Group cognitive behavioral therapy for bipolar disorder: a feasibility and effectiveness study

Journal of Affective Disorders 65 (2001) 145–153www.elsevier.com/ locate / jad

Research report

Group cognitive behavioral therapy for bipolar disorder:a feasibility and effectiveness study

*Irene Patelis-Siotis , L. Trevor Young, Janine C. Robb, Michael Marriott, Peter J. Bieling,Linda C. Cox, Russell T. Joffe

Hamilton Psychiatric Hospital, Mood Disorders Program, 100 West 5th St., Hamilton, Ontario L8N 3K7, Canada

Received 13 August 1999; received in revised form 9 June 2000

Abstract

Background: Bipolar disorder (BD) is a common disorder that results in significant psychosocial impairment, includingdiminished quality of life and functioning, despite aggressive pharmacotherapy. Psychosocial interventions that targetfunctional factors could be beneficial for this population, and we hypothesized that the addition of group cognitive behavioraltherapy (CBT) to maintenance pharmacotherapy would improve functioning and quality of life. Methods: Patients diagnosed(by SCID) with bipolar disorder attending an outpatient clinic of a mood disorders program participated in the study. Allpatients were on maintenance mood stabilizers, and were required to have controlled symptoms before entering the study.Mood symptoms were assessed with the Hamilton Depression Rating scale and Young Mania scale at baseline and 14 weeks.Objective and subjective functioning was rated at the same interval using the Global Assessment of Functioning scale andthe Medical Outcomes Survey SF-36. Treatment was provided via a specific manual based on CBT principles that could beapplied to this population. Results: Forty nine patients participated in this open trial, and 38 patients completed treatment.Objective and subjective indices of impairment showed improvement after 14 weeks. Both GAF and MOS scores increasedsignificantly by the end of treatment. Limitations: This study was an open trial, and lack of control groups limits theinterpretation of results. Because the study concerned effectiveness, the results do not clarify whether the improvementrepresents the normal course of illness or whether it is the result of the CBT intervention. Conclusions: The addition ofgroup CBT to standard pharmacological treatment was acceptable to patients, and nearly 80% of patients complied withtreatment. Despite the fact that mood symptoms were controlled at entry into the study, psychosocial functioning increasedsignificantly at the end of treatment. Adjunctive CBT should be further investigated in this population. 2001 ElsevierScience B.V. All rights reserved.

Keywords: Bipolar disorder; Cognitive behavior therapy; Group treatment; Psychosocial functioning

1. Introduction

Bipolar Disorder (BD) is a common psychiatric*Corresponding author. illness which has a severe impact on the individual

0165-0327/01/$ – see front matter 2001 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 00 )00277-9

146 I. Patelis-Siotis et al. / Journal of Affective Disorders 65 (2001) 145 –153

not only in terms of illness variables such as relapse needed. Responding to this need, several inves-or recurrence (Gitlin et al., 1995; Goldberg et al., tigators have published reports on maintenance psy-1995; Harrow et al., 1990), but also in other im- chosocial treatments for BD with multiple modalitiesportant domains such as psychosocial functioning, including couple, family and group treatments (Fit-quality of life, and socio-economic status (Cooke et zgerald, 1972; Shakir et al., 1979; Volkmar et al.,al., 1996; Harrow et al., 1990; Tohen et al., 1990b; 1981; Kripke and Robinson, 1985). However, few ofRobb et al., 1997). Even during periods of euthymia these investigations have used a comparison group orand maintenance pharmacotherapy, the psychosocial a measure of outcome, limiting the interpretability ofconsequences of this illness can be severe (Robb et their results (Davenport et al., 1977; Glick et al.,al., 1997). Indeed, compared to patients with serious 1985; Haas et al., 1988; Spencer et al., 1988). Onemedical illnesses such as multiple sclerosis and end promising treatment strategy for improving func-stage renal disease, bipolar patients have more tioning is Cognitive Behavioral Therapy (CBT). Thiscompromised interpersonal relationships, worse typically short term, focused and active psychothera-marital adjustment, and lower incomes (Coryell et py has been shown to be at least as effective asal., 1993; Robb et al., 1997). Following BD patients pharmacotherapy for acute treatment of unipolarover time, Coryell and colleagues found that BD and depression (Elkin et al., 1989; DeRubeis and Crits-unipolar patients had a decline in annual income, Christoph, 1998). Perhaps more importantly, a num-worse marital and family relationships, and more ber of trials have shown CBT to be more efficaciousdifficulties with recreational activities over 5 years in preventing relapse of depression than antidepres-when compared to matched relatives with no history sant medication (Evans et al., 1992; Kovacs et al.,of affective disorder. Similarly, Goldberg and col- 1981; Simons et al., 1986; Fava et al., 1998).leagues followed patients with BD and unipolar Whether CBT could also be effective in BD is andepression for 4.5 years post-hospitalization and empirical question.found that only 41% of patients had achieved a good Interest in a CBT approach to bipolar disorder hasoverall outcome. In that study, the BD group had been growing among clinicians and in 1996 onemore severe work impairment than the unipolar book detailing CBT interventions for patients withgroup and over half of the BD patients were hospital- BD was published (Basco and Rush, 1996). In 1998,ized at least once during the study (Goldberg et al., Bauer and colleagues (Bauer et al., 1998) published1995). Examining residual mood symptoms in BD, an open trial of Group Therapy (Life Goals Program)Keller (Keller et al., 1992) reported that the presence for Bipolar Disorder based on a modified CBTof subsyndromal symptoms predicted a much higher intervention described in their earlier book (Bauerrelapse rate at 2 years, regardless of whether lithium and McBride, 1996). Despite this interest from alevels were optimal. In summary, there is consistent, clinical perspective, there is as yet no availablecompelling evidence that bipolar disorder results in efficacy data from randomized controlled trials onsignificant impairment beyond its discrete symptoms this approach in BD. However, three publishedand that this impairment persists between episodes of reports concerning the use of CBT in BD aredepression or mania. available. One initial study in this area compared

