Psychosocial problems may be causes or consequences of BP relapses,and adding psychologic therapies to usual-treatment approaches may improve the prognosis of those at risk of persistent symptoms or frequent episodes. The three core individual manualized therapies (IPSRT, cognitive therapy, and FFT) have all developed specific models for use in BP. Colom et al's group psychoeducation model also has a clearly developed rationale and format, and it allows individuals to share their views of BP with others, to learn adaptive coping strategies from the other 8 to 12 members of the group, and to have regular contact with an expert therapist. Careful review of the four more extended and comprehensive approaches and the brief technique-driven interventions demonstrates that the effective therapies incorporate one or more of the modules show in Box 1. At present,the choice between the four extended models is more likely to be dictated by patient choice or the availability of a trained therapist. The technique-driven interventions are briefer than the specific therapies (about 6-9 sessions compared with about 20-22 sessions) and usually offer a generic, fixed treatment package targeted at a circumscribed issue such as medication adherence or managing early symptoms of relapse. These brief interventions can be delivered by a less-skilled or less-experienced professional than the specific model. They potentially seem to be useful in day-to-day clinical practice in general adult psychiatry settings; additional larger-scale, randomized trials should be encouraged. Given the reduction in relapse rates and hospitalizations associated with the use of psychologic therapy as an adjunct to medication, it is likely that these approaches will prove to be clinically and cost effective. They may provide a significant improvement in the quality of life of individuals with BP (and indirectly to that of their partners and family members). Brief,evidence-based therapies represent an important component of good clinical practice in the management of BP. Studies of a comprehensive, whole-system approach to the collaborative psychobiosocial management of BP are being undertaken in the United States. If these approaches improve the quality and continuity of care for individuals with BP, they will have further implications for the delivery and organization of mental health services. The number and variety of trials of psychosocial interventions is exciting for researchers and clinicians interested in BP. Enthusiasm for advocating these approaches should be tempered by an acknowledgment that the trials undertaken so far largely demonstrate efficacy in selected samples of patients treated at specialist BP clinics or psychologic treatment research centers. Translating efficacy into effectiveness requires evidence that the approaches used in the treatment trials are equally beneficial when used by the wider therapist community treating patients seen routinely in non-specialist or nonresearch centers. These patients often have multiple problems or complex presentations that preclude their involvement in pharmacologic or psychologic treatment studies, but monitoring the outcomes of these representative samples will be important in determining the true place of psychologic approaches in the management of BP. Large-scale studies are now underway on both sides of the Atlantic (the Medical Research Council study in the United Kingdom and the STEP-BD project in the United States). These trials are likely to answer basic questions about the benefits and limitations of psychologic therapies in the acute and maintenance treatment of BP in the clinical realm and will increase understanding of the effectiveness-versus-efficacy question.
