There is consensus among clinicians that psycho-therapy plus medication treatment reduces symptoms of mood disorders more effectively than either treatment alone. However, there remain contro- very about whether adding psychotherapy to medication treatment lowers the risk of relapse in individuals with bipolar disorder. This question has been addressed in several previous studies with no clear answer. In the October issue of JAMA Psychiatry, Dr. David Miklowitz, author of The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, and his colleagues discuss their analysis of 39 published, randomized controlled trials (36 in adults, 3 in adolescents) that examined the effectiveness of combining psychotherapy and medication. Using sophisticated statistical methods, they concluded that, when added to medication treatment, family therapy,cognitive-behavioral therapy, and psychoeducational therapies were more effective in preventing manic and depressive episodes compared with other types of psychotherapy, what the au-

thors call “treatment as usual” (likely to consist of therapies that blend supportive and psychodynamic approaches). This report marks the first time that manualized psychotherapies (so-called because written manuals guide such treatments) have been shown to reduce the risk of relapse in bipolar disorder to a greater extent than more common forms of psychotherapy. This ought to put more pressure on psychiatrists to recommend (or to deliver) these specific psychotherapies and for insurance companies to ensure that their provider networks include psychotherapists trained to conduct family, cognitive-behavioral, and psychoeducational therapies.
That said, it is understood that only a minority of practicing psychotherapists possess the necessary training to offer manualized psychotherapy, and, as such, accessing these treatments is difficult. Psychotherapists possessing these specialized skills typically do not participate in insurance networks. There is a growing awareness that we need novel mechanisms to deliver such treatments to patients with bipolar disorder, perhaps by leveraging the resources of primary

care practices, which often employ clinicians experienced in health education and family-focused care.
As behavioral health care research continues to identify effective and even essential – treatments, it will become more important for patients and families to advocate for access to care. It is in the interest of both insurers and employers (the chief purchasers of health care insurance) to both reduce and prevent psychiatric hospitalization. Dr. Miklowitz’s research deserves to be discussed and promoted as one method of reaching these goals.
References:
Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-analysis doi:10.1001/ jamapsychiatry.2020.2993
Beyond Efficacy and Toward Dissemination and Personalization of Psychotherapy for Bipolar Disorder doi:10.1001/ jamapsychiatry.2020.2980
David Brody is a medical advisory to MDSG and serves on the board of directors.