Bipolar Disorder: Psychosocial Factors and Psychological Therapies. Steve Jones Spectrum Centre for Mental Health Research

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1 Bipolar Disorder: Psychosocial Factors and Psychological Therapies Steve Jones Spectrum Centre for Mental Health Research

2 Overview Scale of the Problem Factors associated with Bipolar course and outcome Where do people with Bipolar disorder sit within services? Are there effective psychological interventions for bipolar disorder? Access issues for people with bipolar disorder want psychological therapy Risks when people receive the wrong therapy Key challenges with bipolar clients What is happening in IAPT services currently New therapy developments Exciting opportunities to transform people s lives

3 Key messages 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

4 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 1/7 th of the research spend on schizophrenia despite similar prevalence and morbidity Mental Health Research Funders Report, 2005

5 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 Akiskal et al., 2000 Angst et al., 2003 Grant et al., 2005 Merikangas et al., 2007

6 Course Peak risk for onset years Recurrent mood episodes over time 4 per year in recent study Similar patterns in men and women Switch to mania following initial unipolar diagnosis 46% over 15 yr follow-up in young adults Kupfer et al., 2002 Merikangas et al., 2007 Post et al., 2003 Baldassano et al., 2002 Goldberg et al., 2001

7 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

8 Negative Consequences 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

9 Factors associated with course and outcome Increasing evidence for the importance of psychosocial factors in bipolar disorder DCP report highlights psychological factors in understanding and treating bipolar disorder (Jones et al. 2010)

10 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

11 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

12 Psychosocial Factors in Bipolar All of these factors are potentially amendable to psychological interventions

13 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

14 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!

15 Research bias Most research has been focussed on those in mental health services Tends to be those with most consistent levels of clinical need Biases outcome research negatively

16 Psychosocial Interventions Aims traditionally symptom focused but becoming more recovery orientated Range of interventions many common elements 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

17 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)

18 NICE Guidelines 2006 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

19 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

20 Risk of Wrong Treamtent Inappropriate treatments can: trigger mania be ineffective and increase resistence to more appropriate care trigger severe anxiety problems fail to recognise common comorbidity issues fail to recognise risk factors including risk taking and suicidality

21 Wrong Treatments Pharmacological interventions focussed solely on depression Psychosocial approaches focussed only on depressive episodes EWS interventions done badly

22 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

23 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

24 What is happening in IAPT and elsewhere currently? 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?

25 What is happening in IAPT and elsewhere currently? 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)

26 Current 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

27 New Therapy Developments At Spectrum current RCTs include Group psychoeducation delivered by services 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)

28 New Therapy Developments Self management approaches Self management intervention for relatives (psychosis including BD: Lobban) Web intervention for adults with BD (Todd) Web intervention for bipolar parents (Jones)

29 Manchester Other Developments (Not exhaustive) 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) Oxford Holmes Development of imagery related approaches to BD

30 A cautionary (but not uncommon) tale from ERP Bob s CC had a go at an EWS intervention with Bob and his wife Reviewed previous episodes Bob found this very traumatic Identified EWS but failed to make them specific and sensitive enough this led to Bob becoming very anxious by very slight changes in sleep, drinking and mood as he worried they were indicative of a relapse Coping strategies largely focussed on ringing the team or taking additional medication. Bob felt very dependent on the mental health services who also got frustrated in managing his anxiety Bob s life then became very restricted and caused relationship difficulties as his wife also intrusively monitored for warning signs

31 Conclusions It is not good enough to offer people therapies developed for other conditions This is likely to be unhelpful and could cause harm To provide better access we need to help clinicians get better at detecting bipolar disorder earlier

32 Conclusions Lots of exciting developments with potential to help people with bipolar Many skills that can be trained to disseminate widely BUT if we do not train people properly we risk making them worse

33 Key messages 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

34 Keep in touch

35 Report is downloadable from DCP website For further information contact: For updates visit

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