Evidence-Based Reviews

Beyond lithium: Using psychotherapy to reduce suicide risk in bipolar disorder

Current Psychiatry. 2011 October;10(10):39-45

Moshe S. Torem, MD

Dlfapa

Novel approach teaches patients to ‘disown’ suicidal thoughts, internalize future

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References

1. McIntyre RS, Konarski JZ. Bipolar disorder: a national health concern. CNS Spectr. 2004;9(11 suppl 12):6-15.

2. Tsai SY, Lee CH, Kuo CJ, et al. A retrospective analysis of risk and protective factors for natural death in bipolar disorder. J Clin Psychiatry. 2005;66(12):1586-1591.

3. Osby U, Brandt L, Correia N, et al. Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry. 2001;58(9):844-850.

4. Baldessarini RJ, Pompili M, Tondo L. Suicide in bipolar disorder: risks and management. CNS Spectr. 2006;11(6):465-471.

5. Gelenberg AJ. Can lithium help to prevent suicide? Acta Psychiatr Scand. 2001;104(3):161-162.

6. Schou M. Suicidal behavior and prophylactic lithium treatment of major mood disorders: a review of reviews. Suicide Life Threat Behav. 2001;30(3):289-293.

7. Burgess S, Geddes J, Hawton K, et al. Lithium for maintenance treatment of mood disorders. Cochrane Database Syst Rev. 2001;(3):CD003013.-

8. Baldessarini RJ, Tondo L, Davis P, et al. Decreased risk of suicides and attempts during long-term lithium treatment: a meta-analytic review. Bipolar Disord. 2006;8(5 Pt 2):625-639.

9. Tondo L, Baldessarini RJ. Long-term lithium treatment in the prevention of suicidal behavior in bipolar disorder patients. Epidemiol Psichiatr Soc. 2009;18(3):179-183.

10. Miklowitz DJ. Adjunctive psychotherapy for bipolar disorder: state of the evidence. Am J Psychiatry. 2008;165(11):1408-1419.

11. Hirschfeld RMA, Harris TH, Davis HK. Making efficacious choices: the integration of pharmacotherapy and nonpharmacologic approaches to the treatment of patients with bipolar disorder. Current Psychiatry. 2009;8(10 suppl):S6-S11.

12. Rucci P, Frank E, Kostelnik B, et al. Suicide attempts in patients with bipolar I disorder during acute and maintenance phases of intensive treatment with pharmacotherapy and adjunctive psychotherapy. Am J Psychiatry. 2002;159(7):1160-1164.

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Patients with bipolar disorder (BD) have a high risk for suicidal ideation, suicide attempts, and suicide.^1-3 Approximately 25% to 50% of BD patients attempt suicide at least once, and their attempts often are lethal—the ratio of attempts to completed suicides in BD patients is 3:1, compared with 30:1 in the general population.⁴ Lithium has been shown to effectively stabilize BD patients’ mood and significantly reduce the rates of suicide attempts and completed suicides,^5-9 but does not reduce BD patients’ long-term suicide risk to that of the general population.

Literature on psychotherapeutic treatments for patients with BD primarily focuses on improving patients’ adherence to pharmacotherapy and achieving faster recovery and remission.¹⁰ Nonpharmacologic treatments for patients with BD include psychoeducation, family-focused psychoeducation, cognitive therapy, and interpersonal and social rhythm therapy (Table 1).¹¹ Literature on nonpharmacologic treatments to address suicidality in BD patients is limited,^12,13 and additional psychotherapeutic interventions to reduce suicide risk in BD patients are needed.¹⁴

In this article, I describe a novel psychotherapeutic intervention I use that integrates cognitive therapy principles with ideas derived from the psychosynthesis model.^15,16 It consists of teaching patients to “disidentify” from suicidal thoughts, followed by a guided-imagery exercise in which patients experience a future positive life event with all 5 senses and internalize this experience. This creates a “hook into the future” that changes the present to match the future event and acts as an antidote to suicidal thoughts. I have used this strategy successfully in many patients as an adjunct to pharmacotherapy.

Table 1

Nonpharmacologic interventions for bipolar disorder

Goals	Techniques
Psychoeducation
Increase illness awareness Improve medication compliance Early detection of relapses Establish lifestyle regularity	Education based on books, pamphlets, and Web sites regarding the symptoms, course, treatment, and self-management of BD Self-monitoring of symptoms and behaviors Discussion
Family-focused psychoeducation
Accept notion of vulnerability for future episodes Accept need for mood-stabilizing medications Educate to distinguish between patient’s personality traits and BD symptoms Reestablish functional relationships after a mood episode	Education based on books, pamphlets, and Web sites regarding the symptoms, course, treatment, and self-management of BD Enhance communication skills in the family Education about problem-solving skills
Cognitive therapy
Challenge the patient’s dysfunctional thoughts and beliefs regarding self and the world as influenced by BD	Self-monitoring of dysfunctional thoughts and behaviors Monitor moods and early signs of relapse Develop a plan of action to deal with early signs of relapse Emphasize the need of combined pharmacotherapy and psychotherapy Promote the importance of regular sleep and healthy lifestyle
Interpersonal and social rhythm therapy
Stabilize daily routines and sleep/wake cycles Gain insight into relationship between moods and interpersonal events Relieve stress and interpersonal problems	Review history of illness Track and identify connections between sleep patterns, activities, and mood Develop a plan to stabilize social and circadian rhythms by maintaining consistent sleep/wake times and reducing excessive social stimulations Explore and resolve interpersonal problems
BD: bipolar disorder Source: Reference 11

A theoretical model

Clinical Point

The psychosynthesis model proposes it is easier to change thoughts identified as foreign to ‘the self’

Roberto Assagioli, who established the approach to psychology called psychosynthesis, formulated a fundamental psychological principle in controlling one’s behavior: “We are dominated by everything with which our self becomes identified. We can dominate and control everything from which we disidentify ourselves.”¹⁵ According to the psychosynthesis model, it is easier to change thoughts we identify as foreign to “the self” (ego-dystonic) than thoughts we identify as being part of “the self” (ego-syntonic).

Patients whose suicidal thoughts are ego-syntonic identify with the thoughts as representing themselves and take ownership of these thoughts. Such patients are at a greater risk of acting on suicidal thoughts.

Patients whose suicidal thoughts are ego-dystonic consider the suicidal thoughts foreign to their core self and do not believe such thoughts represent them. In essence, they “disown” the thoughts and typically want to control and eliminate them. Examples of patients’ ego-syntonic vs ego-dystonic suicidal thoughts are listed in Table 2.

Clinical Point

Patients whose suicidal thoughts are ego-syntonic identify such thoughts as representing themselves and may act on them

This construct calls for an intervention to help patients who have ego-syntonic suicidal thoughts restructure them as a manifestation of BD, rather then the patient’s core self belief. The intervention emphasizes the patient is not “a suicidal patient” but suffers from an illness that may manifest with suicidal ideation. Many BD patients overly identify with their disease, stating, “I am bipolar” or “I am suicidal.” The “I am” statement originates from the verb “to be,” which implies the disease is part of the patient’s identity. The goal of this intervention is to help the patient learn to disidentify from the disease and decide that suicidal thoughts do not represent their core self, but are a manifestation of the underlying disease.