Functional remediation: the pathway from remission to recovery in bipolar disorder

Bipolar disorder is not just a mood disorder. Patients nowadays do not just want to feel well, they want to do well because they want to be well. This is equivalent to say that the critical endpoint is not anymore mere improvement, nor even remission, but recovery. The current therapeutic armamentarium, consisting of traditional drugs such as lithium, plus anticonvulsants, antipsychotics and, in some cases, antidepressants, has made remission an achievable goal for many patients with bipolar disorder. Illness-focused psychological interventions, such as psychoeducation, have helped many to stay well for longer periods of time, and in some cases, indefinitely. But many patients with bipolar disorder stay there, more or less feeling well, but not doing well at all. Many take their medicines, after having learnt that stopping them leads to relapse and misery and, in addition, more medication, but are unable to get their jobs back or to finish their studies. Many live on the ashes of what used to be their social life before everything was gone with the fire of the illness. For a long time, the assumption was that recovery was difficult due to social factors, stigma and discrimination. And those are indeed powerful reasons for many to feel socially disabled. But we also learnt that the illness itself carries an increased vulnerability to stress and cognitive difficulties, which were historically neglected, and that those problems persist over time beyond clinical remission. Functional remediation is an intervention that aims to fill the gap between remission and recovery. Obviously inspired by traditional neurocognitive remediation techniques, such as those that have worked well in brain damage and other neuropsychiatric conditions, its major feature is that it focuses on functioning rather than cognition1. The intervention has, therefore, a neurocognitive and psychosocial background including modeling techniques, role playing, self-instructions, verbal instructions, and positive reinforcement, together with metacognition, with objective functioning as the main target. It includes education on cognitive deficits and their impact on daily life, and provides strategies to manage deficiencies across several cognitive domains, such as attention, memory and executive functions. The family and caregivers can also be involved in the process to facilitate the practice of these strategies at home and for reinforcement2. Functional remediation is not a mere sensible proposal. It is manualized and evidence-based. The first randomized, controlled trial to test it has been published3 and is now being replicated. The primary outcome was the improvement in global, clinician-rated measure of psychosocial functioning. A total of 268 outpatients were enrolled across 10 academic sites in Spain. After 21 weekly group sessions, functional remediation improved aspects related to work functioning and interpersonal abilities, increasing personal autonomy and reducing financial dependence. The intervention works for patients with bipolar I and bipolar II disorder as well, and the positive effects last at least 6 months beyond the final session of the program4. In its current format, it is intended for late-stage bipolar disorder, but with some modifications it could be tailored to enhance cognitive reserve5 and prevent further progression of cognitive and functional impairment in patients at early stages. Hence, there is great potential in designing an intervention combining psychoeducation and functional remediation with focus on early stages and prevention of further morbidity and mortality. As Insel6 has questioned, is it realistic to expect conditions as complex as psychotic, mood or anxiety disorders to respond to a singular intervention? Bipolar disorder, perhaps the most polymorphic and complex of all psychiatric conditions, clearly needs a multidisciplinary and integrative approach, combining the best of drug therapy, biophysical techniques, and psychosocial interventions. A common criticism that is made to sophisticated and lengthy psychotherapies is that they are difficult to implement in a community-care based system and may not be cost-effective. There have been several attempts to reduce the length and intensity of evidence-based psychoeducational packages, but most of those are unpublished because they failed. There is often a "wishful thinking" background in those aiming at designing an intervention that is effective and brief. It would be like learning a second language or to play a musical instrument with only a few sessions. Cost-effectiveness is an issue but, if one counts indirect costs, it is likely that any intervention that works is actually cost-effective, especially when occupational outcome is concerned. There is some hypocrisy and discrimination in restricting access to sophisticated psychotherapies when access to complex and very expensive medical procedures, such as transplantation, is granted for most patients in the Western world. The paradox is that you can have a liver transplantation if you are 69 years old and abstinent for 3 months, but you cannot have access to the (psycho)therapy that will keep you abstinent for the rest of your life. Once again, there is no health without mental health. Functional remediation is not just a fashionable therapy for bipolar disorder. Across the 21 sessions, the patients are walked through plenty of practical challenges and exercises that help them in improving their interpersonal, social and occupational skills. A major strength of this approach is that it fills the gap between neurocognitive processes and social skills, bringing in neuroscience to the traditional scope of social therapies. Hence, changes in the ability to deactivate the default mode network under neurocognitive challenges are expected in bipolar patients who have received this sort of therapy, and studies are ongoing to confirm that. It is happening in many fields within psychiatry that traditional outcomes, such as psychotic, depressive, manic or anxious symptoms, are being replaced or perhaps upgraded with other targets that are more closely correlated with functioning7. Neurocognitive symptoms are the best example. Conditions such as major depression, which were never the focus of neuropsychological assessment except to exclude patients at risk of dementia, are now being studied using not only mood, but also processing speed, executive function and memory as primary outcomes8. Neuroimaging and neuropsychological assessments, among other biomarkers, will be increasingly incorporated into clinical trials. Clinical staging will become part of routine assessment9. The growing interest in distal outcomes such as functioning as opposed to quality of life or symptoms will run in parallel with molecular and translational psychopathology10 and the explosion of personalized medicine as applied to mental health. Functional remediation is a novel psychosocial intervention that has been found to improve the outcome of patients with bipolar disorder. In contrast with patient and family psychoeducation, cognitive-behavioral therapy, and interpersonal social rhythm therapy, the focus of this intervention is not improvement of mood or relapse prevention, but psychosocial adjustment. It proved to be effective in reducing global disability and enhancing interpersonal and occupational functioning. Albeit considered a therapy for late-stage, functionally impaired bipolar patients, there is huge interest in tailoring it for the prevention of cognitive and psychosocial impairment in recently diagnosed patients, following the principle that prevention is better than cure. The final aim is to allow people with bipolar disorder not only to feel well, but to do well and to be well. Getting closer. Eduard Vieta, Carla Torrent Bipolar Unit, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain