ArticleLiterature Review

Self-management in bipolar disorder: The story so far

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Abstract

Research suggests that psychoeducation, relapse prevention and recovery are all the key aspects of psychological treatment for bipolar disorder and the common components of self-management programmes. This review traces the origins of self-management interventions as it appears in physical health research and evaluates the current evidence associated with self-management interventions for depression and more specifically for bipolar disorder. Literature review. Despite significant clinical and cost benefits associated with self-management programmes for physical and mental health problems, to date there has been less progress in the development of self-management interventions for bipolar disorder. Preliminary evidence indicates that people with bipolar disorder will engage with self-management support. The rapid development and evaluation of self-management programmes for bipolar disorder is an important research and clinical priority.

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... The term "self-management" encompasses various approaches; however, its core focus is on an individual taking greater responsibility for their health care by learning about their illness and developing the skills necessary to identify and control symptoms (Jones, Deville, Mayes, & Lobban, 2011). Self-management programs can be purely self-help, or can include a minimal amount of professional assistance (Jones et al., 2011). ...
... The term "self-management" encompasses various approaches; however, its core focus is on an individual taking greater responsibility for their health care by learning about their illness and developing the skills necessary to identify and control symptoms (Jones, Deville, Mayes, & Lobban, 2011). Self-management programs can be purely self-help, or can include a minimal amount of professional assistance (Jones et al., 2011). Self-management of BD incorporates a number of strategies and is a growing area of interest (Mansell, Powell, Pedley, Thomas, & Jones, 2010;Murray et al., 2011;Pollack, 1996;Russell & Browne, 2005;Suto, Murray, Hale, Amari, & Michalak, 2010;Todd, Jones, & Lobban, 2013;Wang, Tse, & Michalak, 2009). ...
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Objective: Internet (eHealth) and smartphone-based (mHealth) approaches to self-management for bipolar disorder are increasingly common. Evidence-based self-management strategies are available for bipolar disorder and provide a useful framework for reviewing existing eHealth/mHealth programs to determine whether these strategies are supported by current technologies. This review assesses which self-management strategies are most supported by technology. Method: Based on 3 previous studies, 7 categories of self-management strategies related to bipolar disorder were identified, followed by a systematic literature review to identify existing eHealth and mHealth programs for this disorder. Searches were conducted by using PubMed, CINAHL, PsycINFO, EMBASE, and the Cochrane Database of Systematic Reviews for relevant peer-reviewed articles published January 2005 to May 2015. eHealth and mHealth programs were summarized and reviewed to identify which of the 7 self-management strategy categories were supported by eHealth or mHealth programs. Results: From 1,654 publications, 15 papers were identified for inclusion. From these, 9 eHealth programs and 2 mHealth programs were identified. The most commonly supported self-management strategy categories were "ongoing monitoring," "maintaining hope," "education," and "planning for and taking action"; the least commonly supported categories were "relaxation" and "maintaining a healthy lifestyle." eHealth programs appear to provide more comprehensive coverage of self-management strategies compared with mHealth programs. Conclusions and implications for practice: Both eHealth and mHealth programs present a wide range of self-management strategies for bipolar disorder, although individuals seeking comprehensive interventions might be best served by eHealth programs, while those seeking more condensed and direct interventions might prefer mHealth programs. (PsycINFO Database Record
... Self-management of BD education is a complex intervention aiming to improve health outcomes and is mostly delivered by nursing staff (Clark, 2013;Coster & Norman, 2009;Jones, Deville, Mayes, & Lobban, 2011). However, in some studies, it is questioned if nurses are sufficiently trained to comprehend the complexity of self-management education (Been-Dahmen, Dwarswaard, Hazes, van Staa, & Ista, 2015;Lawn et al., 2009, Pols et al., 2009. ...
... Nevertheless, we solely focused our attention on MHNs assuming that they are the over-represented discipline in delivering self-management support (Coster & Norman, 2009). Yet, the treatment of BD is interdisciplinary (Bauer et al., 2009;Jones et al., 2011;Kupka et al., 2015). Therefore, we recommend that future studies use multidisciplinary and thus more representative samples to strengthen the transferability of study results (Lincoln & Guba, 1985). ...
Article
Background: Self-management of bipolar disorder (BD) education is a complex nursing intervention in which patients and informal caregivers are taught to be actively involved in self-monitoring and self-regulating activities. Some studies question if nurses are sufficiently equipped to deliver these educational tasks. Other studies suggest that nurses have gathered their knowledge implicitly by experience, but to date this tacit knowledge is not described from the experiences of mental health nurses (MHNs) in ambulant BD care. Objective: To detect the tacit knowledge used by MHNs by interpreting their experiences in delivering self-management education to people with BD and their informal caregivers. Methods: A phenomenological-hermeneutical study amongst MHNs (N=9) from three ambulant BD care clinics in the Netherlands. Face-to-face, open, in-depth interviews guided by a topic list, were conducted and transcribed verbatim prior to the hermeneutical analysis. Findings: We found five categories resembling the complex character of self-management interventions provided by MHNs; Building a trustful collaboration, Starting a dialogue about needs and responsibilities, Explaining bipolar disorder, Utilizing mood monitoring instruments, and Conceptualizing self-management of BD. Conclusion: Eventually MHNs use tacit knowledge to cope with situations that demand an outside-the-box approach. Self-management education is partially trained, and partially mastered through experience. Practice Implications: In order to facilitate long-term self-management of BD, the collaboration of a supporting network is essential.
... Self-management of BD education is a complex intervention aiming to improve health outcomes and is mostly delivered by nursing staff (Clark, 2013;Coster & Norman, 2009;Jones, Deville, Mayes, & Lobban, 2011). However, in some studies, it is questioned if nurses are sufficiently trained to comprehend the complexity of self-management education (Been-Dahmen, Dwarswaard, Hazes, van Staa, & Ista, 2015;Lawn et al., 2009, Pols et al., 2009. ...
... Nevertheless, we solely focused our attention on MHNs assuming that they are the over-represented discipline in delivering self-management support (Coster & Norman, 2009). Yet, the treatment of BD is interdisciplinary (Bauer et al., 2009;Jones et al., 2011;Kupka et al., 2015). Therefore, we recommend that future studies use multidisciplinary and thus more representative samples to strengthen the transferability of study results (Lincoln & Guba, 1985). ...
Article
Background: Self-management of bipolar disorder (BD) education is a complex nursing intervention in which patients and informal caregivers are taught to be actively involved in self-monitoring and self-regulating activities. Some studies question if nurses are sufficiently equipped to deliver these educational tasks. Other studies suggest that nurses have gathered their knowledge implicitly by experience, but to date, this tacit knowledge is not described from the experiences of mental health nurses (MHNs) in ambulant BD care. Objective: To detect the tacit knowledge used by MHNs by interpreting their experiences in delivering self-management education to people with BD and their informal caregivers. Methods: A phenomenological-hermeneutical study amongst MHNs (N = 9) from three ambulant BD care clinics in the Netherlands. Face-to-face, open, in-depth interviews guided by a topic list, were conducted and transcribed verbatim prior to the hermeneutical analysis. Findings: We found five categories resembling the complex character of self-management interventions provided by MHNs: Building a trustful collaboration, Starting a dialogue about needs and responsibilities, Explaining BD, Utilizing mood monitoring instruments, and Conceptualizing self-management of BD. Conclusion: Eventually MHNs use tacit knowledge to cope with situations that demand an outside-the-box approach. Self-management education is partially trained and partially mastered through experience. Practice implications: In order to facilitate long-term self-management of BD, the collaboration of a supporting network is essential.
... The concept of SM originated with a chronic disease selfmanagement course (CDSMC) (8), and has been applied in a variety of fields related to health. "Self-management is about the methods, skills, and strategies we use to effectively manage our own activities toward achieving certain objectives" (9). ...
... Self-management has been shown to be effective among persons with chronic depression (12). Studies reported that SM can result in positive health outcomes (8). SM may relieve or prevent the occurrence of depressive symptoms among elderly adults (13), postpartum women (14) and persons with chronic illness comorbid depression (15)(16)(17). ...
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Objective: This study aimed to investigate the current status of depression self-management (DSM), and to identify influencing factors of DSM among Chinese community residents. Methods: Stratified random sampling methodology was adopted in this cross-sectional survey. Respondents completed a collection of self-administered questionnaires Results: The majority of participants were female (72.2%), having a mean age of 39 years (SD = 17.3). The total mean score on the DSSM was low (31.63 ± 4.69). Using multiple linear regression analysis, age ranging from 25 to 64 years old (Beta = −0.176, p = 0.008), having personal stigma (Beta = −0.143, p = 0.020) and perceived stigma (Beta = 0.127, p = 0.037), and having a nuclear family structure (Beta = −0.313, p = 0.046), good family function (Beta = 0.278, p < 0.001) and good help-seeking attitude (Beta = 0.159, p = 0.008) were associated with DSSM-knowledge. Older age (≥65 years) (Beta = −0.152, p = 0.034), higher CES-D scores (Beta = −0.162, p = 0.005), having a father with a bachelor's degree or higher level of education (Beta = −0.134, p = 0.047), being female (Beta = 0.147, p = 0.012), indicating a religious preference (Beta = 0.145, p = 0.017) and having good family function (Beta = 0.247, p = 0.001) were significantly associated with DSSM-activities. Conclusions: Reducing stigma related to depression and enhancing help-seeking attitudes may be potential strategies for managing depressive symptoms among Chinese community residents.
