Unit 4 is devoted to teaching patients how to identify a relapse, take prompt action from the behavioral standpoint, and work out an emergency drug treatment plan. Early detection of relapses is a technique that has already been discussed, especially in individual format, and many of our patients benefit from its being built into a group psychoeducation program.

Perhaps the best study on individual psychological intervention in bipolar disorders is the one by Perry et al. (1999); the type of intervention was a variable number of sessions, between 7 and 12, in which the therapist used a distinctly psychoeducative approach in helping patients to identify their most habitual relapse signals. The results indicate that the patients in the treatment group (N = 34) took longer to experience a manic relapse and, at the end of the follow-up period, had a smaller number of manic relapses than the control group (N = 35). It seems that there was no prevention effect for depressive episodes.

In our program we place special emphasis on early detection of hypomanic and manic symptoms for various reasons, most important of which are:

• The speed with which hypomania warning signs (“prodromes”) become a full-blown episode is far greater than in the case of depression. While in depression several weeks usually elapse between the first warning signs and the actual episode, in the case of hypomania and manic this can happen in a matter of days or hours.

Goal

The goal of Session 1 is to take contact with the group and to explain the existing rules to the members. These rules are basic for the good functioning of the group, and are also intended to create a good environment that would facilitate patient participation. Although one of the scientific fathers of group treatment, Yalom, openly defines the bipolar patient as “one of the worst calamities that may befall a group, ” the truth is that our experience indicates quite the contrary. The bipolar patient usually adapts very well to the psychoeducation group, especially if we achieve proper homogeneity/heterogeneity balance among the members concerning age, sex, seriousness, etc. To date, there are many patients who have become perfectly integrated in the functioning of the group, taking a participative role and being extremely collaborative and respectful to the other group members and the therapist. This is not at all strange: our patients correctly integrate in the group because they understand immediately that they may get great benefits from the experience, that both of them and their disorders will be quickly accepted and understood, and that in the psychoeducation program the aspects of great interest to them are being worked on. This is something that probably did not happen in Yalom's groups.

Procedure

• Before starting the session, we will prepare the room by placing several chairs in a circle and, slightly distanced from the others, as many chairs as there are therapists by the blackboard.

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The primary purpose of any treatment, whether psychological or pharmacological, should always be the curing of a disorder, or at least an improving of the symptoms. Thus, we should be very critical of those treatments that offer only improvements of secondary aspects, like quality of life, or unspecific results, like the patient's subjective evaluation of the treatment in question. The latter is especially common for psychological treatments. Thus, it can be said that most psychological treatments might be useless because, perhaps due to lack of tradition, there is a limited number of psychological treatments that are properly validated by controlled clinical trial that includes a large enough sample, a prospective design, an adequate control group, randomized assignment of groups, blind evaluation of results and a medium- to long-term follow-up of patients. To make matters worse, some studies that have a good part, if not all, of these features use very indirect measurements of effectiveness that do not make it possible to show that a specific psychological treatment significantly reduces one type of symptoms, the number of hospitalizations, etc. And in reality, strictly speaking that is really the only thing that should be important to us, at least in principle, as therapists. This does not mean that an improvement in certain non-nuclear aspects of the disorder is not important: it is, but at a level immediately below symptomatic improvement, and therefore two levels below the primary objective (“curing” the disorder, somewhat utopian for more than 90% of psychiatric disorders).

Goal

The goal of this session is to provide the patients in the group with a structured action plan if any decompensation begins. It is not a session designed to improve any symptoms by cognitive–behavioral intervention as, let us point out one more time, patients in psychoeducation must be euthymic. The goal of the session is prevention, that is, for our patients to learn techniques or acquire resources while they are euthymic that can later serve them during a decompensation.

Procedure

• In a single session we will discuss how to act with all types of decompensation. It is advisable not to mix up useful tips for mixed episodes, hypomania, and mania – which are practically the same – with tips for depression, as this may confuse our patients. Thus, we have to divide the session time in the most appropriate way according to our patient profile, and reinforce this or that point according to explicit requests from the group members. Our experience tells us that it is usually necessary to spend more time on mixed episodes, hypomania, and mania than depression. We will now relate the content of a session with 50 min spent on mixed episodes, hypomania, and mania and 30 min on depression, leaving you, the reader, to allocate the time in your own future groups.

