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

Table 4 Suggestions for the use of adjunctive nonpharmacological treatments in rapid-cycling bipolar disorder

	Suggestions
Goals of acute treatment[18,45]	The priority for acute treatment is to ensure that patients respond to treatment and no longer meet criteria for an acute mood episode
	A rapid response is necessary to provide relief for patients and their families and reduce the risks of self-harm, aggression, and physical complications
	The concurrent and early use of treatments such as ECT or wake therapy for depression, and dark therapy for mania may be considered if there is inadequate response to pharmacotherapy
	Treatments that are likely to be useful during long-term treatment should guide the use of treatments in the acute phases
Goals for long-term treatment[29,30,45,51,55]	Rather than focusing on acute treatment, the primary objective should be to prevent further episodes of rapid cycling
	The model for a chronic medical disorder with acute exacerbations should guide the long-term treatment plan for RCBD
	Adjunctive maintenance ECT, wake therapy, bright light treatment, dark therapy, and triple chronotherapy can be considered at this stage
	Education, support, and the involvement of the family is useful for all patients. Psychoeducational treatments, CBT, family treatment can be implemented if required
Improved functioning rather than complete remission should be the goal of long-term treatment[18,20,25,30]	Full remission and complete absence of recurrences is an unrealistic goal
	Clinicians should focus on an enduring response that consists of reduced frequency, intensity, and duration of mood episodes
	Clinicians should attempt to restore optimal functioning in the occupational, family, and social spheres
Basic tasks[2,4,54,55,162]	Careful diagnosis and comprehensive assessment of the patient including psychosocial factors
	Avoidance of precipitants such as stress, irregular sleep routines, and antidepressant medications when it worsens the course of RCBD
	Treatment of physical and psychiatric comorbidities especially hypothyroidism and substance use
Longitudinal approach and use of life charts[2,26,45,55,163]	Acute episodes should be viewed in the context of the long-term course of bipolar disorder/RCBD
	Life charts may be used to delineate the course of illness, possible precipitants, and treatment response. They might help patients and families understand the course of RCBD and the longitudinal approach to treatment
Use of treatments effective in bipolar disorder[27,30,45,49]	Options for adjunctive nonpharmacological treatment should be chosen based on the evidence for their efficacy in BD
Sequential trials of treatment for long durations[25-27,30,51]	Treatment of RCBD requires several trials of each treatment regimen lasting for about 3–4 mo before the acute-phase efficacy of the treatment regimen can be determined
	Frequent changes in treatment should be avoided since they might worsen rapid cycling
Combining pharmacological and nonpharmacological treatments[25,30,32,45,163]	One option is to add nonpharmacological treatments only in refractory patients in whom several medications have been tried and have failed
	An alternative option recommends the early use of adjunctive nonpharmacological patients even in those patients who are not medication resistant
Monitoring treatment response[17,18,25,35,51]	More intensive monitoring during acute phases which can be relaxed once the patient becomes more stable
	Mood charts can be used to assess response to treatment
	At least 12 mo of treatment is required to determine the efficacy of long-term treatment
Working with patients and families[4,32,45,51,127]	Education: explaining RCBD, its causes, and the treatment approach including lifestyle changes is necessary for ensuring the collaboration of patients and families. Psychoeducational treatments that reduce stress, improve attitudes to treatment, enhance treatment engagement, and reduce caregiver burden can be tried. CBT is another option
	Support: ongoing support for patients and families is essential. This can be provided by developing a strong collaborative relationship. Nonadherence can also be addressed by fostering a strong treatment alliance
	Patience: the protracted nature of the illness requires the clinician to accept that it will take a long time for the results to become apparent. Patience and perseverance on the part of patients and families has to be stressed repeatedly so that they learn to focus on long-term goals
	Sleep hygiene: regular sleep routines can be advised in all patients. Chronotherapeutic techniques can be tried when required and feasible

CBT: Cognitive behavioural therapy; ECT: Electroconvulsive therapy; RCBD: Rapid-cycling bipolar disorder.