The Demonstration Site So Far –
Improving Recovery for People with a
Diagnosis of Bipolar Disorder
Birmingham and Solihull Mental Health Foundation Trust
And
The Spectrum Centre for Mental Health Research
The Team
Birmingham and Solihull
Mental Health Trust
(BSMHFT)
Spectrum Centre for
Mental Health Research
Dr Amanda Gatherer
Karen Charles
Dr Jayne Eaton
Chris Mansell
Elizabeth Kyte
Professor Steven Jones
Dr Fiona Lobban
Dr Elizabeth Tyler
Rita Long
Professor
Bruce Hollingsworth
IAPT and Severe Mental Illness
6 demonstration sites:• Personality Disorder (3)
• Psychosis (2)
• Bipolar Disorder (1)
www.iapt.nhs.uk
Background Information
• A person diagnosed with bipolar disorder in their mid 20’s
loses
–9 years of life
–12 years normal health
–14 years of working life
Prien & Potter, 1990
• Bipolar disorder (BD) has received only 1/7th of the research
spend on schizophrenia despite similar prevalence and
morbidity
Mental Health Research Funders
Report, 2005
How common is bipolar disorder?
• 1-2 in 100 people for DSM-IV bipolar disorder
• Equate about 1 million people in UK
• 4-8 in 100 for bipolar spectrum conditions
–Similar clinical and functional outcomes to BD
• Around 50% of people presenting with depression
may fit in the bipolar spectrum
Negative consequences
•
•
•
•
Cost to UK £ 5.2 billion
Unemployment rates of over 50%
Completed suicide 18 times higher than general population
Elevated mortality from cardiovascular disease and accidents (x1.5-2)
Gareth Hill et al, 1996; Kupfer et al 2002; Angst et al., 1999
•
•
•
High rates of drug and alcohol misuse
Lifetime prevalence rates for
-46% alcohol disorder
-41% drug disorder
12 month rates of dependence compared to general population
-10 times higher for drug
-8 times higher for alcohol
Regier et al., 1990;Compton et al., 2007; Hasin et al., 2007
Key issues
• It is not good enough to offer people therapies developed for other
conditions
• There are a wide range of psychological interventions available for
BD
• The right intervention delivered by correctly trained therapists
significantly improves functional and symptom outcomes
• Badly matched treatment delivered by inadequately trained
therapists makes people worse
IAPT for Bipolar Disorder Project Objectives
1. Identify a best practice pathway across primary
and secondary specialist services
2. Create a knowledge, skills and competencies
framework
3. Develop a suite of resources and outcome
measures
Key deliverables
1. Identify a best practice pathway across primary and secondary
specialist services




Right treatment, right time, right place
Review current pathway by mapping current service
And speaking to service users and their families
Review of unmet need and undetected case stories / missed
opportunities
 Explore the primary care pathway within selected GP practices
Key deliverables
2. Create a knowledge, skills and competencies framework for
clinicians
 Focused project in selected GP surgeries – understand awareness
and educational / training needs
 Develop and test education and awareness raising tools
 Evaluate resources to support primary care
 Review awareness and skill set in secondary specialist services
 Identify and respond to training needs
Key deliverables
3.
Create a suite of resources and outcome measures
 Thorough evaluation of existing clinical interventions delivered
via Bipolar Disorder service in Birmingham and Solihull
 Formalise a minimum data set for use within Bipolar Disorder
services
 Review the introduction of self-management resources for
selected primary care settings
 Create and consult on a Charter for Good Practice
 Publication and dissemination of data and good practice
findings at the end of the 12 month period
BSMHFT Bipolar Disorder Service
• Psychology-led service but integrated pathway with specialist
mental health care
• Provided across the whole of Birmingham and Solihull (pop.
