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
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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
• 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
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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
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• 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 sector
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 (>12)
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
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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 depression
• Psychosocial approaches focussed only on
depressive episodes or psychotic experiences
• EWS interventions done badly
NICE Guidelines 2006
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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
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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
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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
• 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 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 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
supervision
IAPT SMI
• 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 SMI
• 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
• G
• roup
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 (Jones)
New Therapy Developments
• 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)
• 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
• Funding funding funding …
• 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
• Contact for further information:
[email protected]
www.spectrumcentre.org
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National Initiatives in the Development and Delivery of