... Unfortunately, few individuals with BD have access to psychological services (Lam et al., 2010). Consequently, the development of self-management skills in young adults, who are in the early stages of BD, is an important alternative and adjunct to clinical care (Jones et al., 2011;Leitan et al., 2015). ...
... Self-management refers to the individual taking central responsibility for the management of their health, through the development of skills to effectively manage symptoms and maintain QoL (Janney et al., 2014;Jones et al., 2011;Lorig and Holman, 2003;Sterling et al., 2010). Quality of life considerations are of particular importance due to the consumer driven rise of the personal recovery perspective in mental healthcare, which has extended the meaning of recovery beyond that of the medical model (Leitan et al., 2015;Sterling et al., 2010). ...
... Evaluations of WRAP reveal improvement in self-reported symptoms, hopefulness, self-advocacy, and physical health as well as selfmanagement skills, detection of early warning signs and coping plans (53,55). The ReThink self-management program aims to provide practical tools for self-management through support groups, peer support and structured individual information (56). A small pilot evaluation of the ReThink service found improvements in accessing more productive, fulfilling lifestyles, better problem-solving skills and greater awareness of personal strengths (57). ...
Article
Objectives Self-management is emerging as a viable alternative to difficult-to-access psychosocial treatments for bipolar disorder (BD), and has particular relevance to recovery-related goals around empowerment and personal meaning. This review examines data and theory on BD self-management from a recovery-oriented perspective, with a particular focus on optimizing low-intensity delivery of self-management tools via the web.MethodsA critical evaluation of various literatures was undertaken. Literatures on recovery, online platforms, and self-management in mental health and BD are reviewed.ResultsThe literature suggests that the self-management approach aligns with the recovery framework. However, studies have identified a number of potential barriers to the utilization of self-management programs for BD and it has been suggested that utilizing an online environment may be an effective way to surmount many of these barriers.Conclusions Online self-management programs for BD are rapidly developing, and in parallel the recovery perspective is becoming the dominant paradigm for mental health services worldwide, so research is urgently required to assess the efficacy and safety of optimization methods such as professional and/or peer support, tailoring and the development of ‘online communities’.
... A valid understanding of recovery must be grounded in lived experience. Todd and colleagues (2012) explore the meaning of recovery for people with bipolar disorder, adding to growing evidence based on self-management in this group (Jones et al., 2011). Their findings make clear that the key dimensions of personal recovery differ from traditional clinical preoccupations. ...
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Health Service and Population Research Department, Institute of Psychiatry, London, UKIntroductionRecovery has come of age. The recoveryapproach has gained traction in mental health policythroughout the English-speaking world, and – at least rhetorically – within mental healthsystems internationally (Slade et al., 2008). But with age comes responsibility. An idea caninitiate change, but that change must work in practice if it is to be sustained.This special issue on recovery marks a shift from ideology to empirical investigation. Thestudies report dataaddressingimportant questions.Webeginbyidentifying someideologicalstatements made by recovery proponents, and reviewing recent evidence relating to thesebeliefs. We then consider some of the scientific challenges in investigating recovery.“Recovery is a process, not just an outcome”A valid understanding of recovery must be grounded in lived experience. Todd and col-leagues (2012) explore the meaning of recovery for people with bipolar disorder, adding togrowingevidence basedonself-managementinthisgroup(Jones etal.,2011).Theirfindingsmake clear that the key dimensions of personal recovery differ from traditional clinicalpreoccupations.To clarify what personal recovery means, a systematic review was undertaken to collateand synthesise published frameworks and models of recovery (Leamy et al., 2011). A totalof 97 papers from 13 different countries which offered new conceptualisations of recoverywere identified. The types of papers included qualitative studies, narrative literaturereviews, book chapters, consultation documents reporting the use of consensus methods,opinion pieces, editorials, quantitative studies, as well as papers which combined differentmethods.Empirical studies recruited participants from a range of settings including commu-nity mental health teams and facilities, self-help groups, consumer-operated mental healthservices and supported housing facilities. The majority of studies used inclusion criteriathat covered any diagnosis of severe mental illness.A modified narrative synthesis of these papers showed that recovery can be thought of (a)as a journey which varies from one person to another, (b) as inter-linking sets of processes,
... Во однос на ова застапувањето е претставено како особено значаен фактор во процесот на бегство од насилството (26). И покрај тоа што групите на самопомош се подолго истражувани во различни полиња (27,25,28,29) во литературата, истражувањата на групите на самопомош за жените кои преживеале НИП се многу ретки. Поголемиот број на истражувања на групните интервенции на жени кои биле жртви на НИП се фокусираат на групи за поддршка. ...
Article
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Intimate Partner Violence (IPV) is a serious public health problem and a human rights violation that affects the lives of many women around the world. Victims of abuse report a multitude of adverse outcomes, in the biological, psychological and social domains of their life. Despite extensive research on the effectiveness of support groups, self-help is a methodology little explored in its potential effects in IPV cases. This paper analyzes a self-help experience developed within an anti-violence service of the Municipality of Rome. A collaborative study was carried out to assess the impacts of self-help in terms of participants' quality of life. We adopted the notion of quality of life as formulated by Nussbaum, further defined through her list of ten human capabilities. Participants' narratives were analyzed through thematic analysis. Results showed a significant impact of the group in terms of women's quality of life. Affiliation was highlighted as a central capability, through which the development of the others passes, especially practical reason and emotions. Political control over ones' environment was another crucial capability, manifested in the desire to help other survivors and to engage in activities of advocacy. The self-help group appeared to work as a catalyst of for the development of individual capabilities at least minimally existing, in the presence of where external conditions allow it. Implications in terms of directions for the implementation of antiviolence programs and policies are discussed. © 2018 Institute of Special Education and Rehablitation. All rights reserved.
... One aspect of recoveryorientated care is its emphasis on self-management or self-directed care [126] . Self-management strategies are adopted by many patients with BD and are also essential components of psychosocial treatments for BD [44,127] . Promoting self-management has thus been advocated as a necessary component of effective alliances in BD [88,89] . ...
... Although the term self-management may suggest that individuals living with BD are solely responsible for their outcomes (Janney, Bauer, & Kilbourne, 2014;Jones, Deville, Mayes, & Lobban, 2011;Trappenburg et al., 2013), numerous studies have shown that the active involvement of informal caregivers positively affects the course of BD (Miklowitz, 2007;Perlick et al., 2010;Scott, Colom, Pope, Reinares, & Vieta, 2012). However, caregiver involvement has an excessive cost. ...
Background: The degree of informal caregiver involvement influences the self-management of individuals living with bipolar disorder (BD). Objective: This article aims to provide a description of informal caregivers' learning experiences in self-management support of BD in order to guide professionals in tailoring future psychosocial and psychoeducational interventions. Design: In-depth open interviews with 10 informal caregivers of patients with BD who followed treatment in the context of specialized outpatient bipolar care were conducted. Results: Four learning phases emerged from the phenomenological analysis describing the informal caregivers learning process: (1) understanding BD, (2) overcoming the dilemmas in self-management support for individuals living with BD, (3) dividing tasks and responsibilities, and (4) acquiring a personal definition of self-management support for individuals living with BD. Conclusion: By grasping the concept of BD, informal caregivers gradually learn how to overcome dilemmas resulting from living with someone with BD, and how to control the expression of emotions. They learn to reflect on the nature of conflicts and how to share the responsibilities of illness management with individuals living with BD and professionals. Mastering these skills eventually allows them to define and delimit their supporting informal caregiver role in the self-management of BD. Practice implications: Our findings provide information regarding the educational needs of informal caregivers to tailor counseling, and psychosocial and psychoeducational interventions in specialized outpatient care for individuals living with BD.
... Evidence-supported SM strategies for BD include: medication adherence, monitoring mood, sleep and lifestyle regularity, exercise, healthy diet, detecting and responding to early signs of relapse, and stress-management (Janney et al., 2014;Jones et al., 2011;. SM interventions, whether clinician-led, peer-led or delivered via unguided materials (e.g., workbooks) can facilitate the development of effective SM strategies in BD (Janney et al., 2014). ...
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Background: Self-management (SM) is increasingly emphasised as a key aspect of bipolar disorder (BD) treatment. However, little is known about the subjective experience of SM, which might have both positive and negative impacts. The present study aimed to advance this literature through qualitative investigation of the experiences of people with BD who participated in an SM intervention targeting quality of life (QoL). Methods: Forty-three individuals with BD engaged with an SM intervention and were later questioned about personal experiences of engagement with the intervention, including attempts to enact self-management strategies. Thematic analysis was used to identify important aspects of the experience of SM in BD. Results: Four themes describing people's experiences of SM were identified: 1) SM for BD is empowering, 2) individual responsibility to self-manage BD, 3) SM strategies lack power to control BD, and 4) the relationship of SM to the healthcare system. Limitations: Potential limitations to generalisability may occur from self-selection bias in favour of SM and the QoL-focused nature of the present intervention. Conclusions: The findings of this research generate novel insights into ways in which individuals with BD engage with SM interventions. For most people with BD, SM invokes a sense of empowerment and responsibility, although some feel symptoms remain beyond their control. A sense of partnership between consumers and clinicians may emerge from attention to SM, but traditional medical approaches were perceived as neglecting this aspect of care. Considerations from consumer perspectives are presented to assist clinicians and researchers utilising SM interventions in BD.
