Treatment of bipolar disorder part II: beyond guidelines, the science and the art of combining medication and psychoeducation in bipolar disorders

Although genetic and biological factors are crucial in the pathophysiology of bipolar disorder, the importance of psychosocial factors in triggering or mitigating relapses warrants the implementation of psychotherapeutic interventions. Furthermore, although medication is crucial for the long-term outcome of bipolar illness, poor adherence remains a big problem in the management of the disease. Psychoanalysis, psychoeducation, group therapy, family therapy, cognitive–behavioral therapy, social rythm and interpersonal therapy have been used in the long-term treatment of bipolar patients. To date, none have established efficacy on their own in controlled clinical trials regarding hospitalization, recurrences or suicidal behavior, as medication alone does. However, psychoeducation combined with several cognitive–behavioral techniques, either in group or individually, have started to yield the first positive results in high standard, controlled trials on the combination of medication plus psychosocial intervention versus medication alone. These approaches focus primarily on information, treatment compliance, early detection of relapse, and illness management skills. They basically reinforce treatment alliance between the patient and the treating team, and provide a sense that everybody – the patient, the psychiatrists, the psychologists, nurses and social workers-make their efforts to improve the outcome of the disorder and the well-being of the patient, beyond what medication alone can do.