Remember the deepest sadness you have ever felt and then try to imagine worse, a sadness which envelops you in hopelessness, makes getting out of bed seem impossible and makes you cry at the smallest things. Now try to remember a time when you felt amazing, like anything was possible, and go even bigger… Imagine a manic sense of importance and responsibility, like everyone’s eyes are upon you, like you’re famous, responsible for the whole world’s wellbeing, able to do absolutely anything. Imagine a life riding a roller coaster of ups and downs in mood, never sure when the next plummet will come, never sure what the highs will leave in their wake.
Wouldn’t you want to talk to someone about what was going on and try to make sense of it?
Bipolar disorder involves extreme highs and lows in mood, often, though not always, with associated psychotic-like experiences (e.g. hearing voices or having very unusual ideas). It affects 1 or 2 people in every hundred.
The most recent guidelines on treatment of bipolar disorder from the National Institute of Clinical Excellence (NICE) recommend a combination of drug and talking therapies, in line with recommendations for severe presentations of many mental illnesses (e.g. psychosis, depression, anxiety). Whilst drug or more invasive treatments used to be the only option in psychiatric settings, it is now increasingly recognised that combining psychological therapies with medication is often helpful both for patient experience and outcome (e.g. in depression and panic.)
A recent paper published in The Lancet Psychiatry and discussed here suggests the guidelines are biased towards talking therapies.
The authors of the critique are absolutely right to hold the evidence for psychological therapies to rigorous account. If we believe that talking therapies can be beneficial then we must also acknowledge that they can also be ineffective or harmful (e.g. as argued in the case of some treatment models for borderline personality disorder). It is important that we weigh the evidence carefully.
NICE guidelines for bipolar disorder are candid about the lack of better evidence for talking therapies and measured in their recommendations. They say: “When the [group] examined specific therapies and comparisons, the quality of evidence was mostly very low or low quality.” Despite this caveat, they thought that there was enough emerging evidence that: “structured psychological interventions may have short and long term benefits for people with bipolar disorder.” Not that big a claim really. Certainly no bigger than claims for many drugs where evidence is often just as contentious.
It is difficult to compare drug and therapy trials. How we measure “improvement” is key. The NICE guidelines noted that there was a gap in the use of outcomes that measure changes in how someone is functioning day-to-day and feeling about their experiences, as opposed to measures of frank symptoms. Unfortunately we don’t have a magic wand that makes all symptoms disappear (and some people with bipolar diagnoses would say they wouldn’t want this).
Talking therapies don’t necessarily make voices stop, for example, or stop someone ever feeling sad or manic, but they are often good at helping people make sense of their experiences and notice unhelpful patterns in thinking or behaviour which can be influenced. Talking about what is happening in a structured way can help someone reduce confusion, shame and loneliness, maintain relationships, and carry on with as much of their life as possible. It might also help to be able to talk about past traumas which may have contributed to current difficulties. We should measure whether this works, but in relation to what the treatment aim is. When the authors of the Lancet Psychiatry article say psychoeducation doesn’t reduce symptoms, I don’t feel shocked. The aim of a psychoeducation phase of treatment is to help someone understand what might be happening, not necessarily to change symptoms.
How we expect studies to be carried out is also important. We can’t do double blind trials with talking therapies as we would with drugs because the therapists always know which therapy they are delivering. Basing research studies and treatment protocols purely on drug therapies doesn’t always work.
The NICE guidelines emphasise that there needs to be more and better research into psychological therapies for bipolar disorder. In the absence of these studies they cite the more robust evidence base for CBT for depression, which makes sense since low mood is an important part of bipolar disorder. They conclude that “similar [psychological] services ought to be available to people with bipolar disorder who wish to access them.”
NICE also try to take into account patient and clinician opinion. Warren Mansell, Reader in Clinical Psychology at Manchester University and experienced clinician, thinks it is fair to extrapolate from evidence for other mental illnesses: “Therapies like CBT and others have been tested across disorders and found to be effective. It seems to be the kind of therapy that can be applied usefully across diagnoses.” Mental illnesses have many commonalities: they involve profound human experiences of deep emotion and distress, with effects on our thoughts, feelings and behaviours which can unsettle and uproot relationships and lives. It makes sense to think about therapy across diagnoses in a way that we wouldn’t if we were thinking treatment for different strains of a virus. Mansell sees critique of the evidence as an opportunity: “For me it’s an imperative to do more research to really crack this challenge.”
Peter Kinderman, Professor of Clinical Psychology at Liverpool University, agrees: “Of course it needs a lot of work. It would be ludicrous to suggest that we now have the definitive answer… In fact the amount of money that we spend on mental health is paltry compared to the size of the problem. We absolutely need more research.”
Most day-to-day clinical decisions are messy. They involve getting as much information as possible and making the best decision you can with the evidence you have available, taking into account theory and experience and listening to what the patient wants. NICE guidelines are a similarly pragmatic endeavour – the point is to pull together the evidence, point out gaps and try to make the best recommendations possible. “I think they’ve done a pretty good job,” said Kinderman, who thinks it’s vital that we carry on providing psychological interventions: “To say the evidence is patchy, let’s do nothing, is ridiculous. The alternative is “everything’s fantastic, let’s just leave everything as it is until we get better evidence” – actually people with long term mental health conditions suffer significantly reduced life expectancy and very significant physical side effects from medication.”
Ultimately, critique of evidence for any treatment is crucial. We still have much to learn about whether talking therapies can benefit everyone, and if so which ones help and why. But equally crucial is that we use critique to spur on future research, not as an excuse to reduce treatment options further.
Dr Lucy Maddox is a consultant clinical psychologist, lecturer and writer who works for the NHS and the Anna Freud Centre. These views are her own not those of any organisation she works for. Follow Lucy on Twitter: @lucy_maddox or read her blog Psychology Magpie.