The multidisciplinary team approach to the treatment of bipolar disorder: an overview

Abstracts

O transtorno de humor bipolar (THB) é uma patologia incurável, recorrente e crônica, sendo que inúmeros fatores de vida relacionados ao estresse demonstram influenciar o curso da doença. Devido a estes fatores, a doença está associada com grave disfunção familiar, social e ocupacional, especialmente quando o tratamento farmacológico não é realizado de forma continuada. O papel prioritário da equipe multidisciplinar no tratamento do pacientes com transtorno de humor bipolar é melhorar a aderência medicamentosa, diminuindo os riscos de recaída. Neste artigo, são apresentadas possíveis causas biopsicossociais envolvidas no surgimento e curso da doença, incluindo-se eventos de vida, meio familiar e refratariedade farmacológica. São descritas as funções da equipe multidisciplinar no tratamento da bipolaridade, avaliando-se, neste contexto, a eficácia terapêutica das diversas abordagens psicossociais em uso e as perspectivas neste campo de "intervenção preventiva".

Transtorno bipolar; Transtorno bipolar; Transtornos do humor; Cooperação do paciente; Recivida; Educação do paciente; Família; Apoio social; Equipe de assistência ao paciente

The multidisciplinary team approach to the treatment of bipolar disorder: an overview

Rodrigo Machado-Vieira^I; Aida Santin^II; Jair C Soares^III

^IMood Disorders Program - Federal School of Medical Sciences Foundation of Porto Alegre - Presidente Vargas Mother and Child Hospital, Porto Alegre-RS, Brazil

^IIBipolar Disorder Program - Federal University of Rio Grande do Sul, Porto Alegre Hospital de Clínicas, Porto Alegre-RS, Brazil

^IIIMood and Anxiety Disorders Center - University of Texas, San Antonio, TX, USA

^{Correspondence}

ABSTRACT

Bipolar disorder is a chronic and recurrent disorder, and many factors have been associated with its course and prognosis. Dysfunction in social, professional or family life has been correlated with poor outcomes and increased risk of relapse and recurrence, especially when the patient does not adhere to the treatment regimen. Within the last decade, new treatments, intended to promote better adherence and minimize the risk of morbidity or hospitalization, have been tested. The multidisciplinary team approach attempts to educate patients and their families about such factors. Herein, we evaluate the therapeutic efficacy of this approach in applying the various psychosocial interventions employed in the treatment of bipolar disorder. The objective of this approach is early identification of prodromal symptoms in order to prevent hospitalization and behavioral dysfunction.

Keywords: Bipolar disorder/psychology; Bipolar disorder/therapy; Mood disorders; Patient compliance; Recurrence/prevention & control; Patient education; Family; Social support; Patient care team

Introduction

Bipolar disorder (BD) is characterized as a chronic, recurrent and incurable disease that affects men and women equally worldwide. The causes of BD are multifactorial and complex, although the principal etiology is based on neurobiological changes. Pharmacotherapy is considered the treatment of choice for BD.¹ In addition, psychological and social factors may, when incorporated into the biology of the disease, also affect its onset and course.² For example, it has been demonstrated that genetic factors influence capacity for biological adaptation to various social stresses (e.g. neuroplasticity), resulting in the so-called genetic vulnerability.³ Therefore, BD may be considered endogenous, although it is strongly influenced by both exogenous and psychosocial factors. Over the last decade, it has been shown that innumerable psychosocial factors, including those related to social, family, psychological and occupational function, influence the emergence of BD. Psychosocial factors, most involving situations encountered in daily life, are responsible for 25-30% of the variation seen over the course of the disease.⁴ It has also been shown that innumerable stress-related life events influence the course of BD. In BD, stress secondary to psychosocial events influences circadian rhythms⁵ and social interactions.⁶ According to Post,⁷ the impact of life events gradually diminishes as BD evolves. Reinforcing the validity of this model, epidemiological findings have shown that life events correlate more strongly with the first episode than with subsequent episodes.⁸

Psychosocial deficits are severe in BD patients, and improvement has been correlated with adequate family and social support. Family-related factors such as the expression of negative emotions, lack of knowledge about the disease, stigmatizing the patient, and denying the existence of the disease have a negative impact on patient adherence to drug treatment regimens.⁹ Approximately one-third of all BD patients take less than half of their prescribed medication. This appears to be directly related to increased rates of suicide and hospitalization.¹⁰ In addition, a large proportion of patients present significant residual symptoms between episodes.¹¹ Taking into consideration the fact that adherent patients experience symptom reduction during hospitalization and that approaches combining psychosocial intervention with pharmacotherapy present the best results in the treatment of BD, the current review aims to evaluate the role of multidisciplinary teams in the management of BD, as well as discussing the efficacy of previously studied psychosocial therapies.

