, there were female patients, or that men with BD are hyper no reported cases of treatment non-compliance. sensitive to interpersonal stimuli and find family Handouts and videos can also be used to supplement therapy more stressful (Clarkin et a!, 1990). sessions (Peet & Harvey, 1991). Sufferers and their relatives may also engage in simple diary-keeping to identify early warning symptoms of relapse, or Conclusions record response to medication so that decisions For many decades, the dominant research agenda in regarding changes can be made more objectively. bipolar disorder has been biological. The impact of Identifying ‘¿high-risk situations' for relapse and drugs on acute symptoms and relapse rates has been developing a hierarchyof coping responses(including emphasised so strongly that the role of other how to access mental health services) are other therapies has been ignored. However, there are limits possible uses of such data. to the efficacy of pharmacotherapy and, although Some research suggests that the first year after the treatment adherence is a recognised issue, little is onset of BD is a crucial time for patients in terms known of the psychological barriers to compliance of adjusting to the disorder, developing insight (Rush, 1988). The paucity of psychosocial research and complying with treatment, systematic clinical in BD has many parallels with the situation regarding management at this stage may be a simple strategy

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for improving outcome. Lastly, although clear guidelines for BD are not available, the use of cognitive, brief dynamic, interpersonal, couples or family therapy should at least be considered more often. Research implications

There are a number of obvious areas for future research.

A greater understanding of individual and environmental vulnerability factors that influence onset or outcome of BD episodes is required. In unipolar depression there is evidence that cognitive dysfunction and problem-solving deficits influence the course of the disorder. No similar literature exists for BD. If certain dysfunctional attitudes were associated with persistence of symptoms, then it might be possible to develop non-drug strategies to modify these beliefs. The work on AS and EE also needs to be extended to larger patient samples. If the evidence confirms that drugs do not protect the individual against the adverse effects of high EE, it clearly has implications for the use of adjunctive family therapy techniques. Lastly, while many life events are unavoidable, their occurrence signals a period of increased risk of relapse in patients with BD and offers an opportunity for integrated biopsychosocial research. The problems of medication compliance need to be examined. Only 1—2% of the papers written on lithium explore this, and even less is known about adherence to other drugs. Frank eta! (1985) suggest that researchers have a duty to identify and account for cases of non-compliance in treatment studies so thatwe canimproveourunderstanding. More work on attitudes towards BD and its treatment should be undertaken. Family attitude studies were mainly undertaken in the USA some time ago and therefore need to be repeated. Randomised control trials are required to establish the short- and long-term benefits of psychotherapy over the usual treatment regime. Evidence of which approaches will be most effective is lacking, so different psychotherapies need to be compared. It will be important to distinguish specific and non specific benefits (Lam, 1991). Short-term structured, ‘¿manualised' therapiesadapted for use with BD, such as cognitive therapy, IFI, BET and interpersonal therapy, should be investigated initially. Follow-up in these studies must extend beyond the acute phase to assess any longer term benefits and, as drop-out rates are likely to be high, recruitment will have to be active and extensive to ensure that the sample is sufficiently large to reliably assess outcome.

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Professor Jan Scott, MRCPsych, University Department of Psychiatry, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP (First received 22 November

1994, final revision 6 March 1995, accepted

18 May 1995)