• Before going into appropriate action at the start of a decompensation, we have to know what resources our patients have available for a mixed or (hypo)manic decompensation, so we can reinforce the right ones and advise against the wrong ones.

Goal

The goal of this session is for patients to learn to detect their (hypo)manic relapses in time, and make their own lists of operational early signs so that these are available for identification of future episodes. Procedure

• The session can begin with a reminder of the symptoms of mania and hypomania, and the difference between the two as, although this may seem strange, at this stage in the program there are still patients who do not have the clear distinction between depression and mania.

• To meet our objective, we quickly go around the group to name all the symptoms of mania.

• We ask the group the following questions: “Do you believe all these symptoms can act as alarm signals? Which should we remove from the list? Should we add anything?”

• The answers to these questions will lead to some important considerations for the session: some symptoms appear so suddenly that they are of no use as warning signs, while other – non-pathological – behaviors are actually good indicators of a relapse.

• With the co-operation of the group, we go around again to come up with the General Warnings List.

• We explain to the patients how to prepare the Personal List of Operational Warnings, always emphasize the need to individualize the knowledge of the disorder: I am trying to learn not about the illness of bipolar disorder but about my bipolar disorder – an idea that perfectly fits the concept the patients have of their psychiatric disorder.

Goal

The objective of this session is for the patient to understand the need for periodic tests in order to determine serum levels. Many patients do not do these serum determinations regularly, either because they forget, because they do not understand their importance or because they are afraid of needles. Others, on the contrary, overestimate the need/usefulness of these tests and give them diagnostic or prognostic value concerning the evolution of their disorder. This tenth session is intended to focus on and stress the importance of serum determinations of mood stabilizers.

Procedure

• As usual, the session starts with the presentation of two life charts.

• After these presentations, we may start asking our patients how many of them take lithium, valproate, and carbamazepine and how many of them have had a lithium, valproate, or carbamazepine plasma concentration taken in the last half year. If the number does not match, we will ask why some of them did not have the test. Later we can ask whether they know why they must have regular determinations of their levels of mood stabilizers and we will review the homework.

• We will present the material of the session and will open the round of questions and the discussion.

• We will deliver the material and the assignment and will end the session.

Goal

The objective of this ninth session is to inform the group about the pharmacological treatment of the depressive and mixed phases. As already happened in the clinical section (see p. 85), in the session on depression information on mixed phases is included for purely logistical reasons of time availability, although the treatment of the mixed phases is more similar to the treatment of mania than to the treatment of depression.

Procedure

• As has been usual in the last sessions, we will start the session with an informal conversation after which we will ask (two) volunteers to present their life chart.

• After completing the presentation of the life charts, we will ask the patients which they believe is the conduct to adopt in the event of depression, their opinion on the use of various antidepressant drugs and adherence, and what they think about the possible role of a psychological treatment. Again, we can make a list of use frequencies of antidepressants on the blackboard, as we did in the previous two sessions.

• Before starting to explain at length the treatment of depression, we will insist on the difference between depression and sadness as a normal emotion and will specify that sadness, like any other regular mood, cannot and must not be “treated, ” since it is not a disease.

• Then, we will present the material of the session.

• The session is closed as always after the questions round and discussion, and after delivering the material and the homework.

Goal

The objective of the eighth session is to give the group updated information on the pharmacological treatment of the manic and hypomanic phases in order to improve patient adherence in these phases, since it is usually deficient.

Procedure

• As usual, we will start the group with a brief informal conversation, after which we will ask (two) volunteers to present a life chart.

• Next, we will ask our patients about the use of various antimanic drugs (“How many of you had to take olanzapine?” “How many have taken risperidone?” etc.), on their indication (“Do you remember at what point they were prescribed to you?”“Were you in a manic or depressed phase?”) and about adherence (“How many of you stopped taking it without the physician telling you to?”). We can make a list of usage frequencies on the blackboard, as we did in the session on mood stabilizers.

• At this point, the patients probably have already introduced the topic of antimanic drugs and their advantages and inconvenience, and we can start presenting all material. From time to time, we will interrupt our explanation to ask the patients about the side effects of a certain drug, if they had taken it, and thus make our presentation more interactive.

• We switch to a phase of questions and discussion and, after delivering the material and homework, we close the session.

Goal

The objective of this session is to inform our patients the various types of mood stabilizers, their differences and specific indications, and their advantages and side effects. It is very important not to ignore this last part, since the patients may feel cheated if we only talk about the positive aspects of pharmacological treatment. The final objective of this session and of the entire Unit 2 is to improve adherence.

Procedure

• After initial and formal conversation, we will ask the volunteers to present their own life charts or ones invented by them. It is to be expected that a commented presentation of a life chart will take about 15 min, so that it is advisable to make a maximum of two presentations per session.

• Next, we can start discussing the topic of the session. Taking into account that this is the first session we dedicate to drugs, we must first answer a series of questions or fears, which certain patients have about psychotropic drugs; we must make it very clear that psychotropic drugs are not addictives – except for benzodiazepines, if not properly used; that they do not “brainwash” or destroy the mind; that most of them are not stimulants; that they are not drugs “for weak people”; and that their purpose is not under any circumstance to replace the will of those who take them. Thus, we tackle at once the entire black legend surrounding psychotropic drugs.

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Goal

The goal of Session 5 is to convey to our patients the idea that depression is a medical illness, moving away from pejorative social considerations or popular meanings associated with the term that lead one to believe that depression is caused by a person's surroundings and that it can be resolved by the person him or herself, without needing to consult a professional or receive treatment. Therefore, we will impart just the opposite message: depression is an illness or – the point in case – part of an illness that has clearly defined biological causes and generally requires pharmacological treatment. We will again insist on the need to differentiate normal emotions from pathological ones.

Procedure

• To begin the session, after we have greeted group members, we go around the room and have patients ask questions about the last session.

• It is a good idea to start the session by reading some news articles (from recent newspapers or magazines) that improperly use the word “depression, ” something that unfortunately is not uncommon. There are plenty of headlines in the press like “Manchester United Goes Through November Depression: Five Defeats Straight” or “Katia, Very Depressed After Being Eliminated From Big Brother. ” We will invite the patients to give their opinion about the use of the unspecialized press makes of psychiatric terms, particularly the word “depression. ”This will give us a way to introduce the medical concept of depression, in terms that it is a biological illness and does not necessarily require triggering factors for it to appear.

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Goal

The goal of Session 4 is to have patients come into contact for the first time with what a manic or hypomanic episode is. We have grouped mania and hypomania into the same session because of their clinical similarities. Ideally, we should also have included mixed episodes here, because from a clinical standpoint and – most of all – a therapeutic and psycho-social impact standpoint, mixed phases resemble mania more than they do depression. Mixed episodes were included in Session 5 (see p. 85) due to time constraints and to the fact that it does not look sensible to try to explain mixed phases before the patient has heard about both mania and depression. The purpose of Session 4 is not to teach patients how to detect a manic or hypomanic episode in time, but rather it simply tries to show them what a hypomanic or manic episode is. To do this, it is important in this session that we go directly to explaining the possible symptoms, without getting sidetracked into talking about the signs of relapse.

Procedure

• As always, we will begin the session informally and open the group up to questions about last session.

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Goal

Many bipolar patients seek the help of alternative treatments (homeopathy, naturopathy, esoteric therapies, etc.) and from parascientific professionals (clairvoyant, spiritual advisors, or healers), in most cases ignoring the differences between the medical treatment of the disorder and the alternative treatments as to evidence and efficacy. The objective of this session is to explain to our patients what this difference is, what steps are followed in a treatment before its approval and why certain supposed alternative therapies do not work in the case of bipolar patients.

Procedure

• If there are still patients who volunteer to present their life chart, we will dedicate the first 20–30 min to a couple of cases.

• Unlike the previous sessions, in Session 12 we will not start our presentation with an open question to the patients. As most of the general population does not know how the scientific method works and what a clinical study is, we will start by explaining these two issues, and this will allow us to make constant references to the scientific or non-scientific character of a certain treatment during the debate, after presenting the material of the session, without having to interrupt ourselves in order to clarify these terms to our patients.

• Based on the material of the assignments, we will facilitate the discussion between patients about the role of alternative therapies in bipolar disorders.

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