It also seems that even after improvement in mood standard clinical management to a 6-week trial ofsymptoms occurs there is a delay, or lag, in func- individual CBT in 28 bipolar outpatients maintainedtional recovery for patients. This gap between symp- on lithium (Cochran, 1984). The CBT protocol intomatic and functional recovery during maintenance this study was specifically designed to increasepharmacotherapy, reported by both Tohen and Gitlin, medication compliance. At 3 and 6 months follow-points to the ongoing psychosocial deficits ex- up, the CBT group showed a significant improve-perienced by these patients following treatment of ment in lithium compliance and fewer hospitaliza-the acute phase of illness (Tohen et al., 1990a, Gitlin tions than the control group. Subjects in the psycho-et al., 1995). Treatments which target inter-episode therapy group were also less likely to terminatefunctioning and help individuals cope with the treatment against medical advice. More recently,impact of the illness on their environment are clearly Palmer et al. (1995) used a one sample repeated

I. Patelis-Siotis et al. / Journal of Affective Disorders 65 (2001) 145 –153 147

measures design to evaluate the effectiveness of a functioning and improve self-report of quality of life.17-week group CBT in six patients diagnosed with We made no specific predictions about what areas ofBD on maintenance mood stabilizers. Results functioning would improve because CBT targetsshowed significant improvement for two patients and multiple domains and because of the paucity ofa trend for a third on the Well Being scale of the previous research. We also examined whether CBTInternal State Scale. Overall social adjustment, as would impact subsyndromal depression symptommeasured by the Social Adjustment Scale, also levels.improved from pre- to post-treatment in these pa-tients. In another study, Palmer and colleagues(1999; personal communication), using a series of 2. Methodsingle case designs and non-equivalent group design,found that 25 patients diagnosed with BD who The current study was an open-trial project de-participated in group CBT experienced a significant signed to assess the effectiveness of a 14-session,improvement in social functioning. Finally, Zaretsky standardized, adjunctive group CBT treatment ap-et al., 1999, in one of the more rigorous studies proach for patients with BD. Subjects were recruitedavailable, found that currently depressed bipolar from outpatients referred to the Mood Disorderspatients improved as much as matched unipolar Program at McMaster University who met criteriadepressives on depression symptom measures after for bipolar disorder type I or II based on the20 sessions of CBT. Structured Clinical Interview for the DSM-IV (First

In summary, treatment of BD using CBT remains et al., 1994). Written informed consent was obtainedan understudied area though existing studies suggest from all patients. During CBT, all patients werethat depression symptoms and non-compliance can maintained on one or more mood stabilizers (withbe decreased, while psychosocial adjustment can be therapeutic blood levels), and all patients continuedimproved. As yet, there are no studies that have to be treated by their regular psychiatrist, whospecifically examined the impact of CBT on be- adjusted medications as clinically indicated. Adjust-tween-episode psychosocial functioning in patients ments in mood stabilizers and increase in antidepres-whose symptoms are subsyndromal or in patients sant dosages were permitted. Patients who requiredwho are euthymic. If CBT can be shown to improve the administration of a new antidepressant during thepatients’ social, occupational, and recreational func- course of treatment were excluded from the study.tioning between episodes, such an approach may also Mood symptoms were assessed in all participants byhave an impact on recurrence and relapse. Use of unblinded research nurses experienced with theCBT has previously been shown to reduce administration of the Hamilton Depression Ratingsubsyndromal symptoms and reduce relapse risk in Scale (HamD; Hamilton, 1967) and the Youngunipolar patients, followed for 6 years (Fava et al., Mania Rating Scale (YMS; Young et al., 1978).1998). Psychosocial functioning was measured objectively