1.2 million)
• Psychological interventions and recovery focused
• 100 – 120 referrals a year (2.6 wte Clinical Psychologists, 1
wte Assistant and full time admin)
• Mood on Track – 10 group sessions (80 – 90 complete p/a)
• Follow up and on-going support – individual and group
Current and Planned Pathway
Intake
(via GP referral, Healthy Minds
or acute care pathway)
Mental Health
Services for
Older People
(MHSOP)
Self Referral
Referral / assessment
in secondary services
- CMHT
On-going follow-up
by CMHT
Youth and
Early
Intervention
for Psychosis
(EIP)
Direct
Referral from
GP and
Healthy Minds
(IAPT)
Referral to Bipolar
Service
MOT course declined
or not suitable
Assessment
Mood On Track
Programme
Discharge from
CMHT to Primary
Care/ Healthy Minds
On-going Relapse
Prevention Sessions
‘Mood On Track’ Programme
Assessment
by Bipolar
Disorder Team
Psychologist
(invite to
session
extended to
family or friend)
10 sessions
of group
work:
‘Mood On
Track’ course
Session 6:
Family
therapy
engagement
session
4 – 6 Individual
Relapse
Prevention
Sessions: to
develop an early
warning signs and
relapse prevention
plan
Family therapy
assessment /
formulation /
intervention
On-going access
to Bipolar
service:
• Newsletter
• Support group
• Refresher
workshops
• Telephone
contact
• Consultation
NB. Some clients will also
continue to receive input from
community mental health
services and family interventions
can be provided at any time
IAPT SMI Outcome Measures for Bipolar Disorder
Generalised Anxiety Disorder-7 Questionnaire
(GAD-7)
Sessional
Symptoms Measure
(Anxiety)
Patient Health Questionnaire-9 (PHQ-9)
Sessional
Symptoms Measure
(Depression)
Work and Social Adjustment Scale (WASAS)
Sessional
Wellbeing and Economic
Internal State Scale (ISS)
Sessional
Symptoms Measure (mood
variability)
Bipolar Recovery Questionnaire (BRQ)
6 weekly throughout MoT course, Recovery
3 monthly thereafter
Bipolar Quality of Life Scale (Bipolar QoL)
6 weekly throughout MoT course, Wellbeing
3 monthly thereafter
EQ-5D-5L
Monthly (4 weekly)
Economic
Patient Experience Questionnaire (PEQ) : Mid and
End of Treatment (MET) version
After assessment, final MoT
session, after Relapse Prevention
sessions
Service User Experience
Outcome data
• Paired samples T-Tests were carried out to determine whether there
were any significant differences between pre-therapy and end of
therapy scores (week 10) on all outcome measures.
• Service user’s scores on depression (PHQ-9) and anxiety (GAD-7)
scales were significantly reduced by the end of the mood on track
programme.
• Scores on the ISS sub-scale – well-being, increased significantly
indicating improvement in well-being.
• Scores on the WASAS significantly reduced indicating that mood
difficulties were impacting less on individuals day to day functioning.
• There was also a significant increase in participant’s scores on the
BRQ measure, indicating a higher subjective sense of recovery
Key Challenges
Project wide
• Cross site project team (across 125 miles)
• However benefits due to applied research / clinical expertise
• Both teams bring knowledge regarding national need
Pathway
• Accessibility of resources and interventions
Knowledge, Skills and Competences
• Didactic versus active facilitation
• Understanding the agents of change within group based interventions
• Practitioner and service user experience e.g. of measures
• Engaging GPs
Resources
• Deciding upon an minimum data set
Any Questions?
Measure
Pre-therapy score
(mean of sample)
Post-therapy score
(mean of sample)
Interpretation
Generalised anxiety
disorder questionnaire
(GAD – 7)
Patient health questionnaire
(PHQ-9)
9.75
7.33
Scored out of 21 - a score of
7.33 indicates ‘mild anxiety’
12.83
8.25
Work and Social adjustment
scale (WASAS)
20.50
13.42
95.69
-
142.08
-
A wellbeing score of 95.69
indicates depression.
A wellbeing score of 142
indicates well being.
Scored out of 27 - a score of
8.25 indicates ‘mild
depression’
Maximum score of 40 – higher
score indicates higher severity
of difficulties
The guidelines for
classification into different
clinical status are:
Depression: Well being < 125
Mania/hypomania: Well being
> 125 and Activation >200
Total: 1889.85
Mood Manageable: 313.77
Developing resources: 640.62
Total: 2161.77
Mood Manageable: 365.15
Developing resources: 755.85
Internal state scale
•
Well-being
•
Activation
•
Perceived Conflict
Bipolar recovery
questionnaire
Scored out of 3600 (higher
score indicates a higher
degree of self-rated recovery)
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The demonstration site so far - Improving recovery for