... Identifying mutable factors that are associated with HRQoL among people with bipolar disorder can inform the development or adaption of interventions for this group. In particular, based on awareness that a large proportion of patients with bipolar disorder are treated exclusively in primary care settings (Kilbourne et al., 2012a), there is growing interest in briefer interventions that aim to improve self-management of mood disorders (e.g., Houle et al., 2013;Jones et al., 2011) and can be delivered both within and outside specialty mental health settings, including in primary care (Kilbourne et al., 2012a,b). Selfmanagement interventions are relatively brief and aid patients in developing a personalized plan to help them to respond to and prevent psychiatric and physical health symptoms so that they may live meaningful lives in the community (Houle et al., 2013;Sterling et al., 2010). ...
Article
People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.
... A meta-analysis of self-management interventions for people with schizophrenia found 13 studies showing significant improvement in symptoms and adherence to medication, with a reduction in relapse of 46 per cent and in readmissions of 45 per cent (Zou et al., 2013). An earlier review highlighted the clinical benefit of self-management for people with bipolar disorders (Jones et al., 2011). ...
Article
Purpose We evaluated the effectiveness and cost-effectiveness of a peer-led self-management intervention for people with severe mental disorders. Design/methodology/approach This is a one-arm longitudinal study without control group. 262 adults with (self-reported) severe mental disorders, who have used secondary mental health services and were living in the community were evaluated at three time-points (baseline, 6 months, 12 months). Socio-demographic data were collected at baseline. Wellbeing (Warwick-Edinburgh Mental Wellbeing Scale), functional living skills (Health Promoting Lifestyle Profile II) and service use (Client Service Receipt Inventory) data were assessed over time. Findings Self-management for people with severe mental disorders improved well-being and health-promoting lifestyles. After an increase in the short term, costs appeared to decrease in the longer term, although this change was not statistically significant. Due to the lack of a control group, we are unable to attribute those changes to the intervention only. Nevertheless, the self-management intervention appears to warrant further attention on both wellbeing and economic grounds. Originality/value Self-management may facilitate recovery, helping to support people with severe mental disorders at no additional cost. Given recent emphasis on recovery, peer workers and self-management, this peer-led self-management approach for people with severe mental disorders appears to have potential.
Article
The recovery movement has generated interest in the concept of personal recovery, but little attention has been paid to it in relation to bipolar disorder (BD). The aim of this study was to examine personal recovery in BD using a staged model, exploring whether different stages are associated with different psychosocial and clinical profiles. Adults with BD in remission (n = 75) were recruited from an outpatient psychiatric clinic in Hong Kong. Their average age was 45 years, with 11% and 45% working part time and full time, respectively. The data included stages of recovery, sociodemographic characteristics, clinical information, and perceptions of the importance of recovery factors and the resilience-engendering features of health services. Decision tree analysis was used to identify the predictors of stages of recovery, and receiver operating characteristic curves were employed to detect the rates of correct classification within the staged model. 'Respect, hope, and self-directed empowerment', older age, binge drinking history, early first diagnosis, and 'meaningful role' were all associated with being in a later stage of personal recovery. The first two variables demonstrated better classification accuracy than the last three. Using these variables, the classification accuracy of Stages 2-4 was adequate. There are associations between the stage of recovery and psychosocial variables among individuals with BD in remission. Interventions that promote 'respect, hope, and self-directed empowerment' have the potential to facilitate personal recovery from BD.
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Self-help support groups are indigenous community resources designed to help people manage a variety of personal challenges, from alcohol abuse to xeroderma pigmentosum. The social exchanges that occur during group meetings are central to understanding how people benefit from participation. This paper examines the different types of social exchange behaviors that occur during meetings, using two studies to develop empirically distinct scales that reliably measure theoretically important types of exchange. Resource theory informed the initial measurement development efforts. Exploratory factor analyses from the first study led to revisions in the factor structure of the social exchange scales. The revised measure captured the exchange of emotional support, experiential information, humor, unwanted behaviors, and exchanges outside meetings. Confirmatory factor analyses from a follow-up study with a different sample of self-help support groups provided good model fit, suggesting the revised structure accurately represented the data. Further, the scales demonstrated good convergent and discriminant validity with related constructs. Future research can use the scales to identify aspects of social exchange that are most important in improving health outcomes among self-help support group participants. Groups can use the scales in practice to celebrate strengths and address weaknesses in their social exchange dynamics.
Article
This review provides clinicians and individuals with bipolar disorder (BD) with an overview of evidence-based skills shown to be effective in BD and amenable to self-management including psychoeducation; monitoring moods, medications, and social function; sleep hygiene; setting goals and relapse plans; and healthy lifestyles (physical activity, healthy eating, weight loss and management, medical comorbidities). Currently available self-management resources for BD are summarized by mode of delivery (workbooks, mobile technologies, internet, and peer-led interventions). Regardless of the self-management intervention/topic, the research suggests that personally tailored interventions of longer duration and greater frequency may be necessary to achieve the maximal benefit among individuals with BD. Means to support these self-management interventions as self-sustaining identities are critically needed. Hopefully, the recent investment in patient-centered research and care will result in best practices for the self-management of BD by mode of delivery. Since self-management of BD should complement rather than replace medical care, clinicians need to partner with their patients to incorporate and support advances in self-management for individuals with BD.
Article
Objective: Self-management of bipolar disorder (BD) is an important component of treatment. Methods: We developed a patient-centered computational software system based on concepts from nonlinear systems (chaos) theory with mobile access to assist in managing BD known as KIOS. KIOS tracks interacting symptoms to determine theprecise state of a BD patient. Once the patient's state is identified and the trajectory of the patient established, specific advice is generated to help manage the course of the disease. KIOS also provides analytics that can be used by clinicians and researchers to track outcomes and the course of illness. A 12-week field test was completed. Results: In 20 BD subjects, use of KIOS was associated with improvements in primary symptom categories of BD. Usability and generated advice were rated as a median of 6 out of a maximum of 7. Conclusions: The KIOS focus on change illuminates problems in the same way that humans experience them, implying that the future state will be consequent to changes made to impact the current state. Randomized clinical trial is indicated.
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Objectives: This qualitative study explored expected possible selves (PS) and coping skills among young and middle-aged adults with bipolar disorder (BD) in Hong Kong. Disruptive or positive experiences associated with BD can shape the development of the sense of PS. Method: Guided by narrative inquiry methodology, 14 Chinese participants (8 women, age range = 22-65 years) were recruited from community mental health services and the public and interviewed. Results: Young participants (18-40 years old) elaborated on their expected PS as they related to health, work, and family, whereas middle-aged (41-65 years old) participants talked about independent PS. The participants used problem-focused, emotion-focused and cultural coping methods to deal with their BD and to achieve their expected PS. Furthermore, the young participants expressed ambivalence toward self-help strategies to manage high mood episodes. Conclusions: This study not only improves our understanding of PS among young and middle-aged adults with BD, but also provides information for designing self-help interventions. Limitations along with directions for future research are discussed.
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Background: The delivery of mobile health (mHealth) services is acceptable to mental health consumers. However, despite the benefits of accessibility, cost-effectiveness, anonymity, and ability to tailor content to individual needs, consumer engagement remains a hurdle for uptake and continued use. This may be unsurprising as few studies have examined app content from the consumer perspective or assessed consumer preferences for the content of apps for mental health management. An opportunity to examine consumer perspectives exists in using naturally generated data that is publically available in the Google Play and Apple app stores. Whereas commercial developers routinely use this data, to date there has been no in-depth evaluation within scientific research. Objective: The aim of our study was to explore what consumers consider useful content for mental health management apps, identify unmet needs, and understand user expectations of mental health apps within the context of apps for bipolar disorder. Methods: Publically available English language consumer reviews of 48 apps for bipolar disorder were used as data, providing a total of 2173 reviews. Review text was coded and analyzed using a team approach to qualitative content analysis. Results were presented in 2 forms: (1) a quantitative summary of the 9 major and minor themes and (2) a qualitative synthesis of key thematic findings. Results: The majority of reviews were for symptom monitoring apps (87.94%, 1911/2173). The qualitative content analysis revealed 5 main themes: (1) laudatory talk, comments regarding the app's benefits including helpfulness and successful design features (74.00% of reviews, 1608/2173); (2) unfavorable feedback, negative reviews largely concerning unmet needs, privacy and technical issues, and potential dangers of app use (25.54%, 555/2173); (3) conceptions of community, referring to both communities of users with mental ill-health accessed via the app and a community created among app users and developers (24.25%, 527/2173); (4) wishlist features, app features requested by users (17.53%, 381/2173); and (5) apps and therapy, app use within clinical care (10.58%, 230/2173). Four minor themes were also identified: (1) app cost, (2) privacy and data security, (3) comparisons with traditional monitoring, and (4) evidence-based mHealth. Conclusions: Although mostly positive, the proportion of reviews containing wishlist requests indicates consumer needs are not adequately addressed by currently available disorder management apps. Consumers value content that is helpful, supportive, and easy to use, and they are integrating apps into their health management and clinical care without necessarily considering the evidence-base or clinical effectiveness of the tool. User expectations regarding developer responsiveness to their needs has implications for community-based participatory research and integrated knowledge translation. However, this expectation is incompatible with current mHealth funding structures.
