HOPES interventions are grounded in the principles of social skills training through the use of modeling and role-playing techniques, provision of positive and corrective feedback, and completion of homework assignments. The curriculum includes seven modules: communicating effectively, making and keeping friends, making the most of leisure time, healthy living, using medications effectively, and making the most of a healthcare visit [21]. Each module includes 6–8 component skills with one specific skill taught each week by a master’s prepared rehabilitation specialist. Participants practice the skills in community group outings. Another form of community practice involved the participant identifying an “indigenous supporter” (family member, friend, clinician, spouse) who could help facilitate opportunities to practice the targeted skills in a safe and natural space.

HOPES care management is delivered by registered professional nurses who evaluate each participant’s medical history and current healthcare needs. The nurses and participants set health-related goals and focus on preventative and primary healthcare benchmarks. The skills training clinicians and registered nurses meet weekly to coordinate each component of HOPES.

As indicated in Table 9.1, one RCT study demonstrated that HOPES participants had greater improvement than treatment as usual (TAU) in measures of performance skills, psychosocial and community functioning, symptoms, and self-efficacy¹ at 1, 2, and 3 years [20, 21].

The multicomponent HOPES intervention is appropriate for older adults with severe mental illness, including BD, who face a combination of psychosocial and medical issues and have persistent impairment in multiple areas of functioning (e.g., work and self-care). The benefits of the program were unrelated to psychiatric diagnosis, i.e., psychotic disorders (schizophrenia–schizoaffective) versus mood disorders (MDD and BD). Nevertheless, because of the small percentage of older adults with BD in the sample, evaluation and potential adaptation of the HOPES program specifically for older adults with BD are needed. Furthermore, because study participants had persistent impairment in functioning, validation of the HOPES program in older adults with higher level of functioning is recommended.

One study, an RCT, compared Specialized Care for Bipolar Disorder (SCBD) versus SCBD with ECI [22] in patients with a wide age range including adolescents (N = 75, 12–18 years of age), young and middle-aged adults (N = 349, 19–64 years of age), and older adults (N = 39, 65 years of age and older). SCBD is a manualized system of clinical disease management for bipolar patients, which includes assessment of psychiatric symptoms and standardized algorithm-driven pharmacotherapy [22]. Because SCBD does not include a psychosocial component, the Enhanced Clinical Intervention (ECI) was added to SCBD. As indicated in Table 9.1, the groups showed comparable improvement on the Clinical Global Index (CGI), the Global Assessment of Functioning (GAF), and Quality of Life Enjoyment and Satisfaction Questionnaire over 18 months of treatment [22]. However, participants in the SCBD + ECI group had greater improvement in the quality-of-life measures. Even though there were no separate analyses in the group of older adults, there were no significant differences in treatment outcomes among age groups [22].

Future investigations may concentrate on the application of ECI in older adults with BD and identification of the most useful and efficacious components in improving symptoms and quality of life in this population.

This component is based on the Life Goals Program, a group psychoeducational program for BD [29]. The program is enhanced with additional material on the cardiovascular disease risk, on diet and exercise, and on engagement of general medical providers. The self-management component is delivered by a care manager in four two-hour group sessions [25] and complementary phone sessions.

In this component, a nurse care manager served as a liaison between patients and providers, addressed patients’ health concerns, referred urgent issues to appropriate medical and mental health providers, reinforced self-management, and followed patient’s progress over time [25]. This component was delivered by regular phone calls for up to 6 months.

Continuing medical education sessions addressed cardiovascular disease risk factors following the American Diabetes Association and American Heart Association guidelines, for all primary care and mental health providers.

In an RCT, BCM was associated with significantly greater improvement in physical health-related quality of life compared to TAU, but there were no significant differences between the two groups in other outcomes including symptoms and functioning (Table 9.1). Evaluation of specific components of BCM and effects in older patients is needed.

Non-adherence to pharmacotherapy is associated with increased risk for relapse, recurrence, hospitalization, and high healthcare costs [12, 23, 33]. MAST-BD is a promising and needed intervention that focuses on this critical issue of medication adherence in older adults with BD. In a pilot study [23], MAST-BD provided the evidence of feasibility, acceptability, and improvement in medication adherence, medication management ability, depressive symptoms, and quality of life (Table 9.1). Future investigations may evaluate its effects in a randomized controlled trial.

In young to middle-aged adults, these three interventions have been studied separately [34–42], but also as part of the Systematic Treatment Enhancement Program for BD (STEP-BD) [43, 44].

Cognitive behavioral therapy has been adapted for BD and includes (1) psychoeducation on the course of BD, medication adherence, and stress management; (2) scheduling of life events; (3) cognitive restructuring; (4) problem-solving training; (5) plans for early detection and intervention; and (6) selected interventions for comorbidity [43, 45, 46].