The primary objective of this study was to evalu- with the Global Assessment of Functioning Scaleate the effectiveness and acceptability of a stan- (GAF, First et al., 1994) administered by a researchdardized CBT treatment (14 weeks) in BD patients nurse who had no other role in the study. Subjectivewho were also being fully treated with maintenance measures of Psychosocial Functioning were assessedmood stabilizers. In addition to examining psycho- using the Medical Outcomes Survey SF-36 (Waresocial functioning, we assessed whether CBT for BD and Sherboume, 1992). The MOS-SF 36 was de-would be acceptable in a group format. Group CBT signed to measure health status, broadly defined, andhas been shown to be as effective and acceptable for examines limitations in functioning related to phys-treating unipolar depression as individual treatment ical activity, social activities, function in specific(Hollon and Shaw, 1979; Scott and Stradling, 1990; roles, and general health. The instrument was care-Shaffer et al., 1981; Zettle et al., 1992; Zettle and fully conceived and has been validated in bothHerring, 1995). We hypothesized that participation in community and a wide variety of medical samplesthe CBT treatment would improve psychosocial (McHorney et al., 1994). Its psychometric properties


have also been carefully studied (McHorney et al., 1979). Other interventions relevant to mania were1993). All of the measures were collected at baseline employed, such as self-monitoring; reduction ofand the end of treatment within 2 weeks of the activity level; and regulation of sleep, eating andbeginning and end of the group. Although no formal exercise patterns, as well as cognitive restructuringtraining for the administration of the GAF was done, to correct the positively biased thinking observedthe nurses administering the scales had over 5 years during this phase of illness. Finally, as described byexperience in research and clinical management of Basco, interpersonal problems in BD were addressedpatients diagnosed with Bipolar Disorder. with specific problem solving interventions to im-

prove coping with the consequences of this disorder2.1. Treatment procedures (Basco and Rush, 1996).

The group CBT sessions were conducted on aweekly basis, and each session was 2 h in duration. 3. SubjectsThe number of participants in the group varied fromseven to 12. There were two phases to the group Subjects were 49 patients diagnosed with BipolarCBT treatment protocol. Phase I focused on psycho- Disorder who were being maintained on one or moreeducation; issues related to medications, symptoms mood stabilizers, and who were mildly depressed orand course of illness were reviewed in detail to euthymic (HamD score , 16). Eleven patientsprovide patients with the basic knowledge necessary (22%) withdrew prior to the end of Phase II, whileto understand BD. This phase consisted of two the other 38 (78%) completed both phases of thesessions, during which both patients and family study. Over the course of the study, three subjectsmembers participated in the discussion of a video who completed both phases of the study begantape and monograph about BD. taking a new anti-depressant agent, and these sub-

Phase II was comprised of 12 skill-training ses- jects were excluded from the analysis. Demographicsions during which patients learned CBT skills, information is presented on Table 1. Of the demo-including specific behavioral and cognitive interven- graphic variables we examined, education was thetions. The CBT treatment protocol employed in the only variable which approached significance in dis-present study is based on a treatment manual that criminating between the completers and non-comple-includes various cognitive behavioral interventions ters. Pre-treatment mood ratings and pre-treatmenttargeting the specific clinical features of BD (Patelis- measures of psychosocial functioning for the subsetsSiotis, 1996; session outlines are described in Ap- of participants who did and did not complete bothpendix A). The primary therapist has been formally phases of the study are presented in Table 1.trained in CBT, by Brian Shaw Ph.D. Moreover, Demographic and outcome variables were comparedsince completion of her training, IPS has treated using t-tests for the demographic and symptomlarge numbers of patients both in individual and variables, and a multivariate analysis of variancegroup CBT. However, there was no assessment of (MANOVA) for the eight MOS subscales. Thesetherapist adherence to the manual. Similar interven- analyses revealed no differences between the twotions, used in this study, are well described in groups on all but one variable. Not surprisingly,‘Cognitive Behavioral Therapy for Bipolar Disorder’ those subjects who dropped out of the study had aby Basco and Rush, 1996. Interventions designed to poorer record of attendance prior to making theimprove adherence to pharmacotherapy, similar to decision to leave the study than those who completedthe intervention described by Meichenbaum and both phases of treatment.Rush were also introduced (Meichenbaum and Turk,1987; Rush, 1988). These skills are needed bypatients with BD in view of the significant number of 4. Resultsindividuals reported to be non-adherent to lithium.The cognitive interventions for the depressive phase The outcome variables of the study, GAF, MOS,of BD were similar to those developed by Beck for YMS, and HamD were compared using paired t-teststhe treatment of unipolar depression (Beck et al., (GAF, YMS, and HamD) and a repeated measures


