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World J Psychiatry. Aug 19, 2023; 13(8): 495-510
Published online Aug 19, 2023. doi: 10.5498/wjp.v13.i8.495
Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder
Subho Chakrabarti, Amal J Jolly, Pranshu Singh, Nidhi Yadhav
Subho Chakrabarti, Nidhi Yadhav, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, Chandigarh UT, India
Amal J Jolly, Department of Psychiatry, Black Country Healthcare NHS Foundation Trust, Dudley DY2 8PS, West Midlands, United Kingdom
Pranshu Singh, Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India
Author contributions: Chakrabarti S, Jolly AJ and Singh P were involved in the planning of the manuscript and conducting the search; Chakrabarti S was involved in preparing the final version of the manuscript; Jolly AJ, Singh P and Yadhav N were involved in writing the patient summaries; Yadhav N helped in preparing the final version of the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Subho Chakrabarti, MD, Professor, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, Chandigarh 160012, Chandigarh UT, India.
Received: April 26, 2023
Peer-review started: April 26, 2023
First decision: June 14, 2023
Revised: June 23, 2023
Accepted: July 11, 2023
Article in press: July 11, 2023
Published online: August 19, 2023

Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.

Keywords: Rapid-cycling bipolar disorder, Bipolar disorder, Adjunctive therapy, Nonpharmacological treatment

Core tip: Rapid-cycling bipolar disorder (RCBD) is a common and highly disabling phase of bipolar disorder. The ineffectiveness of conventional pharmacological treatment for RCBD suggests that adjunctive nonpharmacological interventions could be useful. However, their role has not received much attention. This review carried out a comprehensive search to identify the existing evidence on the subject. We found that electroconvulsive therapy, chronotherapy, and psychotherapy could effectively augment medication treatment of RCBD. However, the evidence is limited and methodologically inadequate. Therefore, clinicians have to rely on general guidelines for the optimal use of the available nonpharmacological options while managing RCBD.