By Dr Thomas Richardson, Associate Professor of Clinical Psychology, University of Southampton

As a clinical psychologist I have worked with a lot of people with bipolar who say therapy helps them to live well with mood changes. Part of my role is to train the next generation of nurses, social workers and psychologists to deliver therapies such as Cognitive Behavioural Therapy (CBT) in the NHS.

The research backs up my lived experience

I have bipolar and have found therapy truly life changing. Research proves that my experience isn’t unique. Meta-analyses pool together all of the clinical trials they can find. A 2017 meta-analysis showed that CBT and a 2021 meta-analysis found that group or family-based psychoeducation all reduce the relapse rate of bipolar.

In other words, there’s a clear evidence base that psychological therapies can work well for people with bipolar. Not for everyone all the time, though. More research to develop new therapies is desperately needed.

NICE recommends therapy

The National Institute for Health and Care Excellence, which recommends NHS treatments, is very clear in its Guidelines for Bipolar:

• Psychological treatments should be offered in both primary care (if you’re not under a mental health team but under your GP) and for longer-term management of bipolar in secondary care (if you're under a mental health team)
• 16-20 sessions should be offered

Lots of people with bipolar don’t have access to therapy

Unfortunately, the work I have been doing with the Bipolar Commission has shown that, despite clear evidence that psychological therapies (defined as counselling, psychotherapy, CBT, a mindfulness group, a psychoeducation/therapy group or family therapy for bipolar) work and despite NICE Guidelines, not everyone is being offered them. A survey of people with a diagnosis of bipolar found:

• 76% had been offered or received therapy at some points in their lives
• 69% had been referred for therapy on the NHS
• One in five had been offered group-based psychoeducation specifically for bipolar
• 29% had never been offered psychological therapy on the NHS
• 26% had been specifically told that they could not get therapy on the NHS and would have to pay for it themselves
• nearly half had had to pay for their own therapy at some point

One of the survey respondents said:

“I have never been offered psychological therapies despite numerous episodes of severe symptoms leading to inpatient admissions. It seems my episodes are only ever managed at crisis point with no follow-up until a further episode.“

The disparity of healthcare

I can’t imagine a physical health condition where people are not offered treatment on the NHS despite it clearly being recommended and effective. Imagine being told ‘This NHS trust doesn’t prescribe insulin for diabetes, you’ll have to pay for it yourself’. Or, ‘This NHS trust doesn’t prescribe statins for heart disease, you’ll have to pay for them yourself.’

In my private practice as a therapist I get people who have bipolar from all over the country contacting me to say that their NHS trust has told them they will never get therapy on the NHS and will have to pay for it themselves. It is a postcode lottery.

In some parts of the UK there are specialist bipolar services. In others there is a general mental health team and staff have limited specialist training on working psychologically with bipolar. I don’t think it’s right that someone in one city gets therapy for free whilst another gets told they will have to pay potentially thousands for the same therapy. Where’s the national in National Health Service here?

Why isn’t therapy available for people with bipolar?

I think the main reason why people with bipolar aren’t being offered therapy is that decision makers, healthcare professionals and the patients themselves think that it is a medical condition, that staying well is about taking medication. While this is really important, and there are undeniably brain and genetic components involved, there are also crucial psychological factors that can lead to relapse: high standards, perfectionism, goal-focused behaviour and an incessant drive to take on more, excessive socialising, shame and self-critical tendencies.

Another reason why people with bipolar might not be offered therapy may be that the condition is an episodic illness. People can be stable and not in contact with mental health services for years. If they relapse and need a hospital admission it depends on their local trust as to whether or not they’re offered therapy after discharge.

One of the Bipolar Commission surveys found that 69% of those with bipolar had been offered therapy after an acute hospital admission. This could be worse, but that’s still nearly one in three who weren’t offered therapy after being in hospital (let alone all the other less severe relapses that didn’t require hospitalisation). I think it should be 100% - therapy is especially important after someone has been in hospital to help understand why they relapsed and help them on the road to recovery

All too often once you are discharged, services have the mindset that you are recovered. I get queries from students training in CBT saying, ‘My patient is stable now so I can’t work with them’. Yes you can! Therapy isn’t just for people who are feeling depressed, it can be used (and is often most effective) when people are stable. It can prevent relapse by helping you understand your triggers and early warning signs and learn skills to reduce the risk of it happening again.

Once someone has recovered from an acute crisis we shouldn’t be washing our hands of them and waiting until the next admission, we should be working with them to stop it happening again.

Falling between primary and secondary care

In England, the Increasing Access to Psychological Therapies (IAPT) programme provides psychological therapies for depression and anxiety in primary care. As the name suggests, it aims to make therapy more readily available. The waiting times are typically a lot shorter than secondary care: weeks rather than months or years. But in most areas bipolar is excluded from IAPT, being seen as something that needs to be provided in secondary care (community mental health teams). Some pilot sites delivered CBT for bipolar in IAPT which showed good outcomes, but this has not been rolled out nationally. A Bipolar Commission survey found that only 15% with bipolar had used IAPT.

Some people with bipolar fall through the cracks between primary care and secondary care. They are told that they are not severe enough for secondary care, but IAPT will not see them for bipolar, so they end up getting no therapy, having to pay for it themselves. This is exactly what I was told when I was assessed by mental health services for the first time in a few years.

A recent study I did with colleagues from Kings College London found that lots of people accessing IAPT may have undiagnosed bipolar, but they do just as well from the therapy. We could try and screen more for bipolar in IAPT, but we don’t want this to mean bipolar becomes a diagnosis of exclusion and ends up with people being not offered therapy or being put on much longer waiting list in secondary care.

Getting a quicker diagnosis of bipolar (instead of the current average delay of 9.5 years) should improve access to specialist care, not hinder it. No wonder one study found that 56% of people with bipolar don’t have a diagnosis.

Extra funding – and how you can help

The good news is that the Department of Health has massively increased funding for training CBT for bipolar. The number of training places for clinical psychologists has also increased considerably. I am working with Bipolar UK and academic and clinical colleagues to try and improve access to therapies. If you have bipolar, you could help by completing a short survey about your experiences of accessing psychological therapy, whether you have received therapy or not, and no matter who provided it.

Ready for therapy? Ask for it

If you haven’t ever had psychological therapy, or haven’t had any for a while, ask for it. Speak to your psychiatrist, mental health nurse, social worker or GP. Just because it is not being offered doesn’t necessarily mean it isn’t available. It is always worth asking.

If you are told it is not available then mention the NICE guidelines which say it is as important as medication. If you have been offered medication (I’m betting you have!), you should have been offered therapy. You have a right to therapy. You have a right to reduce your risk of relapse. You have a right to live well with bipolar.

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Last updated: 17 January 2023