Interpersonal and social rhythm therapy [11] consists of psychoeducation, social rhythm therapy, and interpersonal psychotherapy. Psychoeducation focuses on pharmacotherapy, medication side effects, and early episode warning signs and detection of prodromal symptoms [11]. Social rhythm therapy identifies strategies to prevent the disruption of social routines and sleep/wake cycles [47]. Interpersonal psychotherapy focuses on reducing interpersonal difficulties because of grief, role transitions, role disputes, and interpersonal deficits. An additional area of “grief for the lost healthy self” was added to interpersonal and social rhythm therapy [11].

Family-focused therapy includes psychoeducational sessions focusing on symptoms, course of illness, treatment, and self-management of BD [48]. In the intermediate phase, after psychoeducation, patients and family members participated in exercises to enhance communication skills. In the final phase, families focused on solving problems related to the illness.

Psychoeducation has been a significant component of the interventions for older bipolar patients, as we described above, but to our knowledge, there are no clinical trials of stand-alone psychoeducation in older adults with BD [12, 34]. Psychoeducation has been widely utilized in a group or individual format as a stand-alone intervention or as an adjunct to other psychosocial interventions for young to middle-aged adults with BD and their families [12, 34, 42, 49–51]. It helps patients and their families develop skills to identify early signs and symptoms, monitor the patients’ sleep patterns and symptoms, and avoid relapse [12, 42, 49–51].

Because of emotional lability in BD, assessment and regulation of negative and positive emotions in patients with BD are critical. Emotion regulation strategies have been effective in improving depression and reducing disability in older adults with unipolar or bipolar major depression and varying degrees of cognitive functioning, including older patients with major depression and significant cognitive impairment, or middle-aged and older adults after successful electroconvulsive therapy (ECT) [52, 53]. Emotion regulation techniques that follow the process model of emotion regulation [54] may be effective in the management of emotions associated with a depression, hypomanic, or manic state. These techniques include situation selection (i.e., selecting situations that promote adaptive positive emotions and reduce negative emotions), situation modification (i.e., modifying situations to promote adaptive positive emotions and reduce negative emotions), attentional deployment (i.e., shifting attention to promote adaptive positive emotions and reduce negative emotions), cognitive change (i.e., changing the appraisal of a situation to modify the emotional response, similar to “cognitive restructuring” that is used in cognitive behavioral therapy) or response modulation (i.e., utilizing direct efforts to alter one’s emotional responses).

According to the latest statistics from the Centers for Disease Control and Prevention [55], suicide rates in older adults are alarmingly high and older white men (aged 85 and older) have the highest rate of suicide (54/100,000) [55]. Even though the suicide risk appears to be higher in young adults than in older adults with BD [56, 57], studies on suicide risk in older adults with BD are sparse [58, 59]. In a study of 1354 older adults who died by suicide, BD had a stronger association with suicide (OR 9.20; 95 % CI 4.38–19.33) than depression (OR 6.44; 95 % CI 5.45–7.61) or anxiety disorders (OR 4.65; 95 % CI 4.07–5.32) [60]. Despite the need for interventions to prevent suicide in older adults with mood disorders, no interventions for older patients with BDs have been designed or tested. Clinicians must assess suicidal ideation, past suicide attempts, as well as risk and protective factors for suicide in older adults with BD [58, 61].

Decreased social support is critical in older adults with severe mental illness [62], including BDs, and is associated with increased isolation and decreased pleasure [63, 64]. Belonging to a large family network and having increased instrumental support are associated with a shorter bipolar episode [64]. Social support and family support become increasingly important as disability and cognitive impairment increase [65]. Therefore, clinicians must evaluate the social and family support of an older adult with BD and seek to increase social support and reduce interpersonal tension in the family.

Disability is prevalent in older adults and is associated with increased depression, medical morbidity and mortality, and reduced quality of life of patients and caregivers [66, 67]. Careful assessment of disability domains, the impact of disability on an individual’s emotions and quality of life, and its contribution to increased family stress is critical.

Cognitive impairment, especially deficits in executive functioning, memory, psychomotor speed, and sustained attention, is associated with BD in adults of all ages [13, 68–75]. Cognitive deficits may contribute to reduced quality of life, increased disability, and, in some cases, poor treatment outcomes [13, 76, 77]. Clinicians should assess the specific cognitive deficits and their impact on daily functioning and interference with adherence to pharmacotherapy or psychosocial treatments. A formal neuropsychological assessment may be necessary to fully evaluate these cognitive deficits.