National Initiatives in the Development and Delivery of Psychological Approaches to Bipolar Disorder
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National Initiatives in the Development and Delivery of Psychological Approaches to Bipolar Disorder. Steve Jones. Introductions. Spectrum Centre for mental health research www.spectrumcentre.org. Overview. What psychological approaches are there out there?

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National Initiatives in the Development and Delivery of Psychological Approaches to Bipolar Disorder

Steve Jones


Introductions
Introductions Psychological Approaches to Bipolar Disorder

  • Spectrum Centre for mental health research

  • www.spectrumcentre.org


Overview
Overview Psychological Approaches to Bipolar Disorder

  • What psychological approaches are there out there?

  • What is the mechanism for getting these into practice?

  • Shortfall between aspiration and reality

  • IPT SMI programme

  • Core competencies programme

  • Hopes for the future

  • NB. There are probably new developments I have not heard of yet – if I miss anything please get in touch!


Factors associated with course and outcome
Factors associated with course and outcome Psychological Approaches to Bipolar Disorder

  • Increasing evidence for the importance of psychosocial factors in bipolar disorder

  • BPS report highlights psychological factors in understanding and treating bipolar disorder (Jones et al. 2010)


Psychosocial factors in bipolar
Psychosocial Factors in Bipolar Psychological Approaches to Bipolar Disorder

  • Life events – both positive and negative associated with triggering episodes

  • Cognitive styles –

    • Dysfunctional beliefs

    • Positive self appraisal

    • Depression avoidance

    • Johnson & Fingerhut, 2006

    • Mansell & Scott, 2006

    • Jones, 2006

    • Bentall et al, 2006


Psychosocial factors in bipolar1
Psychosocial Factors in Bipolar Psychological Approaches to Bipolar Disorder

  • Activity and sleep patterns

  • Approach to early warning signs

  • Family environment and communication styles

  • Jones, 2006

  • Lam & Wong, 2006

  • Morris & Miklowitz, 2006


Psychosocial factors in bipolar2
Psychosocial Factors in Bipolar Psychological Approaches to Bipolar Disorder

  • All of these factors are potentially amendable to psychological interventions


Where do people sit within services
Where do people sit within services? Psychological Approaches to Bipolar Disorder

  • Key feature of bipolar is its fluctuating course

  • Care needs fluctuate similarly

  • Many people with bipolar often not in mental health services

  • Many receive care in primary care or from third sector


Diagnostic issues
Diagnostic Issues Psychological Approaches to Bipolar Disorder

  • Average 10 years from first contact with services to bipolar diagnosis

  • Evidence for misdiagnosis even for those within mental health services

  • Many people have bipolar features without meeting full BD criteria

  • Bipolar relevant therapies are potentially relevant to around 5% of population!

    Hirschfeld et al., 2000

    Perlis, et al., 2005

    Smith et al., 2011


Psychosocial interventions
Psychosocial Interventions Psychological Approaches to Bipolar Disorder

  • Aims – traditionally symptom focused but becoming more recovery orientated

  • Meta-analysis of psychological therapies as adjunct to medication (Scott et al 2007)

    • significant reduction in relapse rates (of about 40%) compared to standard treatment alone.

    • most effective in preventing relapses in people who were euthymic when recruited into the treatment trial

    • less effective in those with a high number of previous episodes (>12)

      NB – Scott CBT trial 2006– no benefit


Psychological interventions are effective for some people
Psychological Interventions are effective (for some people) Psychological Approaches to Bipolar Disorder

Established interventions (there are more)

  • Cognitive Behaviour Therapy

    • Lam et al., 2003/2005

    • Scott, 2006

    • Ball, 2006

  • Interpersonal and social rhythm therapy

    • Frank et al.,2005, 2008

  • Family focussed therapy

    • Miklowitz et al., 2003

  • Group psychoeducation

    • Colom et al., 2003, 2005,2009

    • Castle 2010

  • Enhanced relapse prevention

    • Lobban et al., 2010

  • Mindfulness-based Cognitive Therapy (MBCT)

    • Williams et al (2008)


Access issues
Access issues Psychological Approaches to Bipolar Disorder

  • High level of demand for psychological services in bipolar (MDF etc)

  • Access restricted by lack of training, poor detection, lack of specialist knowledge and stigma about use of services

  • Many people not in MH services so even less likely to access bipolar specific help


Risk of wrong treatment
Risk of Wrong Treatment Psychological Approaches to Bipolar Disorder

  • Inappropriate treatments can:

    • trigger mania

    • be ineffective and increase resistance to more appropriate care

    • trigger severe anxiety problems

    • fail to recognise common comorbidity issues

    • fail to recognise risk factors including risk taking and suicidality

  • Surveys at IoP and Manchester indicate access rates to CBT for psychosis around 7-8%. Probably lower for BD as services less configured for them.