Table 1 With regard to the effects of treatment (shown inMean (S.D.) demographic information for subsets of patients who Table 3), there was a statistically significant increasedid or did not complete phase II of CBT treatment

in MOS scores, F (8, 14) 5 2.77, P , 0.05. Examin-Demographic information Non-completers Completers ing the univariate Fs, the vitality subscale and the

(n 5 11) (n 5 38) role-emotional subscales of the MOS demonstratedAge at start of CBT 39.4 (8.7) 40.4 (8.7) significant improvement, F (1, 21) 5 5.83, P , 0.05,Age at onset of illness 22.6 (26.0) 21.8 (9.7) and F (1, 21) 5 16.74, P , 0.001, respectively.Duration of illness 16.7 (31.9) 18.6 (9.4)

a There was also a trend for improvement on the MOSNumber of hospitalizations 1.8 (2.0) 1.7 (1.5)social functioning subscale, F (1, 21) 5 3.29, P ,Number of BD type I / II 3 /8 15/23

Number of non-rapid cycling /RC 6/5 23/15 0.10.Number of males / females 7 /4 14/24

Marital statusMarried 3 (27.3) 19 (50.0) 5. DiscussionCommon-law 2 (18.2) 1 (2.6)Widowed 0 (0.0) 1 (2.6) The addition of group CBT to standard pharmaco-Divorced 2 (18.2) 7 (18.4)

logical treatment was feasible and well tolerated bySeparated 1 (9.1) 4 (10.5)patients diagnosed with BD. Nearly 80% of patientsNever married 3 (27.3) 6 (15.8)who started the treatment completed the treatmentEducationprogram. Those who did not complete the treatmentGrade 7–12 – no diploma 3 (27.3) 1 (2.6)

High school diploma 3 (27.3) 7 (18.4) were not more severely ill, nor did they differ onPartial college 3 (27.3) 7 (18.4) other illness variables. Mood symptoms remained2 Year college degree 2 (18.2) 9 (23.7) unchanged at the end of the 14 week treatment.4 Year college degree 0 (0.0) 7 (18.4)

Thus, subsyndromal symptoms did not show aGraduate /professional degree 0 (0.0) 5 (13.2)decrease. However, this may have largely been dueUnknown 0 (0.0) 2 (5.3)

Employment (yes /no/unknown) 3/8 /0 10/27/1 to the fact that at the outset of treatment theseb cPercent of sessions attended 59.7 (25.4) 85.5 (11.6) patients reported low levels of symptoms. Notably

a however, these patients did demonstrate improvedNumber of hospitalizations unknown for four completers.b Based on sessions prior to withdrawing from CBT treatment psychosocial functioning at the end of the study.

for non-completers. Overall functioning, objectively measured by thec Significant difference between groups, P , 0.001. GAF, increased significantly as did self-reported

vitality (more energy and less fatigue) despite lowscores on the Young Mania Scale. It can be hypoth-

MANOVA (MOS) from pre to post-treatment. The esized that improvement in self reported vitality is aresults are shown in Table 2. As might be expected reflection of the ‘behavioral activation’ component offrom the overall low levels of pre-treatment symp- CBT which encourages increased goal directed andtoms, there were no significant changes on the YMS pleasurable activities. Therefore, CBT may be pro-or HamD. However, psychosocial functioning as moting an improvement in energy or vitality via anmeasured by the GAF did increase significantly, t increase in overall activity level. Participants also(34) 5 3.52, P , 0.001. For the MOS, data from 22 reported fewer limitations in social activities becausesubjects was available (completion of the ques- of physical or emotional problems. These findingstionnaires was optional). Although non-significant, are consistent with an earlier preliminary finding thatthe non-MOS patients tended to be younger, to have group psychotherapy improves social functioning inhad older ages of onset of illness, and higher YMS BD patients (Palmer et al., 1995). Improvement inscores (t (33) 5 1.48, P , 0.15, t (31) 5 1.34, P , social functioning following a CBT intervention may0.20, and t (33) 5 2.90, P , 0.10, respectively) be attributed to the ‘behavioral activation’ com-These differences were not significant and likely do ponent of the treatment and the fact that interperson-no suggest clinically meaningful differences between al interactions are targeted when examining cognitivethose who completed the MOS and those who did distortions. Thus, patients are taught to increase theirnot. social activities and to more accurately assess feed-


