Dual Diagnosis: Open Access Open Access

Short Commentary

Bipolar II disorder is characterised by recurrent mood episodes of depression and hypomania [1]. Patients with bipolar II disorder show lack of awareness about their illness, because a hypomanic does not significantly influence a patient’s social functioning. Lack of awareness may be a cause to prolong time to diagnosis in bipolar II disorder [2]. The low disease awareness and prolonged time to diagnosis might establish psychopathological features that make difficult the progress of the disease.

Psychoeducation plus standard medication is recommended as a first choice for the maintenance therapy [3]. It could be especially benefit in bipolar II disorder patients because of its complicated features. However, it is difficult to apply psychoeducation requiring a significant time commitment from a patient and healthcare professional in clinical practice. Simple and effective psychoeducation is likely to facilitate dissemination by increasing flexibility in the situation with limited resources.

Previously, we reported the case of a patient with bipolar II disorder successfully treated through a simple individual psychoeducation program in Case Reports in Psychiatry [4]. Here, we briefly reintroduce the case and present a short comment from a new perspective.

The patient was a 64-year-old woman who had been treated with antidepressants since the age of 40, following a diagnosis of depression. Approximately 1 year ago, she began feeling very irritable and visited several hospitals for treatment. However, after causing some disruption at each of these hospitals, she was referred for specialized psychiatric treatment, at which time she visited our clinic.

In her first visit to our clinic, she was hypomanic. Following a thorough assessment, her diagnosis was changed to bipolar II disorder, based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). We discontinued antidepressant treatment and subsequently initiated treatment with mood stabilizers. Her condition gradually improved, and she became euthymic after 6 months. However, she did not believe that her mood had stabilized, and she urged us to resume her antidepressants so that she could perform activities without feeling tired, as before. Therefore, we recommended that she take part in a psychoeducation program.

Previously, we developed a simple individual psychoeducation program for patients with bipolar II disorder, as it is difficult to implement systematic and comprehensive psychoeducation in an outpatient clinic in Japan, owing to limited economic and human resources. These sessions were conducted once a week during the waiting period prior to medical examination. In each session, the patient and psychotherapist read aloud from a textbook on bipolar disorder for approximately 20 minutes.

Prior to initiating psychoeducation, we assessed her understanding of bipolar disorder and her subjective mood using our customized questionnaires. Although her knowledge of bipolar disorder was not insufficient, a discrepancy remained between her subjective and objective moods. In the first and second sessions, she read aloud passages of text related to the prevalence of bipolar disorder, as well as those related to manic/ hypomanic and depressive symptoms. She did not show interest in the program.

However, in the third session-during which she read aloud sections on mixed state in bipolar disorder-her perception of the condition dramatically changed. She became convinced that she had experienced a mixed state several times. She felt more interested in learning about her illness through psychoeducation. In the fourth and fifth sessions, she read aloud sections on controlling mood swings and leading a well-regulated life in bipolar disorder. In addition to seeking familial support, she voluntarily started maintaining a diary to objectively record her own mood. In the sixth to ninth sessions, she read aloud the sections on pharmacotherapy and pathology for bipolar disorder. She was satisfied with the medication she received at the time and stopped requesting that the doctor prescribe antidepressants.

After psychoeducation, she displayed a substantial improvement in her understanding of bipolar disorder, and the discrepancy between her subjective and objective moods had been eliminated. Subsequently, the patient also exhibited improvements in family communication and quality of life.

Although our previous report described the successful treatment of a patient with bipolar II disorder via the inclusion of a simple individual psychoeducational program, we would like to make two comments from a new perspective. First, it is important to note that the patient had been treated for depression for 24 years. This is a common occurrence in general medical care because diagnosis of bipolar II disorder is often difficult and time-consuming without professional psychiatric examination. Long-term treatment for depression may have a negative effect on a patient’s perception of bipolar disorder, rendering subsequent treatment difficult. Thus, simple psychoeducation may be effective for such patients. Second, our simple psychoeducation program consists of interactive reading aloud by the patient and psychotherapist, which requires no specialized training and offers several benefits. Such a program leads to open communication and provides patients with an opportunity to ask questions to improve their understanding of the disease. Furthermore, articulatory movements during reading aloud can aid readers in understating a sentence, regardless of their levels of cognitive resources, which may contribute to the patient’s understanding of the written information in the textbook. Therefore, we propose that a simple individual psychoeducation program involving interactive reading aloud may be both effective and feasible for routine clinical management of patients with bipolar II disorder.

References

1. American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association.
2. Scott J, Grunze H, Meyer TD, Nendick J, Watkins H, et al. (2015) A bipolar II cohort (ABC): The association of functional disability with gender and rapid cycling. J Affect Disord 185:204-208.
3. Fountoulakis KN, Grunze H, Vieta E, Young A, Yatham L, et al. (2017) The International College of Neuro-Psychopharmacology (CINP) treatment guidelines for Bipolar disorder in adults (CINP-BD-2017),part 3:The clinical guidelines. Int J Neuropsychopharmacol 20:180-195.
4. Saito-Tanji Y, Tsujimoto E, Taketani R, Yamamoto A, Ono H (2016) Effectiveness of Simple Individual Psychoeducation for Bipolar II Disorder. Case Rep Psychiatry.