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        Psychological therapies for bipolar disorder: addressing some misunderstandings
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        Psychological therapies for bipolar disorder: addressing some misunderstandings
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We would like to reply to the letter published in your journal by Gupta & Brown, 1 concerning a recent British Psychological Society report on understanding bipolar disorder. 2 As authors of that report, we were pleased that it has generated debate. In the main, responses from psychiatric and other clinical colleagues have been overwhelmingly positive: MDF The Bipolar Organisation referred to the report as ‘ground-breaking’ 3 and Stephen Fry's tweet on the report led to 2000 downloads in one day.

We thank Drs Gupta and Brown for their interest in this report, and for giving their opinion. However, they make some criticisms that we feel are based on misunderstandings, and we would like to correct these. In contrast to the view of Gupta & Brown, the report does not present an antipsychiatry position: its explicit purpose is to provide a psychological perspective to supplement the existing literature, which is predominantly based on a biological perspective. The report does discuss the limitations of formal mental health diagnoses, but recognition of these limitations is not discipline specific. In our experience, individuals who have been told they have bipolar disorder are rarely informed about the explanatory and predictive limitations of this diagnosis. By outlining these in our report, we aim to raise awareness that the construct of diagnosis is a subject of debate, and therefore that it may be legitimate to explore alternative means of understanding experiences that are classified in this way. Gupta & Brown propose that diagnoses in mental health are based on specific scientific data about aetiology. We would contest this. Indeed, this is even explicitly spelled out in DSM-IV-TR, 4 which states that recent versions of the DSM ‘attempt to be neutral with respect to theories of aetiology’ (p. xxvi). The authors claim that we do not offer an alternative to diagnostic systems. This is not the case with regard to either the descriptive or the explanatory function of diagnoses. As regards the former, we propose that normal English is sufficient (for example, the report uses ‘a tendency to experience extremes of mood’) and avoids some of the more unhelpful side-effects of psychiatric diagnosis such as stigma. As regards the latter, we propose that this is in any case limited and that individualised multifactorial formulation, where professional and service user work together to identify the various factors contributing to the problem, offers a more useful approach.

We do not claim that bipolar disorder is a lifestyle choice and we do not argue that psychological interventions alone are a preferred solution for all individuals with a diagnosis of bipolar disorder. We do, however, argue (consistent with NICE guidelines 5 ) that more people should have access to psychological interventions and that these can improve outcome for some people. Systematic reviews support the benefits of structured psychological approaches, particularly in relation to reduction of relapse risk. 6,7 We do not argue against the use of medication treatments, but we do discuss the fact that they are not necessarily helpful for everyone and that choice in relation to this, as well as other forms of treatment, is an important consideration. We accept that the evidence for psychological interventions is based mainly on participants who are currently receiving medication as well. This could mean that the sole ingredient offered by psychological interventions is an increase in adherence, but this is no more proven than other possible explanations. Indeed, Lam and colleagues 8,9 found significant benefits of cognitive-behavioural therapy for bipolar disorder after controlling for medication adherence. Gupta & Brown are right to point out that there are no drug-free studies of psychological interventions in bipolar disorder. Such studies prove an enormous challenge, given the present readiness to prescribe. However, it is encouraging that psychological therapies appear to be superior to medication in the long term for a range of other psychiatric disorders, including unipolar depression, post-traumatic stress disorder and panic disorder. 10,11 Nevertheless, our approach sees a key role for medication in services, particularly in situations of acute risk, and for clients for whom the benefits are clear. The authors correctly note that we omitted reference to trials by Scott et al 12 (which had negative results) and Miklowitz et al 13 (which had positive results). This we will address when the report is updated, but it does not significantly change the conclusions of the report (nor did it affect the NICE guideline recommendations on psychological therapy 5 ). The authors suggest that the evidence informing the report is limited. We disagree. In addition to the trials and experimental research that is covered, we provide extensive reports from large numbers of people with bipolar disorder, reporting on how they have learned to cope with their mood swings. We regard such evidence as primary rather than secondary in the pursuit of a scientific understanding of emotion regulation and how it becomes a problem for many people, just as early psychiatrists utilised a phenomenological stance in building their initial categorisations of mental illness. We welcome the opening of a debate on these issues and look forward to further constructive discussions.

1 Gupta, S, Brown, J. Psychological therapies for bipolar disorder – adjunct not alternative to pharmacological treatments. Psychiatrist 2011; 35: 196.
2 British Psychological Society. Understanding Bipolar Disorder – Why Some People Experience Extreme Mood Swings and What Can Help. British Psychological Society, 2010.
3 Syrett, M. A balanced approach to bipolar. Pendulum 2010; 26: 2.
4 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn, text revn) (DSM-IV-TR). APA, 2000.
5 National Collaborating Centre for Mental Health. Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents in Primary and Secondary Care (NICE Clinical Guideline 38). National Institute for Health and Clinical Excellence, 2006.
6 Beynon, S, Soares-Weiser, K, Woolacott, N, Duffy, S, Geddes, JR. Psychosocial interventions for the prevention of relapse in bipolar disorder: systematic review of controlled trials. Br J Psychiatry 2008; 192: 511.
7 Scott, J, Colom, F, Vieta, E. A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders. Int J Neuropsychopharmacol 2007; 10: 123–9.
8 Lam, DH, Watkins, ER, Hayward, P, Bright, J, Wright, K, Kerr, N, et al. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first year. Arch Gen Psychiatry 2003; 60: 145–52.
9 Lam, DH, Hayward, P, Watkins, ER, Wright, K, Sham, P. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. Am J Psychiatry 2005; 162: 324–9.
10 Butler, AC, Chapman, JE, Forman, EM, Beck, AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 2006; 26: 1731.
11 Barlow, DH, Gorman, JM, Shear, MK, Woods, SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder. JAMA 2000; 283: 2529–36.
12 Scott, J, Paykel, E, Morriss, R, Bentall, R, Kinderman, P, Johnson, T, et al. Cognitive–behavioural therapy for severe and recurrent bipolar disorders. Randomised controlled trial. Br J Psychiatry 2006; 188: 313–20.
13 Miklowitz, DJ, Otto, MW, Frank, E, Reilly-Harrington, NA, Kogan, JN, Sachs, GS, et al. Intensive psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry 2007; 164: 1340–7.