Table 2Mean (S.D.) pre-treatment mood ratings and psychosocial functioning for subsets of patients who did or did not complete phase II of CBTtreatment

Non-completers Completers(n 5 11) (n 5 38)

Pre-treatment mood ratingsHamD 9.0 (4.5) 8.1 (3.9)YMS 2.1 (3.1) 1.6 (3.0)

Pre-treatment psychosocial functioningGAF 59.1 (7.0) 63.1 (8.3)

aMOSPhysical functioning 63.8 (30.6) 80.4 (19.3)Role – physical 40.6 (44.2) 41.2 (39.8)Bodily pain 63.4 (27.0) 68.5 (23.7)

bGeneral health 46.4 (29.6) 66.6 (21.7)Vitality 28.1 (21.4) 39.4 (19.3)Social functioning 46.9 (28.1) 58.1 (25.0)Role – emotional 29.2 (41.5) 17.6 (33.1)Mental health 44.0 (22.0) 52.4 (18.0)

a n for non-completers 5 8; n for completers 5 34.b Missing data for one patient was estimated via a mean substitution based on the values for the other 33 patients.

back from others, both of which should lead togreater satisfaction in interpersonal relationships.Finally, it is notable that subsyndromal mood symp-toms did not decrease in these patients, and thereforeimprovements in psychosocial functioning cannot beTable 3

Mean (S.D.) pre-treatment and post-treatment mood ratings and attributed to symptomatic improvement. Whetherpsychosocial functioning for 35 patients who completed phase II such an improvement in functioning would lower theof CBT treatment risk of future relapse in such patients is an un-

Pre-treatment Post-treatment answered but intriguing question.There are, of course, several limitations to thisMood ratings

HamD 7.7 (3.6) 7.1 (5.5) study. First, the lack of a control group limits theYMS 1.5 (3.1) 1.3 (2.8) interpretation of results. It is unclear whether group

affiliation or CBT skills in particular are the activePsychosocial functioningaGAF 63.3 (8.4) 68.3 (9.3) ingredient responsible for the observed improvement.

b,cMOS It can be hypothesized that it is not possible to knowPhysical functioning 81.1 (18.4) 83.9 (17.3) whether time (natural course of the illness), andRole – physical 43.2 (41.7) 52.3 (40.8)

symptom stability alone might have resulted inBodily pain 67.5 (23.4) 69.5 (23.2)improved functioning. However, this is a limitationGeneral health 66.1 (20.6) 71.6 (22.8)

Vitality 40.0 (14.2) 52.3 (19.7) encountered in most treatment effectiveness studiesSocial functioning 56.8 (23.4) 66.5 (19.0) and cannot be entirely eliminated unless one studiesRole – emotional 16.7 (30.4) 45.5 (33.4) individuals with exact same number of previousMental health 54.4 (17.7) 60.9 (18.5)

episodes and can accurately determine the exacta Significant difference between pre-treatment and post-treat- point of episode / illness onset. However, assessing

ment, P , 0.001.b course of illness variables and use of a control groupn 5 22.c would help to shed some light on these issues inSignificant difference between pre-treatment and post-treat-

ment, P , 0.05. future studies. Second, the results may be due to


optimized pharmacotherapy, and changes in indi- peutic treatment that improves psychosocial func-vidual medications may have accounted for these tioning measured both subjectively and objectively.improvements, at least in part. A future study thatmonitors or restricts such medication changes couldexamine this possibility. Another limitation in this

Acknowledgementsstudy is use of the GAF, which is limited due to thenature of the measure (e.g. Roy-Byrne et al., 1996).