Wrong treatments
Wrong Treatments Psychological Approaches to Bipolar Disorder

  • Pharmacological interventions focussed solely on depression

  • Psychosocial approaches focussed only on depressive episodes or psychotic experiences

  • EWS interventions done badly


Nice guidelines 2006
NICE Guidelines 2006 Psychological Approaches to Bipolar Disorder

  • National Institute for Clinical Excellence 2006 guideline

    “Bipolar disorder: The management of bipolar disorder in

    adults, children and adolescents, in primary and secondary care”

    Recommends:

  • Structured psychological therapy for relapse prevention and enhanced coping

  • Delivered by clinician trained in CBT or similar

  • Although there are strengths to NICE it reflects current focus on medical over psychological perspectives

    • i.e. 159 pages on medication

    • 25 pages on psychological support

  • Important because

    • it affects the messages people receive on diagnosis

    • It affects the ways in which care is delivered

    • It affects the types of care that are prioritised and offered


Nice guideline rewrite
NICE Guideline Rewrite Psychological Approaches to Bipolar Disorder

  • Bipolar guidelines currently being updated

  • Substantial increase in volume of psychosocial intervention trials since last guideline

  • Level of evidence assigned is a potential issue (psychological trials less common than drug trials as therapy costs much higher)

  • Reports in 2014


Key challenges with bipolar clients
Key challenges with bipolar clients Psychological Approaches to Bipolar Disorder

  • High needs for autonomy

  • Treatment ambivalence – many value their bipolar experience (not just mania)

  • Varying mood states from depression through euthymia to mania

  • High levels of comorbidity including anxiety, substance use and self harm/suicidality


Key challenges
Key challenges Psychological Approaches to Bipolar Disorder

  • CBT informed psychological approaches ideally placed to address these challenges

  • But requires clinicians with appropriate training, support and supervision

  • Range of needs of clients means that good psychological care can range from self management to intensive psychological therapy


What was happening before iapt smi
What was happening before IAPT SMI? Psychological Approaches to Bipolar Disorder

  • Informal survey of IAPT colleagues and of BABCP Bipolar SIG nationally

  • “CMHT practitioners highlighted that psychological therapy specific for clients with Bi-Polar are not routinely offered in secondary care”

  • “IAPT workers could be seen as useful to bridge the gap between primary/secondary care”

  • “What should I do with people referred to IAPT for depression treatment who have bipolar disorder? I am not trained in BD interventions so do I just treat as unipolar?”


What was happening before iapt smi1
What was happening before IAPT SMI? Psychological Approaches to Bipolar Disorder

  • Modern matron delivering inpatient care to individuals recovering from mania (adapted EWS approach) (Tees)

  • Pilot care pathway BD and psychotic symptoms (East Anglia)

  • Psychology services delivering 10 session group psychoeducation intervention to recent diagnosis clients (Swindon)

  • CBT in primary care for bipolar clients currently stable ? Training? Supervision? Based on own reading? (Preston)


Service developments
Service developments Psychological Approaches to Bipolar Disorder

  • Some great individual initiatives

  • Not a consistent picture nationally

  • Types of intervention not necessarily based on current evidence for what is effective

  • Lack of infrastructure, training, support and supervision


Iapt smi
IAPT SMI Psychological Approaches to Bipolar Disorder

  • Process began in Nov 2011 with national stakeholder event

  • Since then work has been driven forward by an expert advisory group and a series of task and finish groups

  • In parallel a separate expert group has developed core competencies for SMI therapies


Iapt smi1
IAPT SMI Psychological Approaches to Bipolar Disorder

  • Demonstration site programme is intended to provide model for good practice and for future development

  • Our demonstration site is evaluating current good practice, exploring ways of improving access and considering the incorporation of new therapy initiatives


Core competencies
Core Competencies Psychological Approaches to Bipolar Disorder

  • G

  • roup


New therapy developments to inform iapt smi
New Therapy Developments to Inform IAPT SMI Psychological Approaches to Bipolar Disorder

  • At Spectrum current RCTs include

  • Group psychoeducation delivered by service users and clinicians (Lobban)

  • CBT for anxiety in bipolar disorder (Jones)

  • CBT for alcohol use (Barrowclough & Jones)

  • Recovery informed CBT for early bipolar disorder (Jones)


New therapy developments
New Therapy Developments Psychological Approaches to Bipolar Disorder

  • Self management approaches

  • Self management intervention for relatives (psychosis including BD: Lobban)

  • Web psychoeducation intervention for adults with BD

  • Web intervention to relapse in adults with BD

  • Web intervention for bipolar parents


Other developments not exhaustive
Other Developments (Not exhaustive) Psychological Approaches to Bipolar Disorder

  • Manchester

    • Mansell – TEAMS approach based on Mansell’s appraisal model (RCT)

  • Exeter

    • Wright – Physical activity and bipolar disorder

  • Glasgow/Edinburgh

    • Gumley, Schwannuer et al. – Integrated psychological therapy approach (RCT)

  • Cambridge

    • Holmes – Development of imagery related approaches to BD

  • Oxford

    • Williams & Miklowitz – Mindfulness for BD


Challenges
Challenges Psychological Approaches to Bipolar Disorder

  • Funding fundingfunding …

  • Big challenge is to use the outcomes of demonstration sites to extend support for programme

  • This would include setting up appropriate training in line with competencies

  • No chance of the same level of funding for IAPT 1

  • Changes in line with IAPT SMI will be ‘within existing resources’


Thanks for your attention
Thanks for your attention Psychological Approaches to Bipolar Disorder


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