Article
Deze bijdrage beschrijft een onderzoek naar de wensen en behoeften van mensen met een bipolaire stoornis in verband met het gebruik van een zelfmanagementapplicatie voor smartphones. In deze kwalitatieve studie werd aan ervaringsdeskundigen met een bipolaire stoornis gevraagd om samen met ontwerpers en zorgprofessionals hun ideale applicatie te ontwerpen. Aan de hand van een serie creatieve oefeningen konden zij hun visie delen en een innovatief zorginstrument helpen ontwikkelen, waarvan uiteindelijk een eerste ontwerp verwezenlijkt werd. Dit onderzoek legt zo de basis voor een evidencebased smartphoneapp die tegemoetkomt aan de kritiek op de apps voor een bipolaire stoornis die op dit moment op de markt zijn. Tegelijkertijd wil dit onderzoek zorginnovatie stimuleren. Het wordt dan ook besproken in de context van een herstelgerichte zorgvisie, waarin de patiënt als eigenaar van zijn eigen zorgproces centraal staat. Meer in het bijzonder onderstreept deze casus dat de herstelvisie niet alleen van toepassing moet zijn op het verlenen van zorg, maar ook op het ontwerpen van zorg.
Article
Background: Self-management comprises knowledge, behavior, activities and resources providing people with bipolar disorder (BD) control over fluctuating mood and activity-patterns. The 'Self-management and Dialogue in Bipolar Disorder' project entailed the tailoring of an online personal health record (PHR) originally designed for the chronically ill to monitor condition and share information with their clinician to people with BD (PHR-BD). The aim of this study was to evaluate the feasibility, utility and user-experiences of participants with BD, relatives, and healthcare professionals who worked with the PHR-BD. Methods: Post-test online closed- and open ended questionnaires were used to collect information on utility, and user-experiences with PHR-BD. A pre-posttest design to evaluate clinical effects on quality of life, empowerment, symptom reduction, changes in mood and activity, and illness burden and severity at baseline and at 12-months follow-up. Results: Sixty-six participants with BD logged in at baseline. At study endpoint thirty-nine participants with BD, eleven professionals and one family caregiver filled out the evaluations. No significant differences in the clinical outcomes from baseline were found. Qualitative evaluations showed a frequent utility of the mood chart modules, improved communication between clinician and participant with BD and, increased insight in influencing factors of mood fluctuations. Limitations: Small convenience sample, no controls. Conclusions: The option to alternate the interface from a prospective to a retrospective mood chart , and integration with the personal crisis plan was considered to be of added value in self-managing BD. The findings of this study will guide the future implementation of the PHR-BD.
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Background Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment. Objectives A programme of linked studies to reduce relapse and suicide in BD. Design There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5). Setting Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)]. Participants Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders . Interventions In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively. Main outcome measures In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation. Results Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio test p = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ ² = 6.80, degrees of freedom = 2; p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD: n = 72, 72% retention to follow-up; MI-CBT: n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans. Limitations Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group. Conclusion The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support. Future work Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated. Trial registration Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research ; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.
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Background Despite its significant morbidity and mortality, very little is known about how those with lived experience of bipolar II disorder (BD-II) manage their condition. This study sought to understand unmet needs in currently available psychosocial treatments, explore self-management strategies (SMS) that individuals with BD-II currently use, and determine the potential role of digital mental health interventions in this space. Methods Individuals (aged 18-65) confirming they had received a diagnosis of BD-II from a mental health professional were invited to complete an online survey about treatments trialled, coping strategies used to manage their condition and perspectives on the role of digital mental interventions. Results Ninety individuals commencing the survey confirmed a diagnosis of BD-II; of these, n = 35 were screened out based on self-reported hospitalisation for mania and/or experiencing a manic episode. A final sample of n = 55 was subsequently analysed. From the perspective of those with BD-II, current psychosocial treatments fall short in terms of meeting their specific needs. Tailored psychosocial interventions delivered by clinicians with BD-II expertise are sought after, however accessibility and cost are ongoing barriers. Participants were open to digital self-management interventions however uptake was limited. In terms of self-management, actively seeking external help was perceived as most helpful for stopping progression in depression, while self-care strategies were prioritised for hypomania. Limitations The study had several limitations: (1) BD-II diagnoses were not formally verified via standardised diagnostic interview, (2) Borderline personality disorder and comorbid substance abuse disorders were not assessed; (3) the influence of current mood state on participant responses was not assessed, (4) females were over-represented, limiting generalisation of findings to males with BD-II. Conclusions Study findings highlight the need for tailored interventions paying specific attention to nuanced features of BD-II, and the potential role of digital mental health interventions for this underserved group.
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Aims and Method Involvement of service users in the research process and examination of recovery from psychosis are two topics that have generated recent interest within the research community. This user-led study examines the subjective experience of recovery in people with experience of psychosis. Seven interviews were analysed using interpretative phenomenological analysis and several themes emerged from the data. Results Recovery from psychosis was found to be a complex and idiosyncratic process, which often involved rebuilding life, rebuilding self and hope for a better future (each of these themes consisted of sub-themes). Clinical Implications The importance of continuity of care, the need for greater choice in approaches aimed at alleviating distress, access to stories of recovery and encouragement, and the importance of more individualised recovery care plans are among factors highlighted.
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There is growing recognition that bipolar disorder (BPD) has a spectrum of expression that is substantially more common than the 1% BP-I prevalence traditionally found in population surveys. To estimate the prevalence, correlates, and treatment patterns of bipolar spectrum disorder in the US population. Direct interviews. Households in the continental United States. A nationally representative sample of 9282 English-speaking adults (aged >or=18 years). Version 3.0 of the World Health Organization's Composite International Diagnostic Interview, a fully structured lay-administered diagnostic interview, was used to assess DSM-IV lifetime and 12-month Axis I disorders. Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Indicators of clinical severity included age at onset, chronicity, symptom severity, role impairment, comorbidity, and treatment. Lifetime (and 12-month) prevalence estimates are 1.0% (0.6%) for BP-I, 1.1% (0.8%) for BP-II, and 2.4% (1.4%) for subthreshold BPD. Most respondents with threshold and subthreshold BPD had lifetime comorbidity with other Axis I disorders, particularly anxiety disorders. Clinical severity and role impairment are greater for threshold than for subthreshold BPD and for BP-II than for BP-I episodes of major depression, but subthreshold cases still have moderate to severe clinical severity and role impairment. Although most people with BPD receive lifetime professional treatment for emotional problems, use of antimanic medication is uncommon, especially in general medical settings. This study presents the first prevalence estimates of the BPD spectrum in a probability sample of the United States. Subthreshold BPD is common, clinically significant, and underdetected in treatment settings. Inappropriate treatment of BPD is a serious problem in the US population. Explicit criteria are needed to define subthreshold BPD for future clinical and research purposes.
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The science of eHealth interventions is rapidly evolving. However, despite positive outcomes, evaluations of eHealth applications have thus far failed to explain the high attrition rates that are associated with some eHealth programs. Patient adherence remains an issue, and the science of attrition is still in its infancy. To our knowledge, there has been no in-depth qualitative study aimed at identifying the reasons for nonadherence to-and attrition from- online interventions. This paper explores the predictors of attrition and participant-reported reasons for nonadherence to an online psycho-education program for people newly diagnosed with a bipolar disorder. As part of an ongoing randomized controlled trial (RCT) evaluating an online psycho-education program for people newly diagnosed with a bipolar disorder, we undertook an in-depth qualitative study to identify participants' reasons for nonadherence to, and attrition from, the online intervention as well as a quantitative study investigating predictors of attrition. Within the RCT, 370 participants were randomly allocated to 1 of 2 active interventions or an attention control condition. Descriptive analyses and chi-square tests were used to explore the completion rates of 358 participants, and standard regression analysis was used to identify predictors of attrition. The data from interviews with a subsample of 39 participants who did not complete the online program were analyzed using "thematic analysis" to identify patterns in reported reasons for attrition. Overall, 26.5% of the sample did not complete their assigned intervention. Standard multiple regression analysis revealed that young age (P= .004), male gender (P= .001), and clinical recruitment setting (P= .001) were significant predictors of attrition (F(7,330)= 8.08, P< .001). Thematic analysis of interview data from the noncompleter subsample revealed that difficulties associated with the acute phases of bipolar disorder, not wanting to think about one's illness, and program factors such as the information being too general and not personally tailored were the major reasons for nonadherence. The dropout rate was equivalent to other Internet interventions and to face-to-face therapy. Findings from our qualitative study provide participant-reported reasons for discontinuing the online intervention, which, in conjunction with the quantitative investigations about predictors, add to understanding about Internet interventions. However, further research is needed to determine whether there are systematic differences between those who complete and those who do not complete eHealth interventions. Ultimately, this may lead to the identification of population subgroups that most benefit from eHealth interventions and to informing the development of strategies to improve adherence. ACTRN12608000411347; http://www.anzctr.org.au/ACTRN12608000411347.aspx (Archived by WebCite at http://www.webcitation.org/5uX4uYwVN).
