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Role of treatment alliance in the clinical management of bipolar disorder: Stronger alliances prospectively predict fewer manic symptoms
Abstract
The strength of the treatment alliance between patients and their clinicians may play a unique role in the management of bipolar disorder. However, few empirical studies have examined the alliance in bipolar disorder or its effects on patient outcomes. This study investigates variables associated with a strong treatment alliance in bipolar disorder, and the prospective effects of treatment alliance on patients' mood symptoms and treatment attitudes. Participants were 58 longitudinally followed individuals with Bipolar I disorder. We found that alliance ratings covaried with depressive symptoms, such that alliance strength increased as depressive symptoms decreased, and stronger alliances were associated with more social support. Tests of temporal association indicated that stronger alliances predicted fewer manic symptoms 6 months later. Stronger alliances also predicted less negative attitudes about medication and less of a sense of stigma about bipolar disorder. Thus, a strong treatment alliance may help to reduce manic symptoms over time. It may be that a strong treatment alliance encourages patients' greater acceptance of bipolar disorder and psychopharmacological interventions, and thus contributes to improved medication adherence and clinical outcomes. Considered in sum, these findings suggest that the treatment alliance is an integral component of the long-term management of bipolar disorder.
... These have shown that, particularly from the patient's perspective, collaborative aspects (task, goal, bond), trust in clinicians, cooperation, therapist support, and treatment satisfaction are the core components of the treatment alliance [17][18][19][20]. Additionally, existing studies of BD also indicate that apart from patients' views on collaboration with clinicians, their perceptions of trusting and supportive clinician-patient relationships, and their satisfaction with treatment is also associated with the strength and quality of alliances [21][22][23][24][25]. Thus, based on the existing evidence regarding treatment alliance, it was hypothesized that a broader construct of the alliance was more likely to exist among such patients. ...
... Therefore, stronger bonds with clinicians are likely to enhance their agreement on goals and tasks of treatment. Nevertheless, the importance of collaboration as a part of the treatment alliance in BD is supported by several studies that have shown that patients assign a key role to the quality of interactions with their clinicians while rating alliance [23,25,[44][45][46]. The presence of a "support" component as a part of factor-1 was also in keeping with the existing literature on the composition of alliances. ...
... Accordingly, the contribution of perceived trust to alliance formation found in this study has been noted by other factor-analytic studies with the WAI and other scales [17,31,32,52]. Studies of patients with BD have also shown that the trusted physician is regarded by them as a positive asset [22,23,44,53]. The treatment satisfaction component of factor-2 consisted of patients' satisfaction with the outcome of treatment, their confidence in the clinicians' abilities, and their access to the clinicians. ...
Background:
Treatment alliance has an impact on several key patient outcomes in all psychiatric disorders, including bipolar disorder (BD). It has been suggested that the construct of treatment alliance is different among patients from routine psychiatric settings compared to psychotherapeutic settings. However, research on the composition of treatment alliance in psychiatric disorders, such as BD, is relatively limited.
Aim:
To determine whether a broader construct of treatment alliance was prevalent among outpatients with BD.
Methods:
This is a cross-sectional study, conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (September 2018 to September 2019). A consecutive sample of 160 remitted adult outpatients with BD on mood stabilizers for at least a year were selected. The principal instrument to assess treatment alliance was the Working Alliance Inventory-client version (WAI-Client). Other potential constituents of the alliance explored were perceived trust in clinicians assessed by the Trust in Physicians (TRIP) scale, perceived support from clinicians assessed by the Psychosocial Care by Physicians (PCP) scale, and perceived treatment satisfaction assessed by the Patient Satisfaction Questionnaire (PSQ). Associations between scores on all scales were determined by correlational and multiple regression analyses. Exploratory factor analysis of combined items of all scales was conducted using a principal components analysis.
Results:
Scores on all the three WAI-Client subscales were significantly correlated with each other (r = 0.66-0.81; P < 0.0001). The total TRIP scores were associated with the total WAI-Client scores (r = 0.28; P < 0.01). The total TRIP scores and the total PCP scores were also significantly associated with the WAI-Client scores on the Task subscale (r = 0.28-0.29; P < 0.01). The total TRIP scores were significantly associated with the total PSQ scores (r = 0.45; P < 0.0001). Factor analysis yielded two independent and coherent factors, which explained 69% of the variance in data. Factor-1 ("alliance and support"), which explained about 41% of the variance, was comprised of a combined WAI-Client goal-task-bond component as well as the PCP support items. Factor-2 ("trust and satisfaction"), which explained about 28% of the variance, consisted of all the TRIP trust and the PSQ treatment satisfaction items.
Conclusion:
A broader construct of treatment alliance in BD was found. Apart from collaborative components, this construct included patients' perceptions regarding trust in clinicians, support from clinicians, and treatment satisfaction.
... Seven original studies that met the inclusion criteria were selected (Gaudiano and Miller, 2006;Lee et al., 2011;Novick et al., 2015;O'Connor et al., 2008;Sajatovic et al., 2006;Strauss and Johnson, 2006;Sylvia et al., 2013). Fig. 1 shows the selection process of these articles. ...
... Finally, semi-structured interviews were performed in the qualitative research of O'Connor et al. (2008) to obtain information about this construct. Regarding the number of times that the WA was assessed, in four studies this variable was measured only once while in one article it was measured at different times of the intervention (Strauss and Johnson, 2006). Lastly, in another study, the WA was examined at the beginning of the research and one year after the start of the study (Novick et al., 2015). ...
... Five studies included measures that were administered by different kinds of interviewers (e.g., clinicians, research assistants). This is the case in the studies of Novick et al. (2015), O'Connor et al. (2008), Sajatovic et al. (2006), Strauss and Johnson (2006), and Sylvia et al. (2013). In another study, two measures that were administered by the interviewers were combined with the number of months that the patients remained in treatment (Gaudiano and Miller, 2006). ...
Background:
The working alliance plays an essential role in the treatment of patients with different diseases. However, this variable has received little attention in patients with bipolar disorder. Therefore, this systematic review aimed to examine the working alliance's influence on these patients' treatment outcomes, analyze its role in the adherence to pharmacotherapy, and identify the variables that are related to a good working alliance.
Methods:
PubMed, PsycINFO, and Web of Science databases were searched until January 5, 2018 using a predetermined search strategy. Then, a formal process of study selection and data extraction was conducted.
Results:
Seven articles fulfilled the inclusion criteria and they included a total of 3,985 patients with bipolar disorder type I and II. Although the working alliance's ability to predict the duration and presence of manic and depressive symptoms is unclear, a good working alliance facilitates the adherence to pharmacological treatment. In addition, good social support for patients is associated with a strong working alliance.
Limitations:
The selected studies used different definitions and measures of the working alliance and adherence, and most used self-reports to assess the working alliance. Furthermore, the relationships found among the variables were correlational.
Conclusions:
The working alliance can play an important role in adjunctive psychological therapies and in pharmacological and somatic treatments for patients with bipolar disorder. However, the number of studies on working alliance in bipolar disorder is rather limited and there is methodological heterogeneity between the studies.
... Both emotional and practical support are also essential components of a healthy alliance in BD. Strauss and Johnson [124] found that productive treatment alliances were associated with greater levels of social support among patients with BD. Similarly, the importance of a supportive relationship with the clinician in alliance building has formed a major theme in several qualitative studies of BD [83,98,125] . ...
... The positive association between treatment alliance and adherence in BD could be attributed to a number of intervening variables or mechanisms. An effective alliance results in less negative attitudes, a greater acceptance of illness, and the ability to tolerate medication side effects eventually leading to improved adherence [44,60,61,123,124] . Other potential mediators, which have demonstrated a positive association with treatment alliance in BD include reduction of symptom severity [66,72,77,124,128] , enhancement of insight [77] , and improvement in patient functioning or quality of life [72,77,129] . ...
... An effective alliance results in less negative attitudes, a greater acceptance of illness, and the ability to tolerate medication side effects eventually leading to improved adherence [44,60,61,123,124] . Other potential mediators, which have demonstrated a positive association with treatment alliance in BD include reduction of symptom severity [66,72,77,124,128] , enhancement of insight [77] , and improvement in patient functioning or quality of life [72,77,129] . Certain psychosocial processes could also mediate the association between alliance and adherence. ...
... Participant demographic characteristics and effect sizes (eight different studies with 59 distinct samples) are reported in Table 1 and Figure 1. Four studies (five reports) involved treatment of affective disorders (depression or bipolar disorder) (15)(16)(17)(18)(19), two involved treatment of schizophrenia (20,21), and two involved a mixed clinical population (22,23). Therapeutic alliance measures across studies included domains such as collaboration, shared goals, bonding with the therapist, (15)(16)(17)(18)(19), three involved inpatient treatment (21)(22)(23), and one had a mixed inpatient-outpatient sample (20). ...
... Four studies (five reports) involved treatment of affective disorders (depression or bipolar disorder) (15)(16)(17)(18)(19), two involved treatment of schizophrenia (20,21), and two involved a mixed clinical population (22,23). Therapeutic alliance measures across studies included domains such as collaboration, shared goals, bonding with the therapist, (15)(16)(17)(18)(19), three involved inpatient treatment (21)(22)(23), and one had a mixed inpatient-outpatient sample (20). In seven studies, the therapeutic relationship was measured either early in treatment or both early and midtreatment, allowing for a prospective relationship to outcome (15,(18)(19)(20)(21)(22)(23). ...
... Therapeutic alliance measures across studies included domains such as collaboration, shared goals, bonding with the therapist, (15)(16)(17)(18)(19), three involved inpatient treatment (21)(22)(23), and one had a mixed inpatient-outpatient sample (20). In seven studies, the therapeutic relationship was measured either early in treatment or both early and midtreatment, allowing for a prospective relationship to outcome (15,(18)(19)(20)(21)(22)(23). Some researchers measured the alliance three times: in early, middle, and late treatment (16,17; the data utilized in these articles are from the same study and therefore count in the analyses as only one study). ...
Objective:
Patient nonadherence to psychopharmacological treatment is a significant barrier to effective treatment. The therapeutic relationship is known to be a critical component of effective psychological treatment, but it has received limited study. A meta-analysis was conducted to examine the role of the therapeutic relationship in the delivery of effective psychopharmacological treatment.
Methods:
PubMed, PsycINFO, CINAHL, Google Scholar, Ingenta, and the Web of Science-Science Citation Index were searched, including reference lists of found articles. Meta-analytic methods were used to examine the association between the physician-patient therapeutic relationship and outcomes in psychopharmacological treatment.
Results:
Eight independent studies of psychopharmacological treatment reported in nine articles met the inclusion criterion (1,065 participants) of being an empirically based study in which measures of the therapeutic relationship were administered and psychiatric treatment outcomes were assessed. The overall average weighted effect size for the association between the therapeutic relationship and treatment outcomes was z=.30 (95% confidence interval=.20-.39), demonstrating a statistically significant, moderate effect.
Conclusions:
Findings indicate that a positive therapeutic relationship or alliance between the physician and the psychiatric patient is associated with patient improvement over the course of psychopharmacological treatment. Results suggest that more attention should be paid to psychiatrist communication skills that may enhance the therapeutic alliance in psychopharmacological treatment.
