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


Factors associated with course and outcome. Increasing evidence for the importance of psychosocial factors in bipolar disorder . BPS report highlights psychological ... – PowerPoint PPT presentation

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

National Initiatives in the Development and
Delivery of Psychological Approaches to Bipolar
  • Steve Jones

  • Spectrum Centre for mental health research

  • What psychological approaches are there out
  • What is the mechanism for getting these into
  • 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
  • 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
  • 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 Bipolar
  • 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 Bipolar
  • All of these factors are potentially amendable to
    psychological interventions

Where do people sit within services?
  • 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

Diagnostic Issues
  • 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
  • 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 (gt12)
  • NB Scott CBT trial 2006 no benefit

Psychological Interventions are effective (for
some people)
  • 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
  • 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
  • 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
  • Pharmacological interventions focussed solely on
  • Psychosocial approaches focussed only on
    depressive episodes or psychotic experiences
  • EWS interventions done badly

NICE Guidelines 2006
  • National Institute for Clinical Excellence 2006
  • 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
  • i.e. 159 pages on medication
  • 25 pages on psychological support
  • Important because
  • it affects the messages people receive on
  • It affects the ways in which care is delivered
  • It affects the types of care that are prioritised
    and offered

NICE Guideline Rewrite
  • 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
  • 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
  • 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?
  • 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
  • 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 SMI?
  • 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
  • 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

  • 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

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  • Demonstration site programme is intended to
    provide model for good practice and for future
  • Our demonstration site is evaluating current good
    practice, exploring ways of improving access and
    considering the incorporation of new therapy

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Core Competencies
  • G
  • roup

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New Therapy Developments to Inform IAPT SMI
  • 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

New Therapy Developments
  • Self management approaches
  • Self management intervention for relatives
    (psychosis including BD Lobban)
  • Web psychoeducation intervention for adults with
  • Web intervention to relapse in adults with BD
  • Web intervention for bipolar parents

Other Developments (Not exhaustive)
  • Manchester
  • Mansell TEAMS approach based on Mansells
    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

  • Funding funding funding
  • Big challenge is to use the outcomes of
    demonstration sites to extend support for
  • 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
  • Contact for further information