Supported by a Stanley International ResearchHowever, use of the GAF as an indicator of func-

Centre Grant (LTY and RTJ). LTY is a careertioning is consistent with its intended purpose (En-

scientist of the Ontario Ministry of Health.dicott et al., 1976) and has been shown to haveconsiderable validity and is related to importantclinical parameters (Patterson and Lee, 1995). Final-ly, as reported in our results, only 22 subjects Appendix Acompleted the MOS. If all our participants hadcompleted the MOS, a power analysis suggested that Phase Iwe would have found a significant improvement in Session 1 Psychoeducation – Overview of treat-Social Functioning and perhaps in General Health. ment expectations of participants andAlthough there was a non-significant increase in family membersscores following treatment for the other MOS sub- Session 2 Psychoeducation – Discussion ofscales (Physical functioning, Role – Physical, Bodily monograph on and videotape on BDpain, Mental health) the sample size /effect size Phase IIestimates suggest that these improvements were of Session 3 Treatment compliance – Learninglittle practical or clinical significance. about compliance and adherence, In-

Questions for future research include evaluating creasing comfort level when discussingthe efficacy of adjunctive CBT in preventing relapse adherencein bipolar disorder. Other topics for research include Session 4 Treatment compliance – Personal dif-evaluating the depressogenic cognitive processes ficulties with adherence, Developingpresent in BD. For example, are depression related specific interventions to overcomecognitive processes similar or different to those adherence problemsfound in unipolar depression? Preliminary results Session 5 Behavioral change in depression – Theindicate shared cognitive processes in unipolar and CBT model of depression, Behavioralbipolar disorder (Reilly-Harrington et al., 1999). interventions (pleasure and masteryHowever, it remains unclear whether a change in activities, graded task assignments)cognitive processes is necessary to sustain symptom- Session 6 Cognitive changes in depression – Theatic and functional improvement. Results in two cognitive triad and dysfunctionalprevious studies (Zaretsky et al., 1999; Reilly-Har- thought record, cognitive distortionsrington et al., 1999) indicate that cognitive processes Session 7 Cognitive interventions – Examiningmay not change following a course of CBT in BD negative thoughts using evidencedespite an improvement in symptomatology. It is gathering to examine thoughtspossible that a brief (12–14 week) protocol is not Session 8 Behavioral changes in mania – Moni-sufficient to change underlying cognitive processes toring activity level, set limits on ac-in bipolar disorder and that a more long term tivity levels, using feedback fromtreatment is required to decrease relapse. others

In conclusion, when evaluated from the perspec- Session 9 Cognitive changes in mania – Moni-tive of effectiveness in symptomatically stable yet toring mood shifts associated withotherwise unselected BD patients, CBT is well mania, monitoring and examining posi-tolerated and attended. Moreover, group CBT for BD tively biased thinking in maniaappears to be a potentially valuable psychothera- Session 10 Review session – Review and sum-


Evans, M.D., Hollon, S.D., DeRubeis, R.J., Piasecki, J.M., Gar-mary of sessions 5–9, questions andvey, M.J., Grove, W.M., Tuason, V.B., 1992. Differentialanswers using group’s examplesrelapse following cognitive therapy, pharmacotherapy, andCognitive interventions to increaseSession 11combined cognitive-pharmacotherapy for depression. Arch.

adherence – Recognition of dysfunc- Gen. Psychiatry 49, 802–808.tional thinking and its impact on adher- Fava, G.A., Rafanelli, C., Grandi, S., Canestrari, R., Morphy,ence, applying cognitive techniques to M.A., 1998. Six-year outcome for cognitive behavioral treat-

ment of residual symptoms in major depression. Am. J.increase adherencePsychiatry 155, 1443–1445.Session 12 Assertion – Learning assertiveness,

First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1994.cognitive aspects of assertion, be-Structured Clinical Interview for sxis I DSM-IV Fisorders-

havioral aspects of assertion Patient Edition (SCID I /P). Biometrics Research Department,Session 13 Interpersonal problems – Interpersonal New York State Psychiatric Institute.

Fitzgerald, R.G., 1972. Mania as a message: treatment with familydifficulties experienced in BD, nor-therapy and lithium carbonate. Am. J. Psychother. 26, 544–malizing problems encountered in BD553.Session 14 Review of treatment goals and wrap-up

Gitlin, M.J., Swendsen, J., Heller, T.L., Hammen, C., 1995.Relapse and impairment in bipolar disorder. Am. J. Psychiatry152, 1635–1640.

References Glick, I.D., Clarkin, J.F., Spenser, J.H., Gretchen, L., Haas, G.L.,Lewis, A.B., Peyser, J., DeMane, N., Good-Ellis, M., Harris,E., Lestelle, V., 1985. The controlled evaluation of in-patientBasco, M.R., Rush, A.J., 1996. Cognitive-Behavioral Therapy forfamily intervention: preliminary results at the 6 month followBipolar Disorder. Guilford, New York, NY.up. Arch. Gen. Psychiatry 42, 882–886.Bauer, M.S., McBride, L., 1996. Structured Group Psychotherapy

Goldberg, J.F., Harrow, N., Grossman, L.S., 1995. Course andfor Bipolar Disorder: The Life Goals Program. Springer, Newoutcome in bipolar affective disorders: a longitudinal follow-upYork, NY.study. Am. J. Psychiatry 152, 379–384.Bauer, M.S., McBride, L., Chase, C., Sachs, G., Shea, N., 1998.