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The purpose of this analysis was to evaluate the outcomes of two statewide initiatives in Vermont and Minnesota, in which self-management of mental illness was taught by peers to people in mental health recovery using Wellness Recovery Action Planning (WRAP). Pre-post comparisons were made of reports from 381 participants (147 in Vermont and 234 in Minnesota) on a survey instrument that assessed three dimensions of self-management: 1) attitudes, such as hope for recovery and responsibility for one's own wellness; 2) knowledge, regarding topics such as early warning signs of decompensation and symptom triggers; and 3) skills, such as identification of a social support network and use of wellness tools. Significant positive changes in self-management attitudes, skills and behaviors were observed on 76% of items completed by Vermont participants (13 of 17 survey items), and 85% of items completed by Minnesota participants (11 of 13 items). In both states, participants reported significant increases in: 1) their hopefulness for their own recovery; 2) awareness of their own early warning signs of decompensation; 3) use of wellness tools in their daily routine; 4) awareness of their own symptom triggers; 5) having a crisis plan in place; 6) having a plan for dealing with symptoms; 7) having a social support system; and 8) ability to take responsibility for their own wellness. Given the rapid growth of this intervention in the U.S. and internationally, these results contribute to the evidence base for peer-led services, and suggest that more rigorous investigations are warranted in the future.
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Although guided self-help for depression and anxiety disorders has been examined in many studies, it is not clear whether it is equally effective as face-to-face treatments.MethodWe conducted a meta-analysis of randomized controlled trials in which the effects of guided self-help on depression and anxiety were compared directly with face-to-face psychotherapies for depression and anxiety disorders. A systematic search in bibliographical databases (PubMed, PsycINFO, EMBASE, Cochrane) resulted in 21 studies with 810 participants. The overall effect size indicating the difference between guided self-help and face-to-face psychotherapy at post-test was d=-0.02, in favour of guided self-help. At follow-up (up to 1 year) no significant difference was found either. No significant difference was found between the drop-out rates in the two treatments formats. It seems safe to conclude that guided self-help and face-to-face treatments can have comparable effects. It is time to start thinking about implementation in routine care.
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This study examined changes in psychosocial outcomes among participants in an eight-week, peer-led, mental illness self-management intervention called Wellness Recovery Action Planning (WRAP). Eighty individuals with serious mental illness at five Ohio sites completed telephone interviews at baseline and one month after the intervention. Paired t tests of pre- and postintervention scores revealed significant improvement in self-reported symptoms, recovery, hopefulness, self-advocacy, and physical health; empowerment decreased significantly and no significant changes were observed in social support. Those attending six or more sessions showed greater improvement than those attending fewer sessions. These promising early results suggest that further research on this intervention is warranted. Confirmation of the efficacy and effectiveness of peer-led self-management has the potential to enhance self-determination and promote recovery for people with psychiatric disabilities.
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The objective of this study was to determine whether the Arthritis Self-Management Programme (ASMP) improves perceptions of control, health behaviours and health status, and changes use of health care resources. The design was a pragmatic randomized controlled study; participants were allocated to ASMP (Intervention Group) or a 4-month waiting-list Control Group. The Intervention Group completed a 12-month follow-up. In total, 544 people with arthritis were recruited from the community--311 in the Intervention Group and 233 in the Control Group. Main outcome measures included: arthritis self-efficacy, health behaviours (exercise, cognitive symptom management, diet and relaxation) and health status (pain, fatigue, anxiety, depression and positive affect). At 4 months follow-up, the ASMP had a significant effect on arthritis self-efficacy for other symptoms and pain subscales. Performance of a range of health behaviours (cognitive symptom management, communication with physicians, dietary habit, exercise and relaxation) was significantly greater among the Intervention Group. The Intervention Group were significantly less depressed and had greater positive mood. In addition, trends towards decreases on fatigue and anxiety were noted. Physical functioning, pain and GP visits remained stable at 4 months. A similar pattern of findings was found at 12 months follow-up for the Intervention Group. Furthermore, a significant improvement was found on pain and visits to GPs had decreased. Apart from a small improvement on physical functioning among the Intervention Group participants with osteoarthritis 12 months, all effects were independent of the type of arthritis. The findings suggest that the ASMP is effective in promoting improvements in perception of control, health behaviours and health status, when delivered in UK settings.
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Anxiety and depression are prevalent in primary care; however, current treatments differ in their availability, cost-effectiveness, and acceptability to patients. Self-help treatments (such as manual-based bibliotherapy) may be an appropriate intervention for some patients. The aim of this research was to determine the clinical and cost-effectiveness of self-help treatments for anxiety and depression in primary care by conducting a systematic review of randomised and non-randomised trials of self-help interventions for patients with anxiety and depression in primary care, from electronic database searches, correspondence with authors, and limited handsearching. Eight studies were identified, examining written interventions based mostly on behavioural principles. Although the majority of trials reported some significant advantages in outcome associated with self-help treatments, the number of included studies was limited and a number of methodological limitations were identified. There were no data concerning long-term clinical benefits or cost-effectiveness. In conclusion, self-help treatments may have the potential to improve the overall cost-effectiveness of mental health service provision. However, the available evidence is limited in quantity and quality and more rigorous trials are required to provide more reliable estimates of the clinical and cost-effectiveness of these treatments.
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Common mental health problems account for up to 40% of all general practitioner (GP) consultations. Patients have limited access to evidence-based psychological therapies. Cognitive behavioural therapy self-help strategies offer one potential solution. To determine differences in clinical outcome, patient satisfaction and costs, between a cognitive behavioural-based self-help package facilitated by practice nurses compared to ordinary care by GPs for mild to moderate anxiety and depression. Randomised controlled trial. Seventeen primary healthcare teams. Patients presenting to their GP with mild to moderate anxiety and/or depression were recruited to the study and randomised to receive either a self-help intervention facilitated by practice nurses or ordinary care. The self-help intervention consisted of up to three appointments: two 1 week apart and a third 3 months later. There were no restrictions on ordinary care. Intention-to-treat analysis showed that patients treated with practice nurse-supported cognitive behavioural therapy self-help attained similar clinical outcomes for similar costs and were more satisfied than patients treated by GPs with ordinary care. On-treatment analysis showed patients receiving the facilitated cognitive behavioural therapy self-help were more likely to be below clinical threshold at 1 month compared to the ordinary care group (odds ratio [OR] = 3.65, 95% confidence interval [CI] = 1.87 to 4.37). This difference was less well marked at 3 months (OR = 1.36, 95% CI = 0.52 to 3.56). Facilitated cognitive behavioural self-help may provide a short-term cost-effective clinical benefit for patients with mild to moderate anxiety and depression. This has the potential to help primary care provide a choice of effective psychological as well as pharmacological treatments for mental health problems.
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Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge. Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally-led programmes. We report the first randomised trial of a lay-led self-management programme - the Chronic Disease Self-Management Programme (CDSMP) (Expert Patient Programme) - in a south Asian group. To determine the effectiveness of a culturally-adapted lay-led self-management programme for Bangladeshi adults with chronic disease. Randomised controlled trial. Tower Hamlets, east London. We recruited Bangladeshi adults with diabetes, cardiovascular disease, respiratory disease or arthritis from general practices and randomised them to the CDSMP or waiting-list control. Self-efficacy (primary outcome), self-management behaviour, communication with clinician, depression scores, and healthcare use were assessed by blinded interviewer-administered questionnaires in Sylheti before randomisation and 4 months later. Of the 1363 people invited, 476 (34%) agreed to take part and 92% (439/476) of participants were followed up. The programme improved self-efficacy (difference: 0.67, 95% confidence interval [CI] = 0.08 to 1.25) and self-management behaviour (0.53; 95% CI = 0.01 to 1.06). In the 51% (121/238) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy (1.47; 95% CI = 0.50 to 1.82) and self-management behaviour (1.16; 95% CI = 0.50 to 1.82), and reduced HADS depression scores (0.64; 95% CI = 0.07 to 1.22). Communication and healthcare use were not significantly different between groups. The programme cost pound123 (181) per participant. A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease. Effects on health status were marginal. Benefits were limited by moderate uptake and attendance.
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To evaluate clinical effectiveness of a self management programme for arthritis in patients in primary care with osteoarthritis. Randomised controlled trial. 74 general practices in the United Kingdom. 812 patients aged 50 and over with osteoarthritis of hips or knees (or both) and pain or disability (or both). Participants were randomised to six sessions of self management of arthritis and an education booklet (intervention group) or the education booklet alone (control group). Primary outcome was quality of life, as assessed by the short form health survey (SF-36). Several other physical and psychosocial secondary outcomes were assessed. Data were collected at baseline, four months, and 12 months. Response rates were 80% and 76% at four and 12 months. The two groups showed significant differences at 12 months on the anxiety subscore of the hospital anxiety and depression scale (mean difference -0.62, 95% confidence interval -1.08 to -0.16), arthritis self efficacy scale for pain (0.98, 0.07 to 1.89), and self efficacy for other aspects of management (1.58, 0.25 to 2.90). Results were similar for intention to treat and per protocol analyses. No significant difference was seen in number of visits to the general practitioner at 12 months. The self management of arthritis programme reduced anxiety and improved participants' perceived self efficacy to manage symptoms, but it had no significant effect on pain, physical functioning, or contact with primary care. Current Controlled Trials ISRCTN79115352 [controlled-trials.com].
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Although self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators. Randomized trials of the effectiveness of self-help interventions versus controls in the treatment of depressive symptoms were identified using previous reviews and electronic database searches. Data on moderators (i.e. patient populations, study design, intervention content) and outcomes were extracted and analysed using meta-regression. Thirty-four studies were identified with 39 comparisons. Study design factors associated with greater effectiveness were unclear allocation concealment, observer-rated outcome measures and waiting-list control groups. Greater effectiveness was also associated with recruitment in non-clinical settings, patients with existing depression (rather than those 'at risk'), contact with a therapist (i.e. guided self-help) and the use of cognitive behavioural therapy (CBT) techniques. However, only guided self-help remained significant in the multivariate analysis [regression coefficient 0.36, 95% confidence interval (CI) 0.05-0.68, p=0.03]. In the subset of guided studies, there were no significant associations between outcomes and the session length, content, delivery mode or therapist background. The results provide some insights into moderators of self-help interventions, which might assist in the design of future interventions. However, the present study did not provide a comprehensive description, and other research methods might be required to identify factors associated with the effectiveness of self-help.
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Supporting patients' self care could have a major effect on the management of long-term conditions, which has led to worldwide interest in effective self care interventions. In England, self care support is being developed through the "Expert Patients Programme", which provides lay-led generic courses to improve patients' self care skills. However, the clinical and cost effectiveness of such courses remains unclear. Two-arm pragmatic randomised controlled trial design with waiting list control in community settings in England. 629 patients with a wide range of self-defined long-term conditions were studied. The lay-led self care support group involved 6-weekly sessions to teach self care skills. Primary outcomes were self-efficacy, reported energy and routine health services utilisation at 6 months. A cost-effectiveness analysis was also conducted. Patients receiving immediate course access reported considerably greater self-efficacy and energy at 6-month follow-up, but reported no statistically significant reductions in routine health services utilisation over the same time period. The cost-effectiveness analysis showed that patients receiving immediate course access reported considerably greater health related quality of life, and a small reduction in costs. If a quality adjusted life year was valued at 20,000 pounds (39,191 dollars; 30,282 Euro), there was a 70% probability that the intervention was cost effective. Lay-led self care support groups are effective in improving self-efficacy and energy levels among patients with long-term conditions, and are likely to be cost effective over 6 months at conventional values of a decision-maker's willingness to pay. They may be a useful addition to current services in the management of long-term conditions.
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Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability. To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting. Randomised controlled trial with 16-weeks follow up. A primary care trust in Manchester. Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention. The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients. A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients.
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Evidence for change in use of health care Recently, a rapid review (commissioned by the National Institute for Health and Clinical Excellence) gave a cautious welcome to lay led self management interventions but pointed out that most evaluations were short term and set in the United States, and some of the data were uncontrolled.11 A recent paper by Buszewicz and colleagues provides the longest duration of controlled follow-up to date (one year).12 Of the four evaluations in the UK, two test the arthritis self management programme1213 and two the chronic disease self management programme, including the national evaluation of the expert patient programme carried out by the National Primary Care Research Centre in Manchester.1415 The results of these four studies are similar (table[t1]). The good news is that these programmes increase patients' self efficacy—in essence their confidence to change behaviour—and can lead to improved psychological health (although the effect sizes seem small). We found the chronic disease self management programme improved self efficacy in Bangladeshi patients, suggesting that it may be useful for ethnic minorities.15 However, the changes in self efficacy are generally modest and it is unclear how much patients value improvements in self efficacy compared with, say, a reduction in symptoms or a gain in health related quality of life. There are also important negative findings: generic measures of self rated health were unaltered in three of four studies, and more importantly, use of health care has remained stubbornly unaltered. The latter is a considerable disappointment because the expert patient programme has been heavily promoted by the UK Department of Health as part of a drive to reduce use of acute health care.Randomised trials of lay led self management programmes in the UKSeveral factors may explain the failure of lay led programmes in the UK to reduce the use of health care. Firstly, lay led programmes may do as much to promote consultation as they do to reduce it. The chronic disease self management programme teaches techniques to improve communication with clinicians, so patients may be encouraged to consult more. Secondly, any reductions in unscheduled (emergency) care may be obscured by increases in scheduled care. Thirdly, self management programmes may not be as effective at reducing healthcare use in settings such as the UK, which have universal healthcare coverage and well established primary care. It is unlikely that poor delivery of the programme in the UK is a cause since course tutors are assessed and course quality is strictly monitored. Three trials of the chronic disease self management programme in the United States show inconsistent effects on use of health care.161718 The much cited report of a 40% reduction in physician visits in the United States comes from a methodologically weak, retrospective comparison, in which arthritis patients in the community who had volunteered for self care education were compared with a group of arthritis patients with no explicit interest in self management who were under the care of rheumatologists.19 Trials examining use of health care in the UK are unlikely to have missed an effect of this magnitude.
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A thoroughly updated version of a key practitioner text, this new edition includes a treatment manual of cognitive-behavioural therapy for Bipolar Disorder which incorporates the very latest understanding of the psycho-social aspects of bipolar illness. Updated to reflect treatment packages developed by the authors over the last decade, and the successful completion of a large randomized controlled study which shows the efficacy of CBT for relapse prevention in Bipolar Disorder Demonstrates the positive results of a combined approach of cognitive behavioural therapy and medication Provides readers with a basic knowledge of bipolar disorders and its psycho-social aspects, treatments, and the authors' model for psychological intervention Includes numerous clinical examples and case studies.
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Objective: The research aimed to investigate how people diagnosed with bipolar mood disorder avoided episodes of illness and managed to stay well. The research also examined the role that personal, social and environmental factors played in helping people with bipolar mood disorder to stay well. Method: This project used a combination of qualitative research methods. The design contained three (3) components: recruitment from general community, preliminary written questionnaire and semistructured interviews. To meet the criteria for inclusion, the participant must have stayed well for the past 2 years. The two main analytical categories were ‘stay well concept’ and ‘strategies to stay well’. The main category ‘strategies to stay well’ contained a number of subcategories. These subcategories were acceptance of diagnosis, mindfulness, education, identify triggers, recognize warning signals, manage sleep and stress, make lifestyle changes, treatment, access support, and stay well plans. Results: 100 people were eligible for inclusion in the study. The sample included 63 women and 37 men. The ages ranged from 18 to 83 years, with 86% over the age of 30. Duration of time since last episode of illness ranged from 2 years to < 50 years. In the sample, 76% of participants were in paid employment. In addition, 36% of participants were parents. Participants actively managed bipolar disorder by developing a range of strategies to stay well. These strategies were based on participants' individual needs and social contexts. The strategies included acceptance of the diagnosis, education about bipolar disorder, identifying both triggers and warning signals, adequate amounts of sleep, managing stress, medication and support networks. Conclusion: Staying well involved participants being mindful of their illness, which enabled them to develop an individual stay-well plan, including intervention strategies to prevent episodes of illness.
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The objective of this study was to determine whether the Arthritis Self-Management Programme (ASMP) improves perceptions of control, health behaviours and health status, and changes use of health care resources. The design was a pragmatic randomized controlled study; participants were allocated to ASMP (Intervention Group) or a 4-month waiting-list Control Group. The Intervention Group completed a 12-month follow-up. In total, 544 people with arthritis were recruited from the community— 311 in the Intervention Group and 233 in the Control Group. Main outcome measures included: arthritis self-efficacy, health behaviours (exercise, cognitive symptom management, diet and relaxation) and health status (pain, fatigue, anxiety, depression and positive affect). At 4 months follow-up, the ASMP had a significant effect on arthritis self-efficacy for other symptoms and pain subscales. Performance of a range of health behaviours (cognitive symptom management, communication with physicians, dietary habit, exercise and relaxation) was significantly greater among the Intervention Group. The Intervention Group were significantly less depressed and had greater positive mood. In addition, trends towards decreases on fatigue and anxiety were noted. Physical functioning, pain and GP visits remained stable at 4 months.
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This article describes a popular and effective self monitoring and response system that was developed in 1997 by 30 people who attended an eight day mental health recovery skills seminar in Vermont. They developed the system in response to their need for a structured way to use their wellness tools to relieve and eliminate their symptoms, and to stay well. While it was developed by and for people who are dealing with troubling emotional symptoms, the Wellness Recovery Action Plan can be used by anyone to deal with any kind of physical or emotional illness or issue. People who use the plan develop it by identifying tools or responses that will help them to relieve symptoms and/or enhance their wellness. They then use these tools to develop a Wellness Recovery Action Plan that includes: (1) a daily maintenance list, (2) identifying and responding to triggers, (3) identifying and responding to early warning signs, (4) recognizing when things are getting much worse and responding in ways that will help them feel better and (5) a crisis plan or advanced directive. The people who developed this plan emphasize that the plan must be developed by the person who will use it, although they can reach out to their supporters for assistance.
BACKGROUND: Although diagnostically homogeneous group therapy is a generally accepted component of the outpatient treatment of persons with bipolar disorder, investigations into the use of this modality in the inpatient setting are preliminary. OBJECTIVES: The purpose of this study was to compare the effectiveness of the Self-Management Group Model with that of the Interactional Group Model in improving the ability of patients hospitalized with bipolar disorder to care for themselves when discharged. DESIGN: This study used a quasi-experimental, nonequivalent comparison group design with repeated measures that were administered before the intervention, after the intervention, and 3 months after discharge from the hospital. Instruments elicited data on self-reported mood states, behavior and symptom identification, coping resources, and satisfaction with the group services. RESULTS: One hundred twenty-two people participated at the first measurement period. No significant total score differences were found between the two groups on any of the four measurements. However, 3 months after hospitalization, Interactional Group Model participants reported significantly less difficulty with behaviors and symptoms at the 3-month measurement period when compared with their admission scores but less satisfaction with the groups than they had at discharge. CONCLUSIONS: Results suggest that each method has advantages; the optimal model may be one that combines elements of both methods within a self-management focus.
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Aims: This review evaluates the evidence associated with the effectiveness of self-help materials designed to help individuals suffering with adult mental health (AMH) problems, and explores the methodological status of the field as well as issues associated with self-help delivery. Methods: An original second-order review perspective was used, where previous individual reviews are systematically retrieved, compared and contrasted qualitatively. Results: Self-help treatment manuals appear to be effective for several types of anxiety disorder as well as with assertiveness difficulties. There is early support for its use with depression. Less powerful and more variable evidence exists for its use with habit disorders and as a computer-delivered modality. Certain methodological limitations remain within the field including, for instance, compliance/drop-out and generalization issues. Conclusions: Self-help looks set to be an important component in AMH services. Studies do not seem to have attempted to fully evaluate the “added-value” dimensions which justify the use of self-help materials. Interventions should be offered which are based on a person's presenting difficulties, personal preferences and their individual characteristics. Several themes associated with the individual characteristics which might advantage the self-help modality are explored and some future research guidance is listed.
Article
Samenvatting Depressie is onder ouderen de meest voorkomende psychische stoornis met dikwijls een chronisch of recidiverend beloop.2 Het gaat gepaard met lichamelijke en functionele beperkingen, een verhoogde zorg-consumptie en zelfs met verhoogde sterfte.3 Het ligt dus voor de hand bij de behandeling uit te gaan van een model voor chronische aandoeningen.
Article
Over the last 20 years or so, self-help mental health care has moved from the "improve your mind" arena into the realms of treatment. However, it is argued that in mental health the self-help cultural context is varied, confusing and contradictory. On the one hand self-help is a philosophical approach where individual strength is valued and the ability to manage one's own mental health is a belief which explicitly promotes individual self-efficacy. On the other hand, self-help is a health technology solution to volume and demand, a way to circumvent the professional skill shortages in psychological treatment to ensure that evidence-based treatments are made more widely available. Opinion on the efficacy of self-help is divided. Recent US reviews suggest that "self-treatment" through bibliotherapy in depression and anxiety achieve clinical effects roughly equivalent to the average achieved in studies of psychotherapy. Self-help is a beguiling answer to many people's diagnosis of what is wrong with mental health services. Paradoxically, it is seen as both a movement to empower the victims of traditional psychiatric services and as a solution for that same resource-strapped state health service. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Self-help interventions in mental health are increasingly seen as one way of overcoming problems with access to psychological therapy, but there is insufficient evidence of effectiveness in routine care settings. This paper investigates the process and outcome of a non-guided self-help manual for anxiety and depression compared to a waiting list control in a primary care setting. Patients with mild to moderate mental health problems were recruited from routine GP referrals to the local Primary Care Mental Health Team. Thirty patients were randomly assigned to either non-guided self-help or a waiting list control group. Patients completed outcome measures at baseline, 6 weeks and 12 weeks. Intention to treat analysis found no significant differences between the two groups on measures of anxiety or depression at 12 weeks. Between 40% to 50% of patients in both groups were no longer clinical cases at the end of the trial. However, there was a high level of satisfaction with the self-help manual. Within the limitations of the small sample size, the study does not support the hypothesis that non-guided self-help is superior to waiting list control in the treatment of anxiety and/or depression in primary care.
Article
Little is known about how patients successfully manage their bipolar disorder (BD). This is a remarkable gap in the BD literature, given that current treatments are inadequate and information about beneficial self-management strategies could have clinical and theoretical implications. Here, we present results from a study of self-management strategies used by a sample of high-functioning individuals with BD. The objectively rated Multidimensional Scale of Independent Functioning (MSIF) was used to confirm high functioning status (score <3) amongst a sample of individuals self-described as functioning well with BD type I or II (N=32). Participants completed quantitative scales to assess psychiatric history, current symptoms, functioning and quality of life, and underwent either an individual interview or focus group to answer open questions about the self-management strategies they used to maintain or regain wellness. Wellness strategies fell into the following themes: 1) Sleep, rest, exercise and diet; 2) Ongoing monitoring; 3) Enacting a plan; 4) Reflective and meditative practices; 5) Understanding BD and educating others; 6) Connecting with others. The wellness strategies described by the current sample have substantial overlap with those identified in the sole comparable qualitative study. They are also broadly consistent with, and serve to elaborate on proposed mechanisms of therapeutic action in adjunctive psychosocial interventions for BD. The findings constitute hopeful stories for people affected by the disorder and suggest further research to confirm and refine mechanisms of beneficial effect in BD.
Article
This study explored the process of recovery from bipolar I disorder from a phenomenological and cognitive perspective. A semi-structured interview was coded and analysed using interpretative phenomenological analysis. Eleven individuals over the age of 30 with a history of bipolar disorder were selected on the basis of having remained free from relapse, and without hospitalization for at least 2 years, as confirmed by a diagnostic interview (Standardised Interview for DSM-IV; SCID-I). This arbitrary and equivocal criterion for 'recovery' provided an objective method of defining the sample for the study. The analysis revealed two overarching themes formed from four themes each. Ambivalent approaches referred to approaches that participants felt had both positive and negative consequences: avoidance of mania, taking medication, prior illness versus current wellness, and sense of identity following diagnosis. Helpful approaches referred to approaches that were seen as universally helpful: understanding, life-style fundamentals, social support and companionship, and social change. These themes were then interpreted in the light of the existing literature and an integrative cognitive model of bipolar disorder. Limitations and future research directions are discussed.
Article
To evaluate computer- versus therapist-delivered psychological treatment for people with comorbid depression and alcohol/cannabis use problems. Randomized controlled trial. Community-based participants in the Hunter Region of New South Wales, Australia. Ninety-seven people with comorbid major depression and alcohol/cannabis misuse. All participants received a brief intervention (BI) for depressive symptoms and substance misuse, followed by random assignment to: no further treatment (BI alone); or nine sessions of motivational interviewing and cognitive behaviour therapy (intensive MI/CBT). Participants allocated to the intensive MI/CBT condition were selected at random to receive their treatment 'live' (i.e. delivered by a psychologist) or via a computer-based program (with brief weekly input from a psychologist). Depression, alcohol/cannabis use and hazardous substance use index scores measured at baseline, and 3, 6 and 12 months post-baseline assessment. (i) Depression responded better to intensive MI/CBT compared to BI alone, with 'live' treatment demonstrating a strong short-term beneficial effect which was matched by computer-based treatment at 12-month follow-up; (ii) problematic alcohol use responded well to BI alone and even better to the intensive MI/CBT intervention; (iii) intensive MI/CBT was significantly better than BI alone in reducing cannabis use and hazardous substance use, with computer-based therapy showing the largest treatment effect. Computer-based treatment, targeting both depression and substance use simultaneously, results in at least equivalent 12-month outcomes relative to a 'live' intervention. For clinicians treating people with comorbid depression and alcohol problems, BIs addressing both issues appear to be an appropriate and efficacious treatment option. Primary care of those with comorbid depression and cannabis use problems could involve computer-based integrated interventions for depression and cannabis use, with brief regular contact with the clinician to check on progress.
Article
Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.
Article
As part of a grounded theory study of the self-management informational needs and activities of inpatients with bipolar disorder, an analysis was conducted to describe how hospitalized people with bipolar disorder manage their illness. Thirty-three people participated in semistructured, audiorecorded interviews that included questions about their self-management. Findings related to three areas: (a) factors that affect self-management, (b) patient-initiated self-management interventions, and (c) information believed by the participants to be important for other people with the disorder. Advances in the understanding of the self-management of people with bipolar disorder are pivotal to the development of strategies that may reduce, and perhaps one day prevent, relapse.
Article
This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities. The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured. Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being. An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.
Article
In this article two consumer leaders use their own experiences to explain the meaning and significance of recovery. They emphasize the importance of hope, personal responsibility, education, advocacy, and peer support. They also address controversial issues, such as the nature of the therapeutic relationship, the place of medications in symptom control, and the need for attitudinal changes in mental health professionals.
Article
The capacity to exercise control over the nature and quality of one's life is the essence of humanness. Human agency is characterized by a number of core features that operate through phenomenal and functional consciousness. These include the temporal extension of agency through intentionality and forethought, self-regulation by self-reactive influence, and self-reflectiveness about one's capabilities, quality of functioning, and the meaning and purpose of one's life pursuits. Personal agency operates within a broad network of sociostructural influences. In these agentic transactions, people are producers as well as products of social systems. Social cognitive theory distinguishes among three modes of agency: direct personal agency, proxy agency that relies on others to act on one's behest to secure desired outcomes, and collective agency exercised through socially coordinative and interdependent effort. Growing transnational embeddedness and interdependence are placing a premium on collective efficacy to exercise control over personal destinies and national life.
Article
This report examines: 1) the magnitude of co-occurrence of threshold and subthreshold-level depression and anxiety in the community, and 2) the relationship between comorbidity and the diagnostic level of depression and anxiety and their clinical correlates. A community sample of 591 subjects was interviewed prospectively five times across 15 years from the ages of 20-35. The diagnostic interview allowed the assignment of diagnoses according to DSM-III criteria and operational definitions of subthreshold syndromes. 1) Comorbidity between depression and anxiety was more frequent when one syndrome reached threshold level; 2) comorbidity at both the threshold and subthreshold diagnostic levels was associated with symptom severity, disability and treatment, whereas the diagnostic level was associated with disability and suicidal attempts. The systematic association between comorbidity across diagnostic threshold levels of anxiety and depression with clinical correlates suggests the importance of a more dimensional approach to their classification.
Article
Several studies have established the efficacy of psychosocial interventions as adjuncts to pharmacotherapy in the symptom maintenance of bipolar disorder. This study concerned a new psychosocial approach - integrated family and individual therapy (IFIT) - that synthesizes family psychoeducational sessions with individual sessions of interpersonal and social rhythm therapy. Shortly after an acute illness episode, 30 bipolar patients (DSM-IV criteria) were assigned to open treatment with IFIT (up to 50 weekly sessions of family and individual therapy) and mood-stabilizing medications in the context of a treatment development study. Their outcomes over 1 year were compared with the outcomes of 70 patients from a previous trial who received standard community care, consisting of 2 family educational sessions, mood-stabilizing medications, and crisis management (CM). Patients in both samples were evaluated as to symptomatic functioning at entry into the project and then every 3 months for 1 year. Patients in IFIT had longer survival intervals (time without relapsing) than patients in CM. They also showed greater reductions in depressive symptoms over 1 year of treatment relative to their baseline levels. The results could not be explained by group differences in baseline symptoms or pharmacologic treatment regimens. Combining family and individual therapy with medication may protect episodic bipolar patients from early relapse and ongoing depressive symptoms. Further examination of this integrative model within randomized controlled trials is warranted.
Article
In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory. This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes. The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests. At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p <.05). At 1 year, the improvements were maintained and remained significantly different from baseline condition. This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.
Article
The research aimed to investigate how people diagnosed with bipolar mood disorder avoided episodes of illness and managed to stay well. The research also examined the role that personal, social and environmental factors played in helping people with bipolar mood disorder to stay well. This project used a combination of qualitative research methods. The design contained three (3) components: recruitment from general community, preliminary written questionnaire and semistructured interviews. To meet the criteria for inclusion, the participant must have stayed well for the past 2 years. The two main analytical categories were 'stay well concept' and 'strategies to stay well'. The main category 'strategies to stay well' contained a number of subcategories. These subcategories were acceptance of diagnosis, mindfulness, education, identify triggers, recognize warning signals, manage sleep and stress, make lifestyle changes, treatment, access support, and stay well plans. 100 people were eligible for inclusion in the study. The sample included 63 women and 37 men. The ages ranged from 18 to 83 years, with 86% over the age of 30. Duration of time since last episode of illness ranged from 2 years to >50 years. In the sample, 76% of participants were in paid employment. In addition, 36% of participants were parents. Participants actively managed bipolar disorder by developing a range of strategies to stay well. These strategies were based on participants' individual needs and social contexts. The strategies included acceptance of the diagnosis, education about bipolar disorder, identifying both triggers and warning signals, adequate amounts of sleep, managing stress, medication and support networks. Staying well involved participants being mindful of their illness, which enabled them to develop an individual stay-well plan, including intervention strategies to prevent episodes of illness.
Article
Few studies have examined the prognostic value of family factors in the course of bipolar affective disorder. The current study examined a self-report measure of expressed emotion as a predictor of the 1-year course of the illness. Patients with bipolar disorder (N=360) filled out the four-item Perceived Criticism Scale concerning one or more relatives or close friends. Independent evaluators followed patients over 1 year and rated them on measures of depressive and manic symptoms and the percentage of days in recovery status. Patients' ratings of the severity of criticisms from relatives did not predict patients' mood disorder symptoms at follow-up. However, patients who were more distressed by their relatives' criticisms had more severe depressive and manic symptoms and proportionately fewer days well during the study year than patients who were less distressed by criticisms. Patients who reported that their relatives became more upset by the patients' criticisms had less severe depressive symptoms at follow-up. Results indicate that a brief rating of subjective distress in response to familial criticism is a useful prognostic device and may aid in planning psychosocial interventions for patients with bipolar disorder.
Article
Bipolar disorder (BPD), or manic-depressive psychosis, is a common and severe mental illness, with a lifetime prevalence of 1-2%. BPD is characterised by two types of recurrence, mania and depression. High rates of recurrence and associated adverse consequences occur in spite of a range of effective treatments. Early warning signs (EWS) interventions, targeted at improving the recognition and self-management of manic and depressive symptoms, are intended to train people with recurrent bipolar affective disorder to recognise early warning signs of recurrence and to avert adverse outcomes. This review demonstrated that these interventions, in addition to treatment as usual (TAU), including medication and regular appointments with health professionals, have benefits on time to recurrence and hospitalisation. Compared with TAU only, EWS interventions also resulted in improved functioning at eighteen months, although these data were sparse and the findings should be interpreted with caution. EWS interventions did not appear to have any effect on depressive or manic symptoms, although again, these findings were based on small numbers of potentially selected patients in remission. It should be noted that EWS was used along with other psychological interventions, and it is not entirely clear what proportion of the beneficial effect was due to the EWS intervention alone.
Article
Education and self-management training assist patients with bipolar disorder to take control of their condition and to reduce disability, but the timeliness and availability of the education are important. A free Web-based bipolar education program has been recently developed to provide accessible evidence-based information for patients, carers and health professionals. The present paper describes the nine-module program, reports usage data and user profiles, and overviews the aims and methodology of a randomized controlled trial to measure its impact. Customized Web reports were developed to measure usage of the Web-based program, and to profile its users on a month-by-month basis. Data on the percentage of completers of each module were also collected. A randomized controlled trial evaluating the program in people with newly diagnosed bipolar disorder was also commenced. More than 8,000 visitors used the online program in its first 6 months. Users were predominantly female, of a broad cross-section of ages, 43.5% with bipolar disorder, and with the remainder describing themselves as health professionals, carers/family/friends of a person with bipolar disorder or members of the general public. The majority (76%) completed the sessions they commenced. The Web-based education program is attracting a steady stream of users and is exhibiting good completion rates. This preliminary support for the program's utility requires validation from our randomized controlled trial before definite conclusions can be drawn.
Article
Self-therapy interventions could potentially reduce healthcare expenses and the need for care in the treatment of depression and anxiety disorders. This study assessed the cost-effectiveness of cognitive self-therapy (CST) in patients with these disorders. A total of 151 patients were randomly assigned to CST or treatment as usual (TAU), and followed during 18 months. The Symptom Checklist 90 (SCL-90) was the primary outcome measure of the study. The reference year was 2003 (US$1.00 = euro 0.92). Mean costs of patients in the CST group (US$4364) were lower than that of the patients who received TAU (US$5241). The results of the SCL-90 were slightly in favour of CST. Valuing an additional unit of health outcome at US$108 will lead to an 83% probability that CST is cost-effective. Cognitive self-therapy appears to be cost-effective. Wider implementation of CST may relieve the burden of many patients with emotional disorders whose treatment needs cannot be met in current healthcare systems.
Article
Although there are some randomized controlled trials that highlight the positive role of family-focused treatment added to pharmacotherapy in bipolar disorder, no trials using contemporary methodologies have analyzed the specific effect of working with caregiver-only groups. The aim of this study was to assess the efficacy of a psychoeducational group intervention focused on caregivers of euthymic bipolar patients. A total of 113 medicated euthymic bipolar outpatients who lived with their caregivers were randomized into an experimental and a control group. Caregivers in the experimental group received twelve 90-min group psychoeducation sessions focused on knowledge of bipolar disorder and training in coping skills. The patients did not attend the groups. Caregivers assigned to the control group did not receive any specific intervention. Patients were assessed monthly during both the intervention and the 12 months of follow-up. The primary outcome was time to any mood recurrence. Psychoeducation group intervention focused on the caregivers of bipolar patients carried a reduction of the percentage of patients with any mood recurrence (chi2 = 6.53; p = 0.011) and longer relapse-free intervals (log-rank chi(2) = 4.04; p = 0.044). When different types of episodes were analyzed separately, the effect was significant for both the number of patients who experienced a hypomanic/manic recurrence (chi2 = 5.65; p = 0.017) and the time to such an episode (log-rank chi2 = 5.84; p = 0.015). The differences in preventing depressive and mixed episodes were not significant. A psychoeducation group intervention for the caregivers of bipolar patients is a useful adjunct to usual treatment for the patients in reducing the risk of recurrences, particularly mania and hypomania, in bipolar disorder.
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