... Attitudes towards medications among patients might be relatively independent of their demographic and clinical characteristics [50,51,108,109] , or they might differ according to age and illness-related factors such as the severity of the illness and its course, comorbid substance use and side effects of medications [85,100,[110][111][112][113] . Additionally, patients' attitudes are more likely to be influenced by their knowledge of the illness, attitudes among their family members and ethno-cultural groups, the clinicianpatient relationship and the overall quality of life among patients [35,60,84,101,103,114] . However, regardless of the place [11,27,41,61] . ...
... In keeping with the research-evidence on treatment-alliance in psychotherapy and other psychiatric disorders such as schizophrenia [115][116][117] , an effective alliance appears to have a significant influence on treatment-adherence in BD as well. Though research on the influence of treatmentalliance on adherence is relatively scarce, the more or less unequivocal finding from several studies is that a strong therapeutic alliance is associated with improved adherence among patients with BD [18,58,91,114,[118][119][120] . A strong alliance appears to enhance treatment-adherence in BD in several ways such as fostering more positive attitudes to treatment and enhancing the acceptance of treatment among patients [1,2,13,14,26,78] . ...
... This bi-directional communication also forms the vehicle for imparting information about the illness and its treatment since patients frequently express the need for such information [75,106,122] . Moreover, information can be used to effectively dispel incorrect beliefs about medications, reduce feelings of stigma and foster positive attitudes to treatment among patients [50,114] . The other necessary component of an effective treatmentalliance is a genuinely collaborative relationship between the patients and clinicians. ...
About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.
... Five studies used the Brief Psychiatric Rating Scale (Calsyn, Morse, Klinkenberg, & Lemming, 2004;Goering & Wasylenki, 1997;Klinkenberg et al., 1998Klinkenberg et al., , 2002Neale & Rosenheck, 1995;Solomon et al., 1995). Other studies used the Positive and Negative Syndrome Scale ( Catty et al., 2008;Dunn et al., 2006); the Psychiatric Status Schedule (Frank & Gunderson, 1990); the Inpatient Multidimensional Psychiatric Scale (Frank & Gunderson, 1990); the Modified Hamilton Rating Scale for Depression (Strauss & Johnson, 2006); and the Bech-Rafaelson Mania Rating Scale (Strauss & Johnson, 2006). Two studies used unvalidated measures, of which one gauged reduction in mental illness symptoms (Chinman, Rosenheck, & Lam, 2000), and the other examined the percentage of time a client was depressed or manic during a follow-up period (Gaudiano & Miller, 2006). ...
... Five studies used the Brief Psychiatric Rating Scale (Calsyn, Morse, Klinkenberg, & Lemming, 2004;Goering & Wasylenki, 1997;Klinkenberg et al., 1998Klinkenberg et al., , 2002Neale & Rosenheck, 1995;Solomon et al., 1995). Other studies used the Positive and Negative Syndrome Scale ( Catty et al., 2008;Dunn et al., 2006); the Psychiatric Status Schedule (Frank & Gunderson, 1990); the Inpatient Multidimensional Psychiatric Scale (Frank & Gunderson, 1990); the Modified Hamilton Rating Scale for Depression (Strauss & Johnson, 2006); and the Bech-Rafaelson Mania Rating Scale (Strauss & Johnson, 2006). Two studies used unvalidated measures, of which one gauged reduction in mental illness symptoms (Chinman, Rosenheck, & Lam, 2000), and the other examined the percentage of time a client was depressed or manic during a follow-up period (Gaudiano & Miller, 2006). ...
... Rater type. Among the 13 studies that measured psychiatric status as an outcome variable, 11 measured the client perspective on the client-provider relationship ( Calsyn et al., 2004;Catty et al., 2008;Chinman et al., 2000;Dunn et al., 2006; Gaudiano & Miller, 2006;Goering & Wasylenki, 1997;Klinkenberg et al., 1998;Neale & Rosenheck, 1995;Solomon et al., 1995;Strauss & Johnson, 2006;Zeber, Copeland, Good, Fine, Bauer, & Kilbourne, 2008), and eight measured the provider perspective (Calsyn et al., 2004;Catty et al., 2010;Dunn et al., 2006;Frank & Gunderson, 1990;Gaudiano & Miller, 2006;Klinkenberg et al., 2002;Neale & Rosenheck, 1995;Solomon et al., 1995). No reviewed studies use ratings from an observer. ...
This systematic review reports on the association of the client-provider relationship with service outcomes across 3 service sectors: substance abuse, child welfare, and mental health. The review includes 60 research reports meeting inclusion criteria: 25 in substance abuse, 7 in child welfare, and 28 in mental health. For each social service sector, we analyze the association of the client-provider relationship to intermediate and ultimate outcomes. In addition, we examine potential moderating mechanisms of rater type (i.e., client, provider, and observer) and treatment setting (i.e., inpatient, outpatient, other). Social services research increasingly seeks to identify the active elements that affect outcomes common to all interventions. Results suggest the client-provider relationship is a consistent predictor of client retention in treatment and a somewhat less-consistent predictor of ultimate outcome across the 3 service sectors. These results contrast with recent findings from the psychotherapeutic literature in which the client-provider relationship demonstrated a weaker association with treatment retention (measured as drop out) than with other outcome measures. Findings indicate a clear need to refine the conceptualization and measurement of key service mechanisms and outcomes, particularly in the area of child welfare given that services research is less developed in that sector. The discussion includes recommendations for future research, including the use of selection criteria to enable researchers to conduct formal meta-analyses and expand the moderational framework with additional moderator variables relevant to social service delivery.
... In particular, we examined 3 patient and caregiver distress variables (depression, anxiety, and quality of life) and 3 variables representing potential treatment targets (stigma, therapeutic alliance, and knowledge of bipolar disorder). On the basis of previous findings, we hypothesized that stigma (Perlick et al., 2001b;Gonzalez et al., 2007), poor therapeutic alliance (Zeber et al., 2008;Strauss and Johnson, 2006), and lack of knowledge about bipolar disorder (Michalak et al., 2004;Rouget and Aubrey, 2006) would be worthwhile targets of treatment in this population for both patients and caregivers, and as such would be related to the degree of distress reported by both at initial assessment. We further hypothesized that distress in patients and caregivers would be positively correlated, reflective of the increased burden of more severe patient illness on caregivers (Reinares and Vieta, 2004;Perlick et al., 2007), and that both would be predictive of treatment adherence. ...
... In a study of patients with serious psychiatric disorders, Tyrrell et al. (1999) found that better therapeutic alliance was associated with more general life satisfaction. In a naturalistic, longitudinal study of bipolar patients, Strauss and Johnson (2006) found that depression and therapeutic alliance covaried over time, with worse alliance associated with greater severity of depression. As patients and caregivers begin family-involved treatment, it will be instructive in the future to examine the caregivers' alliance with the practitioner and its effect on patient and caregiver symptoms and treatment outcome. ...
... In contrast to cross-sectional studies, longitudinal studies provide insight on temporal relationships, including recurrence of mood episodes, symptoms severity, impairment, and levels of social support. In the extant literature, findings are mixed: social support does not influence episode relapse (Staner et al., 1997), social support influences manic or depressive episode relapse (O'Connell et al., 1985;Stefos et al., 1996;Kulhara et al., 1999, Johnson et al., 2003, social support only influences depressive episode relapse (Johnson et al., 1999(Johnson et al., , 2000Cohen et al., 2004;Weinstock and Miller, 2010), and social support influences manic episode relapse (Strauss and Johnson, 2006). Two studies identified by our approach examined social support and lithium outcome, and found that strong social support significantly predicted good lithium outcome (O'Connell et al., 1985;Kulhara et al., 1999). ...
... Two studies identified by our approach examined social support and lithium outcome, and found that strong social support significantly predicted good lithium outcome (O'Connell et al., 1985;Kulhara et al., 1999). The sole study that measured treatment alliance as a form of social support found that a strong treatment alliance is related to strong social support and that treatment alliance is negatively correlated with depressive symptoms (Strauss and Johnson, 2006). These studies may have been limited not only by a small sample size, but a small period of follow-up time (seven out of 10 longitudinal studies had a follow-up period of 1 year or less) which may be too short of a time to measure episode recurrence, especially manic episode recurrence. ...
... Successful outcomes were evidenced by reported increased patient happiness with treatment, adherence to medication and keeping set appointments [22,26]. Another study on therapeutic alliance between psychiatrists and patients with bipolar disorder resulted in fewer negative beliefs towards medication, diminished stigma towards bipolar disorder, and fewer manic symptoms [27]. These improved treatment outcomes are also connected to therapeutic alliance with psychotherapists. ...
This chapter contains an overview of the therapeutic alliance including the purpose and importance of therapeutic alliance as well as recent research that provides knowledge on therapeutic alliance within the group therapy context. This chapter will also take a deep dive into understanding the rupture-repair model, its’ connections with therapeutic alliance, and provide clinical examples of what a rupture and repair may look like in group therapy. Finally, this chapter discusses cultural considerations and includes clinical examples on rupture and repairs where individual and cultural differences are important. In conclusion, therapeutic alliance has been identified as a key contributor to positive outcomes for group therapy clients. While ruptures are expected to occur during therapy, It is important to note that both the rupture and the repair equally effect the therapeutic alliance as well as the outcome of treatment. Outcomes to therapy that align with a strong therapeutic alliance include reduced symptoms, client retention, improved outlook on life, and an improved occupational and interpersonal functioning. Outcomes of therapy associated with a successful repair involve a decrease in anxiety and depressive symptoms, increase in daily living activities, an increase in empathy for their group members, and stronger therapeutic alliance among the group.
... 39 By ensuring that patient perspectives are adequately considered, 40 and enhancing the therapeutic alliance, treatment adherence and outcomes in BP-I may be improved. 41,42 Available data on the perception of people diagnosed with BP-I of the importance of avoiding AEs of medication compared with the aforementioned goals are contradictory, with some studies showing that avoidance of AEs is considered more important than symptom-or functioning-related goals, and other studies suggesting the opposite. 33,43,44 AEs previously reported to have the greatest influence on treatment choice among people diagnosed with bipolar disorder include weight gain, sleeping difficulties, suicidal thoughts, and sedation. ...
Purpose
Bipolar I disorder (BP-I) is associated with significant disease burden, but evidence on treatment goals in people diagnosed with BP-I is scarce. This study sought to quantify treatment goals related to the pharmacological management of BP-I in adults in the US and to identify if subgroups of people with similar treatment goals exist.
Patients and Methods
A best–worst scaling (BWS) of treatment goals was developed based on available literature and input from experts and patients and was distributed as part of a survey between August and September 2021. Survey participants were adults with a self-reported diagnosis of BP-I who were recruited via an online panel in the US. Participants were asked to prioritize the importance of 16 treatment goals using BWS. BWS scores were computed using multinomial logistic regression, with the scores across all goals summing to 100 for each participant. Subgroups of people with similar preferences were identified using latent class analysis.
Results
The most important treatment goals for people diagnosed with BP-I (N=255) were “being less impulsive, angry, or irritable” (score: 9.73), or being “able to feel pleasure or happiness” (score: 9.54). Goals related to reducing the incidence of various potential adverse events of medication (scores: ≤4.51) or “reducing dependence on others” (score: 3.04) were less important. Two subgroups were identified. One subgroup (n=111) prioritized symptom-focused goals, considering “reducing frequency of mania, depression, and mixed episodes” and “being less impulsive, angry or irritable” the most important (scores: 12.46 and 11.85, respectively). The other subgroup (n=144) placed significantly more importance on social functioning-focused goals, including beginning or maintaining a relationship with a partner/significant other, and with family and/or friends (scores: 8.45 and 7.70, respectively).
Conclusion
People diagnosed with BP-I prioritized emotional improvements. Subgroups of people with BP-I prioritized either symptom-focused or social functioning-focused treatment goals.
... It also negatively affects treatment-seeking behavior (Eisenberg et al., 2009) and treatment adherence (Livingston and Boyd, 2010). Finally, although a good therapeutic alliance is correlated with less severe symptoms (Strauss and Johnson, 2006), it is insufficient to improve the experience of selfstigma (Kondrat and Early, 2011). Different reviews on stigma and BD have already been conducted. ...
Background:
Bipolar disorder is a severe and chronic mental illness characterized by recurrent major depressive episodes and mania or hypomania. In addition to the burden of the disease and its consequences, self-stigma can impact people with bipolar disorder. This review investigates the current state of research in self-stigma in bipolar disorder.
Methods:
An electronic search was carried out until February 2022. Three academic databases were systematically searched, and best-evidence synthesis was made.
Results:
Sixty-six articles were related to self-stigma in bipolar disorder. Seven key themes were extracted from these studies: 1/ Comparison of self-stigma in bipolar disorder and other mental illnesses, 2/ Sociocultural context and self-stigma, 3/ Correlates and predictors of self-stigma, 4/ Consequences of self-stigma, 5/ Treatments and self-stigma, 6/ Management of self-stigma, and 7/ Self-stigma and recovery in bipolar disorder.
Limitations:
Firstly, a meta-analysis could not be performed due to the heterogeneity of the studies. Secondly, limiting the search to self-stigma has excluded other forms of stigma that also have an impact. Thirdly, the under-reporting of negative or nonsignificant results due to publication bias and unpublished studies might have limited the accuracy of this reviews' synthesis.
Conclusion:
Research on self-stigma in persons with bipolar disorder has been the focused on different aspects, and interventions to reduce self-stigmatization have been developed, but evidence of their effectiveness is still sparse. Clinicians need to be attentive to self-stigma, its assessment, and its empowerment in their daily clinical practice. Future work is required to establish valid strategies to fight self-stigma.
... Even though we did not find systematic reviews about the relationship between SS and BD patients in euthymia, two reviews about Notwithstanding, some studies evaluated non-euthymic patients to investigate if SS would help to attenuate mania and depressive episodes or reach remission in BD patients. In this sense, they have shown that the presence of SS was crucial for achieving symptomatic remission after depressive and/or manic episodes, as well as reducing an individual's ability to socialize and seek help, which could contribute to a more severe course of the disorder (Cohen et al., 2004;Johnson et al., 2003;Strauss & Johnson, 2006 ...
Introduction:
In spite of the recent increase in scientific publications showing an expressive interest in studies about social support, there are still scarce publications regarding this thematic and bipolar disorder, mostly when evaluating the individuals in the state of euthymia. Euthymia referred a state that a bipolar patient does not have signs/symptoms of (hipo)mania or depression, thus, assessing individuals in this state may reduce response bias.
Objective:
Identify the impact of social support on bipolar disorder in patients in the euthymic phase.
Methods:
A systematic search of observational studies on PubMed/Medline, PsycINFO, EMBASE, Scopus, and Web of Science databases, was performed from February 2021 to August 2022.
Results:
In total, seven studies fulfilled the eligibility criteria. According to three studies, bipolar disorder patients had lower social support than healthy controls. Contrastingly, one study showed bipolar patients did not have different social support compared to healthy controls.
Conclusions:
Even though few papers with low or middle risk of bias were included in this review, we found that not only does social support could act as a protective factor for bipolar patients, but also that clinical manifestations of the disorder seem to affect social support. This systematic review suggests the narrowed evidence field with different measures and type of evaluation from studies on social support and bipolar disorder, which highlights the need for further investigations on this theme.
... All rights reserved non-adherence significantly reduces treatment effectiveness 8,21 . Moreover, experiences of childhood trauma may impede individuals' likelihood of establishing an adaptive therapeutic alliance 8,22,23 ; a strong and positive therapeutic alliance greatly facilitates adherence to pharmacological treatments [24][25][26] . ...
Background:
Childhood trauma affects the course of mood disorders. Researchers are now considering childhood trauma as an influential factor in the treatment of mood disorders. However, the role of childhood trauma in the treatment of bipolar disorder remains understudied.
Methods:
The effect of childhood trauma on treatment outcomes was evaluated among participants randomised to treatment with lithium or quetiapine in the Clinical and Health Outcomes Initiatives in Comparative Effectiveness for Bipolar Disorder (Bipolar CHOICE) study by clinician assessment. Mixed effects linear regression models were used to analyse rates of improvement in symptom severity (assessed with the Bipolar Inventory of Symptoms Scale and the Clinical Global Impression Scale for Bipolar Disorder) and functional impairment (assessed with the Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool).
Results:
A history of any childhood trauma was reported by 52.7% of the sample (N = 476). Although participants with a history of any childhood trauma presented with greater symptom severity and functional impairment at most study visits, participants with and without a history of any childhood trauma showed similar rates of improvement in symptom severity and functional impairment over the 24 weeks of treatment.
Conclusion:
This is the first study to explore the association between childhood trauma and treatment outcomes during treatment with lithium or quetiapine in the context of a randomised trial. In Bipolar CHOICE, a history of childhood trauma did not inhibit improvement in symptom severity or functional impairment. Nevertheless, these findings need replication across different settings.
... Bu açık ve aktif duruşu ilerletmek için klinisyenler yalnızca daha etkili bir şekilde dinlemekle kalmamalı, aynı zamanda hastalarla etkili bağlantılar kurmak için bu iletişime değer vermeyi öğrenmelidir 26,40,41 . Ayrıca, bu iletişim, ilaçlarla ilgili yanlış inançları etkili bir şekilde ortadan kaldırmak, damgalanma duygularını azaltmak ve hastalar arasında tedaviye karşı olumlu tutumları teşvik etmek için kullanılabilir 42 . Etkili bir tedavi ittifakının diğer gerekli bileşeni, hastalar ve klinisyenler arasında gerçekten işbirliğine dayalı bir ilişkidir. ...
Despite the current treatment options, there is no significant increase in the treatment compliance of patients with bipolar disorder. In those with chronic disease, adherence to treatment is an important factor affecting recovery. Non-adherence to treatment is generally explained by "lack of insight" in psychiatric disorders. Adherence to treatment also affects the way the patient's family and himself perceive the disease. Medication compliance is adversely affected by patients with insufficient social support, lack of knowledge about the disorder, dysfunctional attitudes in their families, and fear of stigma. Three main items related to non-compliance with drug therapy were identified in the studies. Patient-related factors; age, gender, marital status, substance use, psychotic disorder, personality disorder, earnings related to patient role, factors related to illness; insufficient insight, insufficient information on long-term drug use, the disease becoming chronic, lack of information about the disease, stigma, disease acceptance/rejection, drug-related factors; improvement or no signs of improvement, side effects, and concerns about drug addiction. Among these substances, the most known are drug-related side effects. In individuals with bipolar disorder, drug non-compliance decreases the quality of life and increases the rate of hospitalization. It also causes high care costs and mortality, depressive episodes and suicides. Identifying and eliminatingthe factors that cause treatment non-compliance will increase treatment compliance and reduce treatment costs and the number of hospitalizations.
... Conversely, adolescents in this study who had higher baseline depression scores had higher scores on therapeutic engagement, suggesting that adolescents may be more motivated to invest in the therapeutic process when in distress. The therapeutic relationship may be strengthened as the adolescent begins to experience symptomatic relief, as was observed in a study of therapeutic alliance and clinical outcome among adults with bipolar disorder undergoing individual therapy (Strauss and Johnson, 2006). ...
Background
Family-focused therapy (FFT) is associated with longer intervals between mood episodes and reductions in suicidal ideation among adolescents at risk for bipolar disorders. However, the mediating processes underlying the efficacy of FFT are not well understood. In an open trial of an 18-week FFT program, we explored the association between the therapeutic alliance of adolescents/parents with their therapists and the symptomatic outcomes of adolescents over 18 weeks.
Method
Participants were enrolled in a treatment development trial of FFT supplemented with a mobile app. We used the System for Observing Family Therapeutic Alliances (SOFTA) to rate alliance between adolescents, parents, and therapists using videotaped FFT sessions from the beginning and end of treatment. Pearson correlations were computed between SOFTA alliance ratings and changes in Children's Depression Rating Scale, Revised (CDRS-R) scores over 18 weeks of treatment.
Results
SOFTA ratings were obtained from sessions conducted with 17 adolescents (mean age 14.9+/-2.0 years; 41.2% female) and 22 parents. CDRS-R ratings were obtained from 16 adolescents at baseline and 18 weeks. Parents had significantly higher levels of engagement and emotional connection with therapists than their offspring. Adolescents’ therapeutic engagement scores were significantly correlated with reductions in CDRS scores over 18 weeks (r(14) = -0.58, p = 0.018; N = 16).
Limitations
We could not draw conclusions about the causal relationship between therapeutic alliance and improvement in depression.
Conclusions
Among high-risk adolescents undergoing FFT, therapeutic alliance is associated with clinical improvement over 4 months. Strategies to enhance adolescent engagement may strengthen the long-term effects of family interventions.
... Recomendações específicas aos psiquiatras e equipes de saúde incluem: considerar a opinião do paciente; considerar tratamentos alternativos; ser um bom ouvinte e ter sensibilidade com relação aos sentimentos dos pacientes. Assim, uma boa aliança terapêutica pode minimizar parte das atitudes negativas dos pacientes, pois pacientes que apresentam relação satisfatória com a equipe de saúde tendem a procurá-la em busca de orientações sobre o tratamento, além de representar um elemento de apoio e escuta em um contexto social que na maioria das vezes os rejeita e estigmatiza 26 . ...
RESUMO Objetivo: Evidenciar a influência dos aspectos subjetivos na adesão ao tratamento do transtorno bipolar. Métodos: Foi realizada revisão sistemática com base nas diretrizes PRISMA. A identificação dos estudos foi realizada por meio da busca nos bancos de dados PubMed, Scopus e SciELO, com base nos descritores “Bipolar Disorder” AND “Treatment Adherence and Compliance” AND “Mental Health”. A busca contemplou todos os artigos publicados até o ano 2020, sem restrição de idioma. Resultados: Foram localizados 743 artigos, 714 foram excluídos no processo de seleção, 29 foram lidos na íntegra e 11 foram elegíveis para a composição da amostra. A influência dos aspectos subjetivos na adesão ao tratamento foi associada (1) às atitudes resultantes das percepções do sujeito sobre o transtorno e o tratamento e (2) as atitudes por influência de pessoas próximas. Os estudos apontam para a ocorrência de atitudes negativas em ambas as esferas, tendo a má adesão ao tratamento como desfecho. Na esfera da percepção do sujeito, evidenciam-se: presença de comportamentos intencionais e não intencionais; percepção de consequências; medo dos efeitos colaterais; sentimentos negativos; falta de compreensão sobre o transtorno e negação do diagnóstico. Na esfera da influência das pessoas próximas, destacam-se a baixa qualidade da aliança terapêutica e o suporte ineficaz oferecido pela família. Conclusões: Para melhorar a adesão ao tratamento do transtorno bipolar, é salutar que os esforços terapêuticos estejam centrados na experiência particular do sujeito, na sua satisfação e na colaboração pactuada com o tratamento.
... For example, studies have shown that survivors of childhood trauma frequently fail to adhere to pharmacotherapy (Lecomte et al., 2008;Rakofsky et al., 2011;Spidel et al., 2015), which significantly hampers treatment effectiveness (Baeza-Velasco et al., 2019;Cotter et al., 2015). Experiences of childhood trauma may also impair an individual's capacity to establish an adaptive therapeutic alliance (Cotter et al., 2015;Lafrenaye-Dugas et al., 2018;Lawson et al., 2013), an essential component in facilitating treatment adherence to pharmacotherapy (Strauss and Johnson, 2006;Sylvia et al., 2013;Zeber et al., 2008) as well as the success of psychotherapy (Beutler and Forrester, 2014;Horvath et al., 2011). ...
Objective: The influence of childhood trauma on the treatment outcomes of pharmacological and/or psychological interventions for adolescents and adults with bipolar disorder was systematically reviewed.
Methods: Randomised and non-randomised studies of interventions for bipolar disorder that included an assessment of childhood trauma were eligible. MEDLINE Complete, Embase, PsycINFO, and the Cochrane Central Register of Controlled Trials were searched. Two independent reviewers completed the screening and extraction process. Two independent reviewers assessed the risk of bias in the included studies using the Cochrane Collaboration's Risk of Bias tool and the Newcastle-Ottawa Scale. Alongside a narrative synthesis, random-effects meta-analyses were performed.
Results: Twelve studies (1175 participants) were included. The narrative review highlighted differential treatment outcomes among individuals with a history of childhood trauma. The meta-analyses suggested that childhood trauma was unrelated to treatment response (five studies, 426 participants; odds ratio 0.58, 95% CI 0.27–1.25, p = .164) but may be associated with greater improvement in global functioning (three studies, 210 participants; Hedge's g 0.65, 95% CI 0.04–1.26, p = .037).
Limitations: The impact of childhood trauma on the effectiveness of specific pharmacological/psychological interventions could not be explored due to the small body of research identified.
Conclusion: The overall quality of the extant evidence is low which precludes definitive comment on the role of childhood trauma in the treatment of bipolar disorder. Additional research that uses large and representative samples is required to ascertain whether a history of childhood trauma affects the treatment outcomes of interventions for individuals with bipolar disorder.
... Such a shift has been argued to improve understanding of nonadherence by emphasizing the importance of negative attitudes, beliefs and stigma. 38 The perception of the strength of the 'therapeutic alliance' between patient and care giver, and the optimization of this collaborative relationship, can itself be seen as a management approach to BD. Stronger alliance has been associated with a reduction in manic symptoms with less negative attitudes about medication and reduced perception of stigma regarding BD. 39 Patients knowledge about their illness and medications can also impact on adherence. In a study of 223 patients using the Satisfaction with Information about Medicines Scale those whose perception that they have received less than satisfactory knowledge about their medications presented with significantly lower adherence rates. ...
A number of effective maintenance medication options exist for bipolar disorder (BD) and these are regarded as the foundation of long-term treatment in BD. However, nonadherence to medication is common in BD. For example, a large data base study in the United States of America (USA) showed that approximately half of patients with BD were nonadherent with lithium and maintenance medications over a 12 month period. Such nonadherence carries a high risk of relapse due to the recurrent nature of the illness and the fact that abrupt cessation of treatment, particularly lithium, may cause rebound depression and mania. Indeed, medication nonadherence in BD is associated with significantly increased risks of relapse, recurrence, hospitalization and suicide attempts and a decreased likelihood of achieving remission and recovery, as well as with higher overall treatment costs. Factors associated with nonadherence include adverse effects of medication, complex medication regimens, negative patient attitudes to medication, poor insight, rapid-cycling BD, comorbid substance misuse and a poor therapeutic alliance. Clinicians should routinely enquire about nonadherence in a nonjudgmental fashion. Potential steps to improve adherence include simple pragmatic strategies related to prescribing including shared decision-making, psychoeducation with a clear focus on adherence, reminders (traditional and digital), potentially using a depot rather than an oral antipsychotic, managing comorbid substance misuse and improving therapeutic alliance. Financial incentives have been shown to improve adherence to depot antipsychotics, but this approach raises ethical issues and its long-term effectiveness is unknown. Often a combination of approaches will be required. The strategies that are adopted need to be patient specific, reflecting that nonadherence has no single cause, and chosen by the patient and clinician working together.
... ,60 Providers should encourage individuals to actively participate in treatment planning, using a shared decision-making approach.61,62 Whenever possible, family members or key friends should be included as part of the care team. ...
The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third- line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment-emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second- line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence-based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first-line treatments for acute mania. First-line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first-line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.
... Clinician-initiated Taking back the reins -self-management in BD conversations around SM in BD offer the opportunity to develop a collaborative alliance: while symptom-focused SM strategies have a vital role in living well with BD, it has been suggested that consumers particularly value attention to broader QoL areas, and incorporating QoL-focused SM strategies may therefore enhance engagement (Murray and Michalak, 2012). Importantly, improvements in therapeutic alliance may in turn enhance medication adherence and predict lower symptoms of mania (Berk et al., 2004;Strauss and Johnson, 2006), pointing to synergies between SM and more traditional clinical approaches. Finally, the experiences of participants here underscores the importance of clinicians adopting a hopeful tone on the prospect of recovery in BD or utilising specific hope-building strategies : through communicating the message that there are actions that can be taken to manage the symptoms and impacts of BD, consumers are likely to feel empowered and take ownership of managing this chronic illness. ...
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.
... en los últimos años se ha investigado la posible influencia de la alianza terapéutica sobre los resultados del tratamiento, encontrándose que existe una correlación positiva entre el hecho de establecer una buena alianza terapéutica y los resultados positivos obtenidos tras la aplicación de la terapia (Martin, Garske y Davis, 2000; Priebe y Mccabe, 2006); relación que se aprecia, especialmente, en el caso de los pacientes diagnosticados de esquizofrenia (Davis yLysaker, 2007) y de trastorno bipolar (Perron, Zeber, Kilbourne yBauer, 2009). también se han encontrado relaciones entre el hecho de establecer una buena alianza terapéutica y la reducción de los síntomas maníacos del trastorno bipolar (Strauss yJohnson, 2006), así como con las expectativas positivas del paciente en cuanto a los resultados que va a obtener sometiéndose a la terapia (Gaudiano y Miller, 2006; Price, Anderson, Henrich y olasov rothbaum, 2008). Un concepto estrechamente asociado al de alianza terapéutica es el de adherencia terapéutica que Martín y Grau (2004) definen como un conjunto de conductas entre las que estaría aceptar formar parte de un programa de tratamiento, poner en práctica las indicaciones propias de la terapia, evitar conductas de riesgo e incorporar hábitos saludables. ...
El objetivo del presente estudio es determinar
si un programa de intervención
grupal destinado a la prevención de recaídas
dirigido tanto personas con diagnóstico
de esquizofrenia como de trastorno bipolar
mejora, por un lado, el insight de los
participantes y, por otro lado, la valoración
de estos acerca de la alianza terapéutica
que se establece entre ellos mismos y
sus psiquiatras de referencia. La muestra
estaba compuesta por 16 participantes, los
cuales recibieron diez sesiones de un programa
que constaba de dos partes claramente
diferenciadas, siendo los objetivos
de la primera parte que los participantes
conocieran y/o aprendieran a identificar
aquellos síntomas prodrómicos que se
han producido habitualmente antes de sus
desestabilizaciones, así como las diferentes
estrategias de actuación a poner en
marcha ante la aparición de los síntomas
prodrómicos. Los objetivos de la segunda
parte fueron que los participantes aprendieran
estrategias destinadas a la reducción
de las creencias disfuncionales que
pudieran estar interfiriendo negativamente
sobre el hecho de comunicar la presencia
de sintomatología prodrómica a su
psiquiatra, así como aprender y llegar a
poner en práctica estrategias destinadas
a facilitar una comunicación efectiva con
el mismo en este tipo de situaciones. Los
efectos que se obtuvieron a la finalización
del programa fueron una mejora significativa
tanto en el insight global como en
los factores asociados al mismo, denominados
«capacidad para reconocer el hecho
de tener una enfermedad mental» y «capacidad
para identificar los sucesos mentales
extraños como patológicos». Por
otro lado, no se observaron mejoras significativas
respecto a la valoración de los
participantes acerca de la alianza terapéutica
que se establecía entre ellos mismos y
sus psiquiatras de referencia.
... en los últimos años se ha investigado la posible influencia de la alianza terapéutica sobre los resultados del tratamiento, encontrándose que existe una correlación positiva entre el hecho de establecer una buena alianza terapéutica y los resultados positivos obtenidos tras la aplicación de la terapia (Martin, Garske y Davis, 2000; Priebe y Mccabe, 2006); relación que se aprecia, especialmente, en el caso de los pacientes diagnosticados de esquizofrenia (Davis yLysaker, 2007) y de trastorno bipolar (Perron, Zeber, Kilbourne yBauer, 2009). también se han encontrado relaciones entre el hecho de establecer una buena alianza terapéutica y la reducción de los síntomas maníacos del trastorno bipolar (Strauss yJohnson, 2006), así como con las expectativas positivas del paciente en cuanto a los resultados que va a obtener sometiéndose a la terapia (Gaudiano y Miller, 2006; Price, Anderson, Henrich y olasov rothbaum, 2008). Un concepto estrechamente asociado al de alianza terapéutica es el de adherencia terapéutica que Martín y Grau (2004) definen como un conjunto de conductas entre las que estaría aceptar formar parte de un programa de tratamiento, poner en práctica las indicaciones propias de la terapia, evitar conductas de riesgo e incorporar hábitos saludables. ...
... Consequently, establishing a therapeutic alliance is often challenging due in part to preexisting histories of significant interpersonal relations problems frequently manifested through client anger, general emotion dysregulation, and mistrust of the therapist (Cloitre et al., 2004;Dalenberg, 2004). Evidence indicates that higher levels of supportive interpersonal relations and less conflicted relationships are related to a strong therapeutic alliance during treatment of substance disorders (Connors et al., 2000) and bipolar disorders (Strauss & Johnson, 2006). However, only one such study has been conducted with CA survivors. ...
The current study explored the dimensions of the early therapeutic alliance (tasks, goals, bonds, and other-therapist [people important to clients who support their involvement in therapy]) as mediators between clients’ interpersonal relations problems and outcome measures of trauma symptoms (dissociation and total trauma symptoms). Seventy-six female participants who were receiving treatment for posttraumatic stress due to child abuse (CA), were recruited from a university training clinic. The bond and other subscales mediated the association between interpersonal relations problems and dissociation. The element of client trust associated with the alliance bond, as well as clients’ sense that people who are important to them support their involvement in therapy, should be focal in treating CA survivors. Clinical implications revolve around developing, maintaining, and repairing the therapeutic relationship, especially the bond, within the context of dissociation, as well as exploring clients’ views of important others and its impact on their therapy.
... Previous studies regarding SS and BD reported that patients with BD receive less SS, and that those with deficient SS have poorer symptomatic outcomes than healthy controls (Romans and MacPherson, 1992;Beyer et al., 2003;Wilkins, 2004;Eidelman et al., 2012). In addition, prospective studies confirmed that SS has a positive influence on only the recurrence of depressive episodes (Johnson et al., 2000;Cohen et al., 2004;Weinstock and Miller, 2010;Oddone et al., 2011); another study showed the positive effect of SS only in the manic period (Strauss and Johnson, 2006). Others affirm that the presence of SS is important in reaching remission for both states of the illness (O'Connell et al., 1985;Kulhara et al., 1999;Johnson et al., 2003). ...
Bipolar disorder (BD) affects the social functioning and quality of life (QoL) of its patients. This study aimed to investigate whether there is an association between social support (SS), and suicidal behavior in BD I patients compared to healthy controls; secondarily, we evaluated the influence of QoL on those variables. A total of 119 euthymic outpatients with BD I, 46 of whom had attempted suicide (SAs) and 73 who had not (non-SAs), were compared to 63 healthy controls, through the Medical Outcomes Study Social Support Scale and World Health Organization's Quality of Life Instrument. No differences were noted in SS and QoL between SAs and non-SAs. Compared to healthy controls, non-SAs showed lower values in the positive social interaction domain of SS, and the patients, as a whole, showed lower values in affectionate and positive social interaction domains of SS. Compared to healthy controls, SAs had lower values in the environmental domain of QoL, and the patients, as a whole, had lower values in the environmental, social, and psychological domains of QoL. There was positive correlation between SS and QoL. Although BD is a disabling disease, patients receive inadequate SS. Interventions that may alter the SS in these patients should be investigated.
... [77] reported that perceived collaboration with, empathy from, and accessibility to providers facilitate adherence to medication regimens; however, providers' degree of experience and discussion of medication risks and benefits do not predict adherence. Strauss and Johnson [79] also found that strong therapeutic alliance led to improved medication adherence by changing illness and medication attitudes. Similarly, Zeber et al. [80] reported a positive relationship between treatment alliance and medication adherence, and Reilly-Harrington and Sachs [81] recommend the use of collaborative patient-provider treatment contracts that incorporate treatment expectations, including adherence and provider availability and accessibility. ...
Poor medication adherence is a pervasive problem that causes disability and suffering as well as extensive financial costs among individuals with bipolar disorder (BD). Barriers to adherence are numerous and cross multiple levels, including factors related to bipolar pathology and those unique to an individual's circumstances. External factors, including treatment setting, healthcare system, and broader health policies, can also affect medication adherence in people with BD. Fortunately, advances in research have suggested avenues for improving adherence. A comprehensive review of adherence-enhancement interventions for the years 2005-2015 is included. Specific bipolar adherence-enhancement approaches that target knowledge gaps, cognitive patterns, specific barriers, and motivation may be helpful, as may approaches that capitalize on technology or novel drug-delivery systems. However, much work remains to optimally facilitate long-term medication adherence in people with BD. For adherence-enhancement approaches to be widely adapted, they need to be easily accessible, affordable, and practical.
... Thus, one can relate these results with other studies that raise the importance of social support in BD. Furthermore, these researchers concluded that strong alliances predict a lower frequency of negative attitudes regarding medication, less stigma relating to BD, as well as the possibility of helping to reduce symptoms over time 23 . ...
Background
Bipolar disorder is a chronic condition that affects the functioning of its carriers in many different ways, even when treated properly. Therefore, it’s also important to identify the psychosocial aspects that could contribute to an improvement of this population’s quality of life.
Objective
Carry out a literature review on the role of social support in cases of bipolar disorder.
Method
A research on the following online databases PubMed, Lilacs and SciELO was conducted by using the keywords “social support” or “social networks” and “mood disorders” or “bipolar disorder” or “affective disorder,” with no defined timeline.
Results
Only 13 studies concerning the topic of social support and BD were found in the search for related articles. Generally speaking, the results show low rates of social support for BD patients.
Discussion
Despite the growing interest in the overall functioning of patients with bipolar disorder, studies on social support are still rare. Besides, the existing studies on the subject use different methodologies, making it difficult to establish data comparisons.
... In a review of health communication, Cruz and Pincus [27] found that therapeutic alliance with a psychiatrist was associated with outcomes, such as patient satisfaction, adherence to pharmacological treatment and keeping appointments. Strauss and Johnson [28] found that stronger alliances between service users and psychiatrists predicted fewer manic symptoms, less negative attitudes about medication and less stigma about bipolar disorder. Furthermore, provider behaviors, such as -conveying confidence‖ in consumers' ability to participate in treatment, -staying in regular contact‖ and -regularly reviewing progress‖ with service users contributed to increased medication adherence [29]. ...
Self-determination within mental health services is increasingly recognized as an ethical imperative, but we still know little about the impact of choice on outcomes among people with severe mental illnesses. This study examines whether choice predicts outcomes and whether this relationship is mediated by therapeutic alliance.
The study sample of 396 participants completed a survey measuring choice, therapeutic alliance, recovery, quality of life and functioning. Multivariate analyses examined choice as a predictor of outcomes, and Sobel tests assessed alliance as a mediator.
Choice variables predicted recovery, quality of life and perceived outcomes. Sobel tests indicated that the relationship between choice and outcome variables was mediated by therapeutic alliance.
The study demonstrates that providing more choice and opportunities for collaboration within services does improve consumer outcomes. The results also show that collaboration is dependent on the quality of the relationship between the provider and consumer.
... The power of the therapeutic relationship can be maximized by adopting a strongly collaborative stance, 23 which in itself has been associated with reduced risk of relapse in BD. 24 Key elements of a collaborative therapeutic relationship are: (1) the clinician is warm, directive and concerned, a problem-solver applying a coping model, (2) the patient is active in determining the specific targets of therapy, while the clinician is expert in proposing pathways to achieve these goals, (3) the patient and clinician therefore work as a collaborative team, (4) the therapeutic emphasis is on measurable changes outside the therapy room and, (5) the therapeutic goals are supported by learning principles (e.g., change as incremental). In practice, a collaborative therapeutic atmosphere can be generated by asking clients to give their opinions about treatment, and what they think might be effective on the basis of past experience. ...
... On the other hand, Rosa et al. (2007) reported that in their study knowledge level was directly related to treatment adherence. Even though we found attitudes to be quite stable, they can likely be modified (Strauss and Johnson, 2006). ...
... This may be of particular relevance to Chinese patients given the Chinese traditional perception of a doctor as an authority fi gure. The importance of attending to treatment alliance in BD is further underscored by research demonstrating that a stronger alliance predicts fewer manic symptoms over time, fewer negative attitudes towards mood stabilizing medications, and a lower sense of stigma (Strauss and Johnson, 2006). ...
Aims
The aim of the study presented in this article was to consider how New Zealand Chinese with bipolar disorder manage their condition, regain and maintain wellness through the use of self-management techniques.
Methods
Nine New Zealand Chinese with bipolar disorder type I or II who had reasonable performance in role functioning were interviewed. Data analysis was guided by the inductive approach.
Findings
In contrast to Western psychosocial interventions, which emphasize the individual's independence, self-advocacy and self-identity, New Zealand Chinese are more likely to value themselves through relationships with others. Most participants emphasized the importance of harmony with self and others, and adopted passive and nature-oriented attitudes encouraged by Taoism to deal with life stress. Strategies of ‘taking it easy’ and ‘looking at problems in others’ shoes' were frequently used when dealing with interpersonal conflicts.
Conclusions
The concepts of health and life as part of traditional Chinese culture were found to be the fundamental elements influencing the participants' coping patterns. There is a strong need for facilitating the connection between health professionals and clients. This study indicates that to do this, health professionals must be aware of the importance of cultural sensitivity when delivering health care in a multicultural environment.
... The attitude toward taking the medications is one of the most important predictors of adherence (3,14,15,(28)(29)(30)(31).Well adherent study patients had a more positive attitude toward medications, compared to the two other groups. Moderately adherent patients also had a more positive attitude compared to poor adherent patients. ...
Objectives: Non-adherence limits the effectiveness of medications among patients with bipolar disorder. Many studies have investigated the predicting factors of non-adherence. This paper aims to present the pattern of adherence in patients with bipolar I disorder (BID). Methods: Seventy six patients with BID enrolled in a prospective study. The Medication Possession Ratio (MPR) was used to evaluate patients' adherence to medications, and repeated measure analysis was performed to reveal the pattern of variations. A Persian translation of Drug Attitude Inventory (DAI-10) (shortened version) was used to assess the attitude of patients toward medications. Results: the repeated measure analysis revealed that the adherence to medications successively decreased (p<0.001). Age, gender, marital status, educational level, comorbid substance abuse did not alter the pattern. Conclusion: There is a decreasing pattern in the adherence to medications among BID patients, regardless of known predicting factors of non-adherence. It means even fully adherent patients could potentially become non-adherents during the course of maintenance treatment.
Background:
For decades we have known that therapeutic working alliance is a key contributor to client engagement and positive outcomes in therapy. However, we have made little progress in narrowing down its determinants, which is critical in supporting trainees to optimize such alliance. We make a case for the value of incorporating social psychological frameworks into models of alliance and explore the role of social identity processes in the development of therapeutic alliance.
Method:
Across two studies, over 500 psychotherapy clients completed validated measures of alliance, social identification with their therapist, positive therapy outcomes, and a range of client and therapist characteristics.
Findings:
Social identification strongly predicted alliance in both samples, whereas client and therapist characteristics showed few such associations. Alliance mediated the relationship between social identification and positive therapy outcomes. In addition, we found evidence that (a) personal control is a key psychological resource in therapy that arises from social identification, and (b) therapists who engage in identity leadership (i.e., who represent and build a social identity that they share with clients) are more likely to foster social identification and its downstream benefits.
Interpretation:
These data show that social identity processes are key to the emergence of working alliance. We conclude with a discussion of how recent social identity and identity leadership interventions might be adapted to train therapists in relevant identity-building skills.
An implementation fidelity study evaluated the quality of the therapeutic alliance (TA) in the counseling services of a Canadian Employee Assistance Program (EAP). The aims were to evaluate the level of TA experienced by EAP users during counseling, to assess the influence of client gender, and to determine the associations between the level of TA and mental health and work functioning outcomes. The TA was assessed with the Brief Therapeutic Alliance Scale (BTAS-5), a self-report quantitative measure developed to rapidly assess multiple elements of the client-therapist alliance from the perspective of the client. The majority of the EAP users (N = 1277) reported experiencing a high level of TA during counseling and men and women reported equal levels. Pretest and posttest analysis with ANCOVA showed that EAP users (N = 505) reporting higher levels of TA had greater mental well-being, lower depression symptoms (Patient Health Questionnaire-2), lower work presenteeism (Workplace Outcome Suite-5; WOS-5), and greater life satisfaction (WOS-5) at follow-up after end of counseling. The TA from the perspective of EAP users can serve as an indicator of well-implemented employee counseling services and its assessment can provide additional evidence of counseling quality and effectiveness, supplementing the findings of traditional outcomes-based EAP studies.
Background:
Childhood trauma is associated with greater depression severity among individuals with bipolar disorder. However, the mechanisms that explain the link between childhood trauma and depression severity in bipolar disorder remain poorly understood. The mediational role of attachment insecurity in childhood and adulthood was assessed in the current study.
Methods:
Participants with bipolar disorder (N = 143) completed measures of childhood trauma (Childhood Trauma Questionnaire), attachment insecurity (Experiences in Close Relationships Scale), and depression severity (Hamilton Depression Rating Scale) as part of the Prechter Longitudinal Study of Bipolar Disorder. A sequential mediation model was tested using path analysis: the direct and indirect effects of childhood trauma on depression severity with attachment insecurity (attachment anxiety and avoidance) in childhood (mother and father) and adulthood (partner) as mediators were estimated.
Results:
The final path model demonstrated an excellent fit to the data (comparative fit index = 0.996; root mean square error of approximation = 0.021 [90% confidence interval = 0.000-0.073]). Supporting the hypothesised sequential mediation model, maternal attachment anxiety in childhood and romantic attachment avoidance in adulthood partially mediated the relationship between childhood trauma and depression severity; this effect accounted for 12% of the total effect of childhood trauma on depression severity.
Conclusion:
Attachment insecurity in childhood and adulthood form part of the complex mechanism informing why people with bipolar disorder who have a history of childhood trauma experience greater depression severity. Addressing attachment insecurity represents a valuable psychotherapeutic treatment target for bipolar disorder.
Objective: Adults with serious mental health conditions (SMHC) experience higher rates of disengagement from treatment. Factors associated with engagement in treatment in general for this population include therapeutic alliance, provider empathy, and perceived coercion. This cross-sectional exploratory study addressed the question: To what extent do client perceptions of therapeutic alliance, therapist empathy, and perceived coercion explain the degree of engagement in outpatient therapy for adults with SMHC? Method: An anonymous online survey measuring study variables was completed by 131 participants. The relationship between variables was tested using multivariate regression analysis with hierarchical blocks. Results: After separating therapeutic alliance and therapist empathy in the analysis due to multicollinearity and accounting for the influence of control variables, therapeutic alliance (B = .43, p < .01) and therapist empathy (B = .25, p < .01), but not perceived coercion, were associated with the degree of client engagement. Conclusions and Implications for Practice: For adults with SMHC enrolled in outpatient therapy, therapeutic alliance explained the greatest variation in the degree of engagement. Participants appeared to use outpatient therapy as a main strategy for pursuing recovery, and engagement in therapy may be increased if providers utilize strategies to strengthen expressions of empathy and bolster alliance. Additional research is needed to enhance understanding of engagement in therapy for this population and to develop more sensitive measures for evaluating these constructs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
This case study describes the implementation of a manualized cognitive-behavioral treatment protocol for bipolar disorder in a private practice setting. The case pertained to a woman in her late 30s who was diagnosed with bipolar disorder and cannabis use disorder and who presented with multifaceted problems especially relating to interpersonal relationships within her family that triggered her manic and depressive episodes. Despite the flexibility in applying the manual in a manner customized to individual client needs, the outcome was favorable. The successes and challenges are outlined both at an individual level for the client (e.g., medication adherence, cognitive style, life events) and on a systemic level for the therapist (e.g., working on one’s own) and the setting (e.g., case management and care coordination). While there are some limitations to applying a manualized intervention in such a setting, the opportunities for growth and positive outcomes are evident based on the results.
Background:
Attitudes toward medication treatment are thought to significantly influence adherence in bipolar disorder (BD) and schizophrenia. However, the actual impact of patients' treatment attitudes on adherence and determinants of attitudes is still uncertain.
Methods:
A longitudinal examination of treatment attitudes and their correlates was conducted among patients with BD and their caregivers compared with those with schizophrenia. Structured assessments of symptom severity, functioning, insight, medication side effects, knowledge of illness, medication adherence, treatment attitudes, and treatment satisfaction were performed among 176 selected patients (106 with BD and 70 with schizophrenia) and their caregivers. Participants were reassessed on these parameters at 3 and 6 months.
Results:
Rates of nonadherence at baseline varied widely between self-reports, clinician ratings, and serum levels. Though symptoms and functioning improved with treatment, overall rates of nonadherence increased in the first 3 months because of early dropouts and remained stable thereafter. However, treatment attitudes and treatment satisfaction remained largely unchanged among patients and caregivers. Both positive and negative attitudes were commonly held and patients' attitudes did not differ between BD and schizophrenia. Patients' attitudes were significantly associated with adherence, insight, knowledge about illness, treatment satisfaction, symptom severity, social disadvantage, and side effects together with caregivers' knowledge, attitudes, and satisfaction. Caregivers of patients with schizophrenia were more knowledgeable and had more positive attitudes than patients.
Conclusions:
Patients' attitudes to medication treatment are associated with adherence over time. They are relatively enduring and mainly associated with insight, knowledge of illness, and treatment satisfaction among patients and their caregivers. These findings could inform psychosocial interventions aiming to improve treatment attitudes and adherence in BD and schizophrenia.
Background:
Systematic reviews about treatment attitudes of patients influencing adherence in bipolar disorder (BD) are rare.
Methods:
A systematic review was conducted according to the PRISMA guidelines and principles of thematic synthesis. Selectively identified quantitative and qualitative studies were used to examine the attitude-adherence relationship in BD, the types and correlates of treatment attitudes, and the impact of psychosocial interventions on attitudes.
Results:
The final list of 163 articles included 114 observational reports (incorporating 21 psychosocial intervention trials), 45 qualitative/descriptive studies, and 4 patient surveys. A positive association between treatment attitudes and adherence was found in most quantitative and qualitative studies, though the strength of the relationship was unclear. Thematic analysis of qualitative studies suggested that patient attitudes influencing adherence were based on perceived advantages and disadvantages of treatment. The principal correlates of patients' attitudes were family attitudes, the clinician-patient alliance, social support, and patients' knowledge of BD. Though negative attitudes such as denial, concerns about adverse treatment consequences, and stigmatizing effects of treatment were common, many patients believed treatment to be beneficial and necessary. The limited data on the effect of psychosocial interventions indicated that treatments selectively targeting attitudes enhanced adherence.
Limitations:
The studies were heterogeneous in design; the quality was uneven (fair to poor); and the risk of bias moderate to high.
Conclusions:
Despite these flaws, awareness of the existing evidence on the attitude-adherence association and other aspects of treatment attitudes in BD can help in efforts to address nonadherence in BD.
Résumé
Les personnes souffrant de troubles psychiques subissent fréquemment une stigmatisation sociale. Elles ont également tendance à s’auto-stigmatiser, c’est-à-dire qu’elles-mêmes intègrent des attitudes négatives à l’égard de leur propre condition. Dans le domaine de la psychose, la problématique de l’auto-stigmatisation est de plus en plus considérée. En revanche, cette problématique reste sous-évaluée chez les personnes souffrant d’un trouble bipolaire. Les conséquences en sont pourtant importantes : la culpabilité, la honte, le repli sur soi et le renoncement à mener sa vie selon ses propres valeurs et croyances péjorent la qualité de vie des personnes, y compris celles qui sont euthymiques depuis plusieurs années. De plus, l’auto-stigmatisation augmente le risque de rechutes thymiques et de ré-hospitalisations. Actuellement, peu de stratégies thérapeutiques ont été évaluées et les données disponibles s’adressent essentiellement aux personnes souffrant de schizophrénie. À travers la description d’un cas clinique, nous présentons une intervention de restructuration cognitive des croyances auto-stigmatisantes, qui pourrait s’avérer une stratégie thérapeutique bénéfique pour faire face à l’auto-stigmatisation.
This paper examines reflective portfolios of graduate students studying co-existing problems (CEP) within an alcohol and drug studies programme in New Zealand. The methodology employs Todd’s principles of treating co-existing disorders (culture, management, engagement, assessment, integrated care, well-being and management). The metaphor, a GPS, is employed in the title to describe how Todd’s principles are used as a GPS to help navigate the murky waters of working with this specialised client population. The principles, allocated as themes within the portfolios, highlight how these principles are reflected upon within their workplace. Culture and engagement principles were the most endorsed themes within the portfolios. The reflective portfolios also allowed us to reflect upon the ongoing process of curriculum development for this specialised client population.
Bipolar disorder is a highly recurrent and potentially disabling disorder, and prevention of recurrence with maintenance therapy is a predominant focus of management. GPs are well placed to provide this long-term care.
Este artículo busca determinar la prevalencia y los factores asociados a la no adherencia en el tratamiento de mantenimiento de pacientes adultos con diagnóstico de trastorno afectivo bipolar.
Dr. Jain stressed that, to fully embrace the cause of maintenance treatment of bipolar disorder, clinicians must first acknowledge the dangers of less-than-optimum maintenance treatment. These dangers include high relapse and recurrence rates, reduced treatment adherence, and adverse neurobiological effects. Several general rules apply to maintenance treatment of bipolar disorder. First, clinicians should routinely offer maintenance treatment because patients often relapse. Second, when selecting pharmacotherapy, multiple issues are important, including the patient's individual needs, the efficacy and side effect burden of individual medications, FDA-approved medications for bipolar maintenance therapy available in the patient's insurance formulary, and the quality of research data. Dr. Jain stated that antidepressants should usually be avoided, especially as monotherapy. While monotherapy mood stabilizer treatment is preferred, combination therapy is indicated if treatment response is suboptimum. A large number of pharmacologic treatment options are available for maintenance treatment, including the FDA-approved medications lithium, lamotrigine, olanzapine, and aripiprazole, as well as other agents such as divalproex, carbamazepine, oxcarbazepine, and atypical antipsychotics, which can be used as monotherapy or as part of combination therapy. Third, psychotherapy has become increasingly well-studied and can be used for the majority of patients as an adjunctive treatment strategy. Psychotherapy for bipolar disorder can delay recurrence, stabilize symptoms, and improve medication adherence.99 Additionally, several types of psychotherapy are available that can be useful to augment the benefits of mood stabilizers, such as group psychoeducation, family-focused therapy, interpersonal and social rhythm therapy, and cognitive-behavioral therapy.100 Dr. Jain asserted that, while patient adherence is important for treatment to succeed, clinician adherence to treatment guidelines is also vital. A recent survey 101 of psychiatrists revealed that only 64% of clinicians reported routinely using any treatment guidelines in making clinical decisions, which leaves room for improvement. Dr. Jain also recommended the use of daily mood ratings to both psychiatrists and nonpsychiatrists to track the progress of patient treatment. Clinical experience and research data102 show that maintaining daily mood ratings can be useful for both patients and clinicians to detect relapse earlier during treatment than without these ratings. The need for maintenance treatment is now widely recognized, and clinicians now have access to multiple tools to ensure optimum maintenance out-comes for patients. Dr. Jain concluded that carefully matching a patient's unique needs with individual treatment interventions is the ideal path to achieving high rates of success.
Objectives. Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes. Methods. The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41(85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness. Results. ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy. SCOPE OF THE PROBLEM: The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses. INTERVENTIONS: It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions. Conclusions. Adherence problems are complex and multi-determined. The experts recommended customized interventions focused on the underlying causes.
Despite wide media coverage in recent years, the stigmatization of people with bipolar disorder still exists. Bipolar people also have their own tendency to self-stigmatize that is to integrate their beliefs, prejudices and stigmatizing behaviors. The consequences are important: shame, guilt, withdrawal and renunciation to lead one's own life according to personal values increasing therefore the risk of mood relapses. Self-stigma is rarely assessed in clinical practice and few strategies have been designed to face them efficiently. Recognizing self-stigmatizing beliefs and challenging them are the first steps of this vast endeavour.
One primary purpose for psychotherapy research is linking empirically based findings to applied treatment interventions. This use of research can potentially define optimal strategies and techniques that can help guide psychotherapy practice in the field. While caution is warranted considering the varied methodological attributes and findings across different studies, clinicians may be informed by the preponderance of extant data. Extensive prior research has consistently found a significant relationship between therapeutic alliance with therapy process and outcome [1–4]. Moreover, alliance has been found to be one of the most robust predictors of positive psychotherapy outcome regardless of the type of therapy utilized or whether assessed by therapist, client, or independent observer [1]. Thus, alliance research has the potential to significantly inform the treatment approach for a wide range of practicing therapists. With this in mind, the aim of this chapter is to review and summarize the contemporary research on the relationship between specific therapist attributes and interventions on the therapeutic alliance. The synthesized research is inclusive and incorporates varied models of psychotherapy, including humanistic, experiential, cognitive-behavioral, supportive–expressive, interpersonal, motivation-enhancing, relational, and other prevalent psychotherapy orientations. We will first summarize techniques that have been found to significantly enhance the alliance during specific, initial phases of psychotherapy and then move to therapist activities and characteristics that have been found to positively or negatively affect the alliance across treatment. Finally, we will discuss how these therapist activities and characteristics related to alliance may be related to both the initiation and resolution of treatment ruptures.
Introduction: This study aims to determine the prevalence and factors associated with non-adherence in maintenance treatment of adult patients diagnosed with bipolar disorder. Methods: Cross sectional study with 124 patients. Adherence to treatment was evaluated by the Morisky-Green Test. A structured questionnaire was applied. It included variables associated with demographics factors and factors related to the patient, illness, treatment, family, therapeutic relationship, and health system. The Global Impression Scale Modified for Bipolar Disorder (CGI-BPM) and Family Apgar were used as well. Results: The prevalence of non-adherence to maintenance drug treatment was 29.8%. It was greater in women (64.9%) than men (35.1%), although this difference was not statistically significant (p = 0.17). The factors statistically significant associated with non-adherence factors were: Increased severity of the disease (OR 1.9), history of non-adherence (39% P=0,001), negative perception of the psychiatrist (100%, P=0.001), less insight (87%, RP4.65), greater stigma (50%, RP 6.2), having no family member to remind taking the drug (73%, P=0.001). Conclusions: The prevalence was inside the range found in other studies. The statistically significant factors associated with non-adherence were: Severity of disease, history of non-compliance, stigma, no family support, poor insight, smoking habit, and negative perception of the psychiatrist.
Poor adherence to medication treatment can have devastating consequences for patients with mental illness. The goal of this project was to develop recommendations for addressing adherence problems to improve patient outcomes.
The editors identified important topics and questions concerning medication adherence problems in serious mental illness that are not fully addressed in the literature. A survey was developed containing 39 questions (521 options) asking about defining nonadherence, extent of adherence problems in schizophrenia and bipolar disorder, risk factors for nonadherence, assessment methods, and interventions for specific types of adherence problems. The survey was completed by 41 (85%) of the 48 experts to whom it was sent. Results of the literature review and survey were used to develop recommendations for assessing and improving adherence in patients with serious mental illness.
ASSESSING ADHERENCE: The experts endorsed percentage of medication not taken as the preferred method of defining adherence, with 80% or more of medication taken endorsed as an appropriate cut-off for adherence in bipolar disorder and schizophrenia. Although self- and physician report are the most common methods used to assess adherence in clinical settings, they are often inaccurate and may underestimate nonadherence. The experts recommend that, if possible, clinicians also use more objective measures (e.g., pill counts, pharmacy records, and, when appropriate, serum levels such as are used for lithium). Use of a validated self-report scale may help improve accuracy.
The majority of the experts believed the average patient with schizophrenia or bipolar disorder in their practices takes only 51%-70% of prescribed medication. FACTORS ASSOCIATED WITH NONADHERENCE: The experts endorsed poor insight and lack of illness awareness, distress associated with specific side effects or a general fear of side effects, inadequate efficacy with persistent symptoms, and believing medications are no longer needed as the most important factors leading to adherence problems in schizophrenia and bipolar disorder. The experts considered weight gain a side effect that is very likely to lead to adherence problems in patients with schizophrenia and bipolar disorder; sedation was considered a more important contributor to adherence problems in bipolar disorder than schizophrenia. The experts rated persistent positive or negative symptoms in schizophrenia and persistent grandiosity and manic symptoms in bipolar disorder as the most important symptomatic contributors to adherence problems in these illnesses.
It is important to identify the specific factors that may be contributing to a patient's adherence problems in order to customize interventions to target those problems. Multiple problems may be involved, requiring a combination of interventions.
Adherence problems are complex and multidetermined. The experts recommended customized interventions focused on the underlying causes.
Bipolar disorder has been conceptualized as an outcome of dysregulation in the behavioral activation system (BAS), a brain system that regulates goal-directed activity. On the basis of the BAS model, the authors hypothesized that life events involving goal attainment would promote manic symptoms in bipolar individuals. The authors followed 43 bipolar I individuals monthly with standardized symptom severity assessments (the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Rating Scale). Life events were assessed using the Goal Attainment and Positivity scales of the Life Events and Difficulties Schedule. As hypothesized, manic symptoms increased in the 2 months following goal-attainment events, but depressed symptoms were not changed following goal-attainment events. These results are congruent with a series of recent polarity-specific findings.
A random-effects regression model is proposed for analysis of clustered data. Unlike ordinary regression analysis of clustered data, random-effects regression models do not assume that each observation is independent but do assume that data within clusters are dependent to some degree. The degree of this dependency is estimated along with estimates of the usual model parameters, thus adjusting these effects for the dependency resulting from the clustering of the data. A maximum marginal likelihood solution is described, and available statistical software for the model is discussed. An analysis of a dataset in which students are clustered within classrooms and schools is used to illustrate features of random-effects regression analysis, relative to both individual-level analysis that ignores the clustering of the data, and classroom-level analysis that aggregate the individual data.
Structural equation modeling with latent variables was used to test whether negative affectivity, or the cross-situational tendency to experience and express negative thoughts and feelings, correlates with spouses' attributions for relationship events and accounts for the association between attributions and satisfaction. Eighty married couples completed measures of marital satisfaction, attributions, and negative affectivity. Spouses high in negative affectivity tended to make maladaptive attributions, but spouses' attributions were unrelated to the level of negative affectivity reported by the partner. Attributions and marital satisfaction remained associated among husbands and wives after controlling for negative affectivity. These findings clarify the link between attributions and marital satisfaction and raise the possibility that negative affectivity contributes to the attributions that spouses make for negative events in marriage.
The Working Alliance Inventory (WAI) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI.
The five-factor model is a dimensional representation of personality structure that has recently gained widespread acceptance among personality psychologists. This article describes the five factors (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness); summarizes evidence on their consensual validity, comprehensiveness, universality, heritability, and longitudinal stability; and reviews several approaches to the assessment of the factors and their defining traits. In research, measures of the five factors can be used to analyze personality disorder scales and to profile the traits of personality-disordered patient groups; findings may be useful in diagnosing individuals. As an alternative to the current categorical system for diagnosing personality disorders, it is proposed that Axis II be used for the description of personality in terms of the five factors and for the diagnosis of personality-related problems in affective, interpersonal, experiential, attitudinal, and motivational areas.
Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualizaton of the alliance. Results from 3 studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. Data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations were also observed between the WAI and other relationship indicators. Results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in the reviewed studies are encouraging, the high correlations between the 3 subscales of the inventory bring into question the distinctness of the alliance components. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This volume provides a guide to conducting cognitive therapy for bipolar disorder. The key theme is respect—people with bipolar disorder are treated as people and not as incidental hosts for the illness. Beyond clinical tools for addressing maladaptive cognitions, the authors provide strategies for helping clients address manic and depressive symptoms, prevent suicidal behavior, communicate with family members, and accept the need for medication. The text also includes a series of clinical vignettes and transcripts that demonstrate how to conduct this therapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Results of 24 studies (based on 20 distinct data sets) relating the quality of the working alliance (WA) to therapy outcome were synthesized using meta-analytic procedures. A moderate but reliable association between good WA and positive therapy outcome was found. Overall, the quality of the WA was most predictive of treatment outcomes based on clients' assessments, less so of therapists' assessments, and least predictive of observers' report. Clients' and observers' rating of the WA appear to be more correlated with all types of outcomes reported than therapists' ratings. The relation of WA and outcome does not appear to be a function of the type of therapy practiced, the length of treatment, whether the research is published, or the number of participants in the study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The Working Alliance Inventory (WAI; A. O. Horvath and L. S. Greenberg [see PA, Vol 76:24600]) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Reviews and elaborates the psychoanalytic concept of the working alliance. It is argued that various modes of psychotherapy can be meaningfully differentiated in terms of the kinds of working alliances (WA) embedded in them. Moreover, the strength, rather than the kind of WA, will prove to be the major factor in change achieved through psychotherapy. Strength of alliance will be a function of the goodness of fit of the respective personalities of patient and therapist to the demands of the WA. The WA includes 3 features: agreement on goals, assignment of tasks, and the development of bonds. (36 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The current study prospectively examined the impact of social support on symptom severity and recovery from episodes in bipolar disorder, both as a direct influence and as a buffer of life events. Fifty-nine individuals with Bipolar I disorder were followed longitudinally with monthly symptom severity interviews. Social support was measured by the Interpersonal Support Evaluation List and the Interview Schedule for Social Interaction, and life events were assessed using the Life Events and Difficulties Schedule. Individuals with low social support took longer to recover from episodes and were more symptomatic across a 6-month follow-up. Results suggest a polarity-specific effect, in that social support influences depression but not mania. Discussion focuses on theoretical implications of a series of polarity-specific findings within the field.
Reliability coefficients often take the form of intraclass correlation coefficients. In this article, guidelines are given for choosing among 6 different forms of the intraclass correlation for reliability studies in which n targets are rated by k judges. Relevant to the choice of the coefficient are the appropriate statistical model for the reliability study and the applications to be made of the reliability results. Confidence intervals for each of the forms are reviewed. (23 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
A test-retest reliability study of the Structured Clinical Interview for DSM-III-R was conducted on 592 subjects in four patient and two nonpatient sites in this country as well as one patient site in Germany. For most of the major categories, kappa s for current and lifetime diagnoses in the patient samples were above .60, with an overall weighted kappa of .61 for current and .68 for lifetime diagnoses. For the nonpatients, however, agreement was considerably lower, with a mean kappa of .37 for current and .51 for lifetime diagnoses. These values for the patient and nonpatient samples are roughly comparable to those obtained with other structured diagnostic instruments. Sources of diagnostic disagreement, such as inadequate training of interviewers, information variance, and low base rates for many disorders, are discussed.
