Bipolar disorder type I (BD-I) is characterized by periodic mood swings, including mania and depression (1,2). The prevalence of BD-I in the general population is approximately 1%, and its 12-month prevalence is estimated at 0.6% in the United States. The average age of the onset of the first manic episode is almost 18 years. Also, 90% of individuals who experience a manic episode are expected to have repeated episodes in the future (3). Evidence suggests that 30% of these individuals experience a significant decline in occupational and functional domains. Research shows that one out of every three people with BD is unable to work within six months after the disorder, and only two-fifths of them can function as expected (2,4).
Since mania is mainly characterized by loss of concentration, restlessness, and impaired judgment, it can lead to defects in social functioning. Consequently, beyond distress, this disorder has destructive effects on the patient’s family members and the stability of marital relationships, imposing heavy costs on the healthcare systems and insurance companies and negatively affecting the patient’s quality of life and economic productivity (5–7). Evidently, the social stigma associated with the diagnosis of BD leads to frustration in patients and their family members and causes severe social isolation and intensified environmental stress, along with depression and anxiety symptoms (3).
Therapeutically, emotional swings that can affect a patient’s cognitive accessibility, lack of insight, and subsequently medication non-adherence are commonly reported in bipolar patients (BPs). According to statistics, 60% of individuals with this disorder do not adhere to their therapies or show poor adherence. Therefore, rapid relapse due to medication discontinuation is one of the main treatment challenges (8). Besides medication discontinuation, environmental stress, family conflicts, lack of social support, celibacy, divorce, separation, and socioeconomic factors have been reported as other influential factors in the relapse of this disorder (2,4).
One of the important social factors influencing the relapse of BD is attention to the family’s role and functioning. Studies show that the family’s attitude and interactions affect the course of BD and that this disorder influences family functioning. When people close to a patient lack sufficient information, support, and training in adaptive coping strategies, the patient’s symptoms may deteriorate, and the risk of relapse is increased (9). According to several studies, a negative family emotional climate after discharge is an important predictor of complications in BPs. Severe negative emotional expression, criticism, hostility, and conflict disrupt the family dynamics and increase the likelihood of relapse. Additionally, these disturbed interactions harm the mental and physical health of the caregivers and other family members (10,11). Inattention to the family’s dynamic role causes a delay in functional improvement compared to other components (10). Given the high relapse rate of BD, it is important to help these patients and their families identify the risk factors for relapse and take the necessary therapeutic measures as soon as the symptoms emerge (12). Considering the mutual relationship between this disorder and family functioning, interventions involving both the patient and the family need to be designed for BPs.
For several decades, different types of psychotherapy have comprised the core components of BD treatment. Interventions, such as psychoeducation, cognitive behavioral therapy (CBT), and interpersonal and social rhythm therapy (IPSRT), have been introduced as effective treatments (1,13). Another evidence-based treatment is family-focused therapy (FFT). This short-term treatment focuses on the present time and increases the mutual trust between the patient and family members. Its main components include psychoeducation (raising knowledge about BD) and training in communication and problem-solving skills for patients and their family members. This treatment has remarkable effects on the improvement of BD by reducing the burden of the disorder, preventing relapse, reducing suicidal ideations, increasing medication adherence, improving family cohesion, reducing isolation and depression, decreasing hospitalization rates, improving daily functions, and increasing quality of life (4,11,14,15). Moreover, another study evaluated and compared the effectiveness of this treatment with psychoeducation and reported a higher quality of life and reduced severity of symptoms in patients who received this treatment (16).
In another study, the likelihood of BD relapse was estimated at 12% in BPs under treatment with FFT versus 66% in the control group (4). However, inattention to the patients’ cognitive defects is one of the major shortcomings of this treatment; therefore, the authors of this treatment protocol suggested cognitive interventions to improve recovery after a course of disease (17). Since cognitive defects have been reported as risk factors for BD and may even exist before the onset of this disorder, causing significant disruptions in the patient’s daily life and social functioning, they should be the target of therapeutic interventions. However, FFT does not focus on these defects; therefore, the need for more specific interventions is strongly felt, because education for promoting the patients’ cognitive skills, along with family education, can influence the consequences of BD (18,19).
According to research conducted in the last 15 years, cognitive dysfunction is an inherent characteristic of BD in a significant percentage of patients (1). Cognitive defects, in turn, increase the risk of relapse and cause significant problems in the occupational domain, as well as interpersonal relationships (20). Defects in social cognition are also one of important cognitive deficits in these patients. Social cognition is defined as mental operations that underlie social interactions and includes the human ability to perceive the intentions and states of others. It is also an underlying process that affects an individual’s capacity to receive, process, and understand social information (21,22). In other words, social cognition is a multifaceted construct that includes capacities, such as the theory of mind, social perception, social knowledge, attribution bias, and emotion perception and processing (23, 24).
Studies show that social cognition acts as a moderating variable for cognitive defects and social functioning (25) and plays a significant role in the consequences of this disorder and the patient’s response to treatment. Any deficit in social cognition weakens the patient’s functioning in daily individual activities, problem-solving skills, interpersonal relationships, occupational performance, and quality of life (26–28). These patients, due to their inability to recognize facial expressions or empathize with others, besides their attribution of negative events to the intentions of others, are unable to interact properly with people around them. Also, the mentioned defects cause aggressive behaviors, social withdrawal, and anxious behaviors (27,28). Some studies have shown that impaired social cognition may be more persistent in BPs compared to schizophrenic patients (29).
Limited studies have compared the social-cognitive functioning of BPs with and without psychotic symptoms; their results indicated that the functioning of BPs with psychotic symptoms was similar to that of schizophrenic patients (30). Based on these findings, attention to treatments that directly address the key determinants of poor social functioning is beneficial for improving functional defects. One of these treatments is social cognition and interaction training (SCIT). The SCIT intervention is an evidence-based treatment for improving different areas of social cognition. It is a relatively new treatment focusing on the symptoms of dysfunctional interactions. Although this treatment has been designed for schizophrenia, it is also used for other disorders associated with damage to social cognition. This treatment contains three main components, including the theory of mind, improvement of emotional perception, and attributional style, based on a conceptual model intertwining social cognition disorders and social inefficiency (28,31).
So far, few studies have evaluated the effectiveness of social cognition interventions for BPs. In a previous study, the effectiveness of this treatment was investigated in these patients. The results showed a significant improvement in the social cognition and social functioning of the experimental group compared to the control group. Nevertheless, this study had limitations regarding the homogeneity of the sample and lack of follow-up (32). Despite the importance of social cognition in BPs, limited research has focused on social cognition training for these patients. Based on a conceptual model intertwining social cognition disorders and social inefficiency, if only the social functioning of BPs is emphasized, and their cognitive defects are neglected, they can trigger a disorder and increase the risk of relapse. The current study aimed to bridge the current research gap.
The Present Study
Recently, in SCIT, particular attention has been paid to the cognitive defects of BPs. This intervention is effective for schizophrenic patients, while limited studies have approved its efficacy for BPs. Therefore, the present study aimed to address the following questions: “Is this treatment effective in improving different factors, such as social functioning, and interpersonal relationships as primary outcome and disease relapse as secondary outcome, in patients with BD-I?”, “Is SCIT comparable to FFT?”, and finally, “Which of these two interventions has clinical superiority?”. By addressing such questions, more comprehensive information can be obtained regarding the effectiveness of evidence-based treatments for BPs.