Mindfulness Interventions in Bipolar Affective Disorder

Ruwan M Jayatunge M.D. 

Bipolar Affective Disorder (BPAD) is a chronic and disabling psychiatric disorder characterized by recurrent episodes of mania/hypomania and depression (Van Dijk et al., 2013).  In BPAD psychosocial functioning and quality of life often remain impaired between mood episodes (Ball et al., 2006; Becerra et al., 2013).  Bipolar Disorder presents in 1-4% of the world's population, carrying significant financial and functional consequences (Stump & Eng, 2018). The long-term outcomes of bipolar disorder range from lasting remission to chronic course or frequent recurrences requiring admissions (Uher et al., 2018).  Bipolar disorder is the sixth leading cause of disability worldwide (Murray et al., 1996).

According to the American Psychiatric Association (2000) symptoms of bipolar disorder include happiness and irritability, decreased need for sleep, racing thoughts, excessive confidence, increased energy, psychomotor agitation, and willingness to engage in reward-oriented behaviors without consideration of potential negative consequences. There are two main types of bipolar disorders; bipolar I and bipolar II.  Bipolar I disorder is defined by at least one lifetime manic episode, whereas bipolar II disorder is defined by less severe hypomanic episodes along with depressive episodes (Johnson et al., 2012).

Bipolar patients are more prone to heart and metabolic diseases as well as a higher risk of suicide compared to the healthy population (Riveros & Retamal, 2018). Yatham and colleagues (2018) state that approximately 6%‐7% of identified patients with BD dying by suicide.

The co-occurrence of bipolar disorder and anxiety disorder is associated with a worse prognosis (van der Veen et al., 2018). According to Simon and team (2005) BPAD has high comorbidity with anxiety disorders which is approximately 62%. Many individuals with bipolar disorder have cognitive difficulties and are disorganized in their daily lives (Deckersbach et al., 2012). 

Deficient emotion regulation is closely related to Bipolar Affective Disorder (Rheenen et al., 2014). Emotion regulation involves a coherent relationship with the self, specifically effective communication between body, mind, and feelings and effective emotion regulation involves the ability to accurately detect and evaluate cues related to physiological reactions to stressful events, accompanied by appropriate regulation strategies that temper and influence the emotional response (Price &Hooven, 2018).

Emotional processing in bipolar disorder is impaired (Howells et al., 2014). Wessa  and  Linke( 2009)  state that in response to emotional stimuli bipolar patients show a dysfunction in a ventral-limbic brain network including the amygdala, insula, striatum, subgenual cingulate cortex, ventrolateral prefrontal cortex and orbitofrontal cortex. They hypothesized that this imbalance between the two networks has been proposed to underlie deficient emotion regulation in bipolar disorder.

BPAD has high relapse rate, morbidity and psychosocial impairment that often persist despite pharmacotherapy, highlighting the need for adjunctive psychosocial treatments (Reinares et al., 2014).

The management of BPAD is a challenge.  Treating bipolar depression is based on the combination of mood stabilizers and psychotherapy (McMahon et al., 2016). Some Psychiatrists recommend mindfulness based interventions for the patients who are diagnosed with BPAD. According to these clinicians there are improvements in cognitive functioning and emotional regulation, reduction in symptoms of anxiety depression and mania symptoms following mindfulness interventions.  

Dr. William Marchand, Professor of Psychiatry at the University of Utah, has experience using mindfulness-based interventions (MBIs) for bipolar spectrum conditions.  He states that anecdotally, individuals with these conditions report that they find MBIs to be helpful in managing their illness. Further, he says that scientific evidence is accumulating that MBIs may be effective adjunctive treatments for bipolar disorders (personal communication, 2018).

Chu and team (2018) reported the effectiveness of adjunct mindfulness-based intervention in treatment of bipolar disorder. Mindfulness interventions are based on teaching patients to pay complete attention to the present experience and act nonjudgmentally towards stressful events. During this mental practice the meditator focuses his or her attention on the sensations of the body. While the distractions (mental images, thoughts, emotional or somatic states) arise the participant is taught to acknowledge discursive thoughts and cultivate the state of awareness without immediate reaction (Bulzacka et al., 2018). It is a moment-to-moment awareness with qualities of kindness, curiosity, and acceptance.

Meditation practice has been found to promote well-being by fostering cognitive and emotional processes (Boccia et al., 2015). Mindfulness based cognitive therapy may improve emotional processing in bipolar disorder (Howells et al., 2014). Mindfulness influences neural processes in midline self-referential and lateralized somatosensory and executive networks (Lee et al., 2017). According to Tang and Posner (2016) mindfulness meditation improves emotion regulation. Stange and team (2011) surmise that mindfulness intervention  may be a treatment option that can be used as an adjunct to medication to improve cognitive functioning in bipolar disorder.