The role of the multidisciplinary team in treating patients with bipolar disorder

The multidisciplinary team has various functions in the treatment of BD patients. To date, there have been few studies evaluating, in a controlled and systematic fashion, the efficacy of the multidisciplinary approach to BD. Research in the area has shown the advantages and disadvantages of combining multiple techniques, but the work of multidisciplinary teams has not been evaluated. Nevertheless, it is obvious that any multidimensional treatment plan should be based on interventions that involve defining both the problems to be addressed and the objectives to be achieved. As a general rule, many aspects of the role of the multidisciplinary team are directly related to the course and prognosis of BD. The need for such a team in the treatment of BD becomes obvious from the first contact with the patient. In the initial evaluation, it is important to establish the possible multiaxial diagnosis, list the problems, and determine the modalities of treatment. The subsequent evaluation of the rate of progress - as well as of the level of patient involvement and degree of therapeutic engagement achieved between patient and team in executing the treatment plan - facilitates the determination of the efficacy of the proposed intervention. A positive therapeutic relationship is still the best predictor of a favorable prognosis. In the treatment of patients with mood disorders, the multidisciplinary team plays many important roles, including providing education about the disease, identifying and managing comorbidities, and encouraging positive lifestyle changes for patients and patient families.

The multidisciplinary team also evaluates the social support model available to the BD patient. In patients with BD, adequate social support is related to the diversity of treatment options and the ease of access to health services. A wide range of therapeutic options, such as day hospitals, group therapy, individual follow-up treatment, and easy access to health services (including referrals and counter-referrals), should be made available to patients and their families. Most importantly, the presence of the multidisciplinary team and easy, systematic and continuous access to medication may improve BD prognosis.

Interventions focusing on treatment adherence and prevention of recurrence

1. Overview of the interventions used by multidisciplinary teams

In recent years, researchers have conducted studies evaluating the efficacy of diverse psychosocial treatments used in combination with pharmacotherapy for patients with BD.¹² It has been demonstrated that there are high rates of nonadherence to treatment and recurrence is common in regimens that involve medication alone, thereby justifying the inclusion of psychosocial treatment modalities. The principal characteristic common to all psychosocial approaches is technical and empathic interaction between and among the patient, the family and the multidisciplinary team, aiding the patient in recovering global functioning. The psychosocial approache reduces life stress, involves monitoring patients in order to identify symptoms early, and improves adherence to drug treatment. Such techniques are intended to make it easier for the patient to accept the disease and improve adherence to drug treatment regimens through changes in lifestyle, thereby preventing subsequent episodes. Other approaches also encorage the patient to deal with conflict and negative life events by emphasizing the positive aspects, unrelated to the disease, of the life the patient leads. In addition, psychosocial approaches attempt to increase patient knowledge of the disease and promote its prevention through identifying appropriate therapies for residual interepisodic and prodromal symptoms.

Until recently, psychosocial approaches were considered useful only for improving adherence to drug treatment regimens, and any improvements in the evolution of the disease were attributed to this mechanism. However, it has now been demonstrated that such approaches aim to achieve a global improvement, addressing patient quality of life as well as training patients to deal with stress-inducing events.¹³ In addition, psychosocial approaches have been shown to promote greater mood stability, reduce hospital readmission rates, and improve patient function in a number of areas. Double-blind, randomized clinical trials have been used to verify these findings.^14-15 These and other recently conducted studies provide consistent evidence of the therapeutic efficacy of using psychosocial approaches in combination with pharmacotherapy. Herein, we describe the principal psychosocial interventions currently used in the treatment of patients with BD.