Haas, G.L., Glick, I.D., Clarkin, J.F., Spencer, J.H., Lewis, A.B.,Manual-Based Group Psychotherapy for Bipolar Disorder: APeyser, J., DeMane, N., Lewis, M., Good-Ellis, M., Harris, E.,Feasibility Study. J. Clin. Psychiatry 59, 9.Lestelle, V., 1988. Inpatient family interventions: a randomizedBeck, A.T., Rush, A.J., Shaw, B.F., Emery, G., 1979. Cognitiveclinical trial. Results at hospital discharge. Arch. Gen. Psychi-Therapy of Depression. Guilford, New York, NY.atry 45, 217–224.Cochran, S.D., 1984. Preventing medical non-compliance in the

Hamilton, M., 1967. Development of a rating scale for primaryoutpatient treatment of bipolar affective disorders. J. Consult.depressive illness. Br. J. Soc. Clin. Psychol. 6, 276–296.Clin. Psychol. 52, 873–878.

Harrow, M., Goldberg, J.F., Grossman, L.S., Meltzer, H.Y., 1990.Cooke, R.G., Robb, J.C., Young, L.T., Joffe, R.T., 1996. WellOutcome in manic disorders: A naturalistic follow-up study.being and functioning in patients with bipolar disorder assessedArch. Gen. Psychiatry 47, 665–671.using the MOS 20-ITEM short form (SF-20). J. Affect. Disord.

Hollon, S.D., Shaw, B.F., 1979. Group cognitive therapy for39, 93–97.depressed patients. In: Beck, A.T., Rush, A.J., Shaw, B.F.,Coryell, W., Scheftner, W., Keller, M., Endicott, J., Maser, J.,Emery, G. (Eds.), Cognitive Therapy of Depression. GuilfordKlerman, G.L., 1993. Enduring psychosocial consequences ofPress, New York, NY, pp. 328–353.mania and depression. Am. J. Psychiatry 150, 720–727.

Keller, M.B., Lavori, P.W., Coryell, W., Kane, J.M., Gekenberg,Davenport, Y.B., Ebert, M.H., Adland, M.L., Goodwin, F.K.,A.J., Rosenbaum, J.F., Walzer, E.A., Baker, L.A., 1992.1977. Couples group therapy as an adjunct to lithium mainte-Subsyndromal symptoms in bipolar disorder: a comparison ofnance of the manic patient. Am. J. Orthopsychiatry 47, 495–standard and low serum levels of lithium. Arch. Gen. Psychi-501.atry 49, 371–376.DeRubeis, R.J., Crits-Christoph, P., 1998. Empirically supported

Kovacs, M., Rush, A.T., Beck, A.T., Hollon, S.D., 1981. De-individual and group psychological treatments for adult mentalpressed outpatients treated with cognitive therapy or pharmaco-disorders. J. Consult. Clin. Psychol. 66, 37–52.therapy: a 1-year follow-up. Arch. Gen. Psychiatry 38, 33–39.Elkin, I., Shea, M.T., Watkins, J.T., Imber, S.D., Sotsky, S.M.,

Kripke, D.F., Robinson, D., 1985. Ten year with a lithium group.Collins, J.F., Glass, D.R., Pilkonis, P.A., Leber, W.R., Docherty,MacLean Hospital J. 10, 1–11.J.P., Fiester, S.J., Parloff, M.B., 1989. National institute of

McHorney, C.A., Ware, J.E., Lu, J.F., Sherbourne, C.D., 1994.mental health treatment of depression collaborative researchThe MOS 36-item Short-Form Health Survey (SF-36): IIIprogram: general effectiveness of treatments. Arch. Gen.Tests of data quality, scaling assumptions, and reliability acrossPsychiatry 46, 971–982.diverse patient groups. Med. Care 32, 40–66.Endicott, J., Spitzer, R.L., Fleiss, J.L., Cohen, J., 1976. The global

assessment scale: a procedure for measuring overall severity of McHorney, C.A., Ware, J.E., Raczek, A.E., 1993. The MOSpsychiatric disturbance. Arch. Gen. Psychiatry 33, 766–771. 36-Item Short-Form Health Survey (SF-36): II Psychometric


and clinical tests of validity in measuring physical and mental Group psychotherapy as an adjunct to lithium maintenance.health constructs. Med. Care 31, 247–263. Am. J. Psychiatry 136, 455–456.

