Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder

Abstract

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.