2. Family focused therapy

The family-based technique used in BD is viewed as an adaptation of the same approach employed in cases of schizophrenia. Since stress in the family environment can induce crises in BD patients, family therapy is designed to reduce the level of such stress. This form of treatment encourages family members to devise ways in which to deal with the disease and to manage its symptoms, with the ultimate goal of preventing recurrence. Family therapy includes the application of exemplary communication used in resolving problems, psychoeducation and recurrence-prevention techniques such as early recognition of symptoms.¹⁶ In addition, placing the treatment within the context of the family and characterizing the medication as something desirable and positive for the patient, as well as providing information and education about the same, may aid the patient in adhering to the treatment plan.

3. The psychoeducational and group therapy approach

Various authors have found that psychoeducation increases treatment adherence, improving the prognosis for patients with BD. Within the BD context, psychoeducation aims to teach patients about the disease and the treatment options, as well as focusing on the early identification of symptoms, especially those related to mania.¹⁵ The psychoeducational approach should also include ongoing support, education, problem-solving strategies and social support (periodic scheduled visits to the physician, easy access to medication and health care services, and availability of beds in psychiatric hospitals). In addition, psychoeducation promotes the incorporation of healthy habits into regular personal routines, a practice previously demonstrated to be efficacious in preventing recurrence and improving the course of the disease in BD patients.¹⁷

4. Interpersonal and social rhythm therapy

Patients with BD present mechanisms that are highly sensitive to the "internal clock". Therefore, regulation of social rhythms, as well as training patients and their families to identify the early warning signs of internal and external stress that are related to the appearance of symptoms, have been considered the fundamental building blocks of a favorable prognosis in cases of BD.⁹ Interpersonal and social rhythm therapy emphasizes the fact that life events can lead to manic and depressive episodes through alterations in sleep patterns, as well as in patterns of nutrition, work and exercise. This approach educates patients and encourages them to deal with their schedules in a more responsible and organized fashion.¹⁸ The establishment of a regular daily routine, including set times for going to bed and getting up, is intended to prevent manic episodes. Thusly, interpersonal and social rhythm therapy highlights the importance of symptom management, training patients to use self-control to stabilize social rhythms, setting specific goals, and having the ultimate objective of cognitive remediation. This technique also teaches patients to cope with guilt, interpersonal conflicts, inferiority complexes, and the gamut of life changes. The application of this therapy, in combination with medication, reduces depressive symptoms by focusing on the influence that stress, life events and social support have on the course of BD.¹⁸ Overall, there is little data available regarding the efficacy of interpersonal and social rhythm therapy. This approach has yet to prove itself in preventing recurrence and ameliorating subsyndromal symptoms between episodes.¹⁹

5. Other therapies

Cognitive-behavioral therapy helps patients modify the characteristics of dysfunctional thoughts associated with BD. However, in the current review, we will not address this approach. Nor will we turn our attention to other psychosocial approaches studied - some of which have produced satisfactory preliminary results - since their efficacy has yet to proven in controlled studies.

Conclusions and perspectives

Psychosocial approaches may be beneficial, especially when their objectives are well focused, limited in their timeframes, quantifiable in terms of efficacy, and reproducible (systematized) in practice. Based on the available findings, we can suggest that prevention should be considered an important form of intervention snce "preventive intervention" can be characterized as the keystone of recurrence prevention and improving prognosis in cases of BD. The importance of social support in achieving total remission of symptoms and preventing recurrence cannot be overstated. It has been shown that patients who have better social support present total remission between episodes more often than do those with weaker social support, who frequently present residual symptoms.¹² In such cases, it is difficult to determine whether remission was achieved due to the better family and social support or to these patients receiving that better support exactly because they presented no residual symptoms.

On the other hand, current approaches have yet to systematize the most significant needs of this patient population. Despite advances, further studies are warranted. Such studies should evaluate drug therapies, assess family psychopathology, identify types of stress, and increased the size of the study samples. So far, studies involving psychosocial approaches to BD treatment have been limited by short duration, by lack of proper controls on medication and by the fact that patients were not randomized. In addition, it is eesential that we seek the answers to questions regarding the mechanisms involved in achieving therapeutic efficacy through psychosocial approaches in order to better understand such interventions. For example, do family therapy and psychoeducation bring about an improvement specifically through increasing the efficiency of communication within the family? Finally, the application of sequential psychotherapeutic techniques, appropriate to the type of mood episode in question, may aid in systematizing and determining the efficacy of such approaches implemented by multidisciplinary teams.

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Publication Dates

• Publication in this collection
  07 Dec 2004
• Date of issue
  Oct 2004