Meichenbaum, D., Turk, D.C., 1987. Facilitating Treatment Simons, A.D., Murphy, G.E., Levine, J.L., Wetzel, R.D., 1986.Adherence. A Practitioner’s Guidebook. Plenum Press, New Cognitive therapy and pharmacotherapy for depression: sus-York, NY. tained improvement over one year. Arch. Gen. Psychiatry 43,

Palmer, A.G., Williams, H., Gorsefield, D., Adams, M., 1995. 43–48.CBT in a group format for bi-polar affective disorder. Behav. Spencer, J.H., Glick, I.D., Haas, G.L., Clarkin, J.F., Lewis, A.B.,Cognit. Psychother. 23, 153–168. Peyser, J., DeMane, N., Good-Ellis, M., Harris, E., Lestelle, V.,

Patelis-Siotis, I., 1996. A maintenance cognitive behavioral group 1988. A randomized clinical trial of inpatient family interven-treatment manual for euthymic patients with bipolar disorder. tion, III: effects at 6 months and 18 months follow-up. Am. J.Unpublished treatment manual, McMaster University. Psychiatry 145, 115–121.

Patterson, D.A., Lee, M.S., 1995. Field trial of the global Tohen, M., Watemaux, C.M., Tsuang, M.T., 1990a. A 4-yearassessment of functioning scale-modified. Am. J. Psychiatry prospective follow-up of 75 patients utilizing survival analysis.152, 1386–1388. Arch. Gen. Psychiatry 47, 1106–1111.

Reilly-Harrington, N., Alloy, L.B., Fresco, D.M., Whitehouse, Tohen, M., Watemaux, C.M., Tsuang, M.T., Hunt, A.T., 1990b.W.G., 1999. Cognitive styles and life events interact to predict Four year follow-up of 24 first episode manic patients. J.bipolar and unipolar symptomatology. J. Abnorm. Psychol. Affect. Disord. 19, 79–86.108, 567–578. Volkmar, F.R., Shakir, S.A., Bucon, S., Pfefferbaum, A., 1981.

Robb, J.C., Cooke, R.G., Devins, G.M., Young, L.T., Joffe, R.T., Group therapy in the management of manic depressive illness.1997. Quality of life and lifestyle disruption in bipolar disorder Am. J. Psychother. 35, 226–234.– euthymic phase. J. Psychiatr. Res. 31, 509–517. Ware, Jr. J.E., Sherboume, C.D., 1992. The MOS 36 item short-

Roy-Byrne, P., Dagadakis, C., Unutzer, J., Ries, R., 1996. form health survey (SF-36). I Conceptual framework and itemEvidence of limited validity of the revised global assessment of selection. Med. Care 30, 473–483.functioning scale. Psychiatr. Serv. 47, 864–866. Young, R.C., Biggs, J.T., Ziegler, V.E., 1978. A rating scale for

Rush, J., 1988. Cognitive approaches to adherence. In: Frances, mania: reliability, validity and sensitivity. Br. J. PsychiatryA.G. and Hales, R.E. (Eds.). Am. Psychiatr. Press Rev. 133, 429–435.Psychiatry 7, 628–642. Zaretsky, A.E., Segal, Z.V., Gemar, M., 1999. Cognitive therapy

Scott, M.J., Stradling, S.G., 1990. Group cognitive therapy for for bipolar depression: a pilot study. Can. J. Psychiatry 44,depression produces clinically significant reliable change in 491–494.community-based settings. Behav. Psychother. 18, 1–19. Zettle, R.D., Haflich, J.L., Reynolds, R.A., 1992. Responsivity of

Shaffer, C.S., Shapiro, J., Sank, L.I., Coghlan, D.J., 1981. Positive cognitive therapy as a function of treatment format and clientchanges in depression, anxiety, and assertion following in- personality dimensions. J. Clin. Psychol. 48, 787–797.dividual and group cognitive behavior therapy intervention. Zettle, R.D., Herring, E.L., 1995. Treatment utility of the socio-Cognit. Ther. Res. 5, 149–157. tropy/autonomy distinction: implications for cognitive therapy.

Shakir, S.A., Volkmar, F.R., Bucon, S., Pfefferbaum, A., 1979. J. Clin. Psychol. 51, 280–289.

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Group cognitive behavioral therapy for bipolar disorder: a feasibility and effectiveness study