Social responses to dysphoria were investigated. Subjects conversed for 15 minutes with persons selected on the basis of the presence or absence of depressed mood. Following the conversations, mood measures were administered along with social perception questionnaires that were described as either being confidential or to be shared with the other person. Subjects who interacted with depressed persons were anxious, depressed, and hostile, and the subjects rejected them. Contrary to predictions, subjects were willing to share their negative responses with the depressed persons. The depressed persons correctly anticipated rejection and reciprocated. The authors argue that cognitive models of depression need to be integrated with a conception of the social environment as being active and responsive. Judgments of cognitive distortion cannot be made without an understanding of the feedback typically available from the social environment.
The characteristically large general factor found in measures of the therapeutic alliance was analyzed by use of confirmatory factor analysis (CFA) in a nested design. Ratings by 38 therapists and their 144 patients on the California Psychotherapy Alliance Scales (CALPAS), the Revised Penn Helping Alliance Questionnaire (HAQ-R), and the Working Alliance Inventory (WAI) were adjusted for therapist effects. A set of models for patient and therapist ratings was tested with CFA, and a 3-factor model was confirmed, chi 2(4) = 7.19, p > .13; GFI = .98; RMSR = .02; CFI = 1.0. A shared-view factor (best represented by HAQ-R) accounted for 44% of patients' and 27% of therapists' variance. Unique factors (best represented by WAI) accounted for 56% of therapists' and 43% of patients' variance. Patient views split between HAQ (helpfulness) and WAI (goals, tasks) factors; The WAI factor was most expressive of therapist views. Patients and therapists tended to agree on helpfulness and on therapist clarity about goals and tasks. A multimeasure approach to alliance assessment is recommended.
A random-effects regression model is proposed for analysis of clustered data. Unlike ordinary regression analysis of clustered data, random-effects regression models do not assume that each observation is independent but do assume that data within clusters are dependent to some degree. The degree of this dependency is estimated along with estimates of the usual model parameters, thus adjusting these effects for the dependency resulting from the clustering of the data. A maximum marginal likelihood solution is described, and available statistical software for the model is discussed. An analysis of a dataset in which students are clustered within classrooms and schools is used to illustrate features of random-effects regression analysis, relative to both individual-level analysis that ignores the clustering of the data, and classroom-level analysis that aggregates the individual data.
The relationship between therapeutic alliance and treatment outcome was examined for depressed outpatients who received interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Clinical raters scored videotapes of early, middle, and late therapy sessions for 225 cases (619 sessions). Outcome was assessed from patients' and clinical evaluators' perspectives and from depressive symptomatology. Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance were significantly related to treatment outcome; ratings of therapist contribution to the alliance and outcome were not significantly linked. These results indicate that the therapeutic alliance is a common factor with significant influence on outcome.
Participants were 54 clients with serious psychiatric disorders and 21 clinical case managers. Clients' serious psychiatric disorders included Axis I diagnoses, such as schizophrenia and bipolar disorder. This study examined how attachment states of mind of both clients and case managers influenced the effectiveness of therapeutic relationships and client functioning. Client and case manager attachment states of mind interacted in predicting the working alliance and client functioning. Specifically, clients who were more deactivating with respect to attachment had better alliances and functioned better with less deactivating case managers, whereas clients who were less deactivating worked better with more deactivating case managers. These findings highlight the importance of clinicians and clients being matched in ways that balance their interpersonal and emotional strategies.
To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.
In an epidemiologic sample of female-female twin pairs, we previously reported analyses of lifetime major depression. Because lifetime mania was not assessed, we could not differentiate unipolar from bipolar illness. Having completed such an evaluation in this sample, we now examine three questions: (i) does removing bipolar cases from our cohort substantially alter estimates for the heritability of major depression?; (ii) does our epidemiologic data support a familial relationship between major depression and mania?; and (iii) do our results for major depression and mania suggest that the two disorders are caused by the same underlying liability? We find that (i) the heritability of major depression declines only trivially if cases with a history of mania are removed; (ii) mania in one twin predicts major depression in her cotwin - suggesting a familial/genetic relationship between major depression and mania; and (iii) a multiple threshold model fits our data well, consistent with the hypothesis that unipolar and bipolar disorders are points on a continuum of a single liability of illness. The validity of these results are tempered by the small number of bipolar cases detected, as expected from the low base rate of mania in general population samples.
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Background: The prevalence of nonadherence with mood stabilizers ranges from about 18% to 52%. Only 1% of publications on mood stabilizers address this issue. This study aimed to explore the prevalence and predictors of nonadherence in a cohort of individuals with affective disorders receiving long-term treatment with mood stabilizers.
Method: Subjects receiving lithium, carbamazepine, and/or valproate were identified from biochemistry laboratory data. Ninety-eight of these subjects had major depressive disorder (N=20) or bipolar disorder (N=78) (DSM-IV) and gave informed consent to participate in a structured clinical interview to assess their medication adherence and the factors that influenced it.
Results: Just under 50% of subjects (46/98) acknowledged some degree of medication nonadherence in the previous 2 years, and 32% (29/92) reported only partial adherence in the last month (missing 30% or more of their prescribed medication). Backward stepwise logistic regression demonstrated that partially adherent subjects were best distinguished from adherent subjects by a more frequent past history of nonadherence, denial of severity of illness, and greater duration of being prescribed a mood stabilizer.
Conclusion: Rates of mood stabilizer nonadherence are high. Attitudes and behaviors are better predictors of nonadherence than side effects from medication. Clinicians need to inquire routinely about problems with adherence.
• The current point and lifetime prevalence rates of affective disorders, based on the application of Research Diagnostic Criteria to a US urban community sample, are reported. The affective disorders studied included major and minor depression, mania, hypomania, bipolar I and II, primary and secondary depression, schizo-affective disorder, depressive and cyclothymic personality, and grief reactions. Epidemiologic surveys that include treated and untreated persons to obtain rates of specific psychiatric disorders are needed for scientific purposes and health care planning.
The history and description of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) is presented. The SCID-II is a clinician-administered semistructured interview for diagnosing the 11 Axis II personality disorders of the Diagnostic and Statistical Manual of Mental Disorders, pins the Appendix category self-defeating personality disorder. The SCID-II is unique in that it was designed with the primary goal of providing a rapid clinical assessment of personality disorders without sacrificing reliability or validity. It can be used in conjunction with a self-report personality questionnaire, which allows the interview to focus only on the Items corresponding to positively endorsed questions on the questionnaire, thus shortening the administration time of the interview.
In the last several years, we have been interested in the role social supports play in protecting people from the pathogenic effects of stress. By social supports, we scan the resources that are provided by other persons (cf. Cohen & Syme, 1985). Although others have investigated and in some cases found evidence for a “buffering” hypothesis—that social support protects persons from the pathogenic effects of stress but is relatively unimportant for unexposed individuals, there are difficulties in interpreting this literature. First, there are almost as many measures of social suppport as there are studies. Hence it is difficult to compare studies and to determine why support operates as a stress buffer in some cases, but not in others. Second, in the vast majority of work, support measures are used without regard to their psychometric properties or their appropriateness for the question under study. For example, studies using measures assessing the structure of social networks (e.g, how many friends do you have?) are seldom distinguished from those addressing the functions that networks might serve (e.g., do you have someone you can talk to about personal problems?). In fact, in many cases, structural and functional items are thrown together into single support indices resulting in scores that have little conceptual meaning.
For over 25 years lithium was regarded as the drug of choice for prophylactic treatment in patients with bipolar disorder. More recently its place in the long term management of this condition has been questioned. A number of long term naturalistic studies have revealed that lithium is less effective in clinical practice than would be anticipated from clinical trial data. A major factor contributing to this discrepancy is the poor adherence to medication shown by over a third of patients taking the drug long term. Another possible reason is a broadening of the diagnostic criteria for bipolar disorder to include patients with mood-incongruent psychotic symptoms and/or comorbid substance abuse.
Following initially favourable reports from open studies, the anticonvulsant compounds carbamazepine and valproic acid (sodium valproate) have come to be widely used in the long term management of bipolar disorder. However, there is, thus far, little confirmatory evidence from controlled clinical trials to support this practice. The same is true for the use of the newer atypical antipsychotics and the newer anticonvulsants in the treatment of bipolar disorder. Until there is convincing evidence from controlled clinical trials that these alternatives are superior to lithium in improving the overall well-being of patients with bipolar disorder, it is my opinion that lithium remains the drug of choice.
Objective: To compare the needs of patients and with those cited by psychiatrists in the current physician study to provide a more balanced view of the scope of unmet needs.
Methods: A US‐based consensus panel categorized unmet needs according to their relevance to patients, providers, or health systems.
Results: Patients need medications that are quicker acting, have less troublesome side‐effects, are more effective, and are significantly less expensive, and they need access to medications most likely to help them by not being at the mercy of restricted formularies. To improve communication with patients, physicians must not only listen more effectively but must also ask patients more direct and targeted questions, particularly regarding all symptoms the patient might be experiencing. Patients gave a high priority to making treatment decisions jointly with their physicians and being partners in their wellness plan. Peer support can also be extremely helpful to people who have bipolar disorder.
Conclusions: By making efficacious, affordable medications available, improving communications, jointly creating wellness strategies and goals, and equally participating as active partners, patients and physicians can work together to achieve optimal wellness not just remission of symptoms.
Previous research demonstrated that depression is associated with attachment insecurity. The present study examined the association between adult attachment and depression in couples, both concurrently and longitudinally. We tested the hypothesis that, when one partner is depressed, both partners will be insecurely attached, particularly when the wife's depression is chronic. Self-reported ratings of attachment were collected in a sample of couples in which wives met DSM-III-R criteria for depression in the past year (N = 52) and in a normative sample of couples (N = 60). The course of the women's episodes also was followed over a 6-month period. Depressed women reported more fearful attachment than did women in the normative sample. Overall, the husbands of the depressed women were not more likely to report insecure attachment. However, husbands of women diagnosed with chronic depression reported less attachment security than did husbands of women with discrete episodes of depression. In addition, husbands' insecurity predicted the maintenance of their wives' depressive symptoms over the follow-up period.
MIXREG is a program that provides estimates for a mixed-effects regression model (MRM) for normally-distributed response data including autocorrelated errors. This model can be used for analysis of unbalanced longitudinal data, where individuals may be measured at a different number of timepoints, or even at different timepoints. Autocorrelated errors of a general form or following an AR(1), MA(1), or ARMA(1,1) form are allowable. This model can also be used for analysis of clustered data, where the mixed-effects model assumes data within clusters are dependent. The degree of dependency is estimated jointly with estimates of the usual model parameters, thus adjusting for clustering. MIXREG uses maximum marginal likelihood estimation, utilizing both the EM algorithm and a Fisher-scoring solution. For the scoring solution, the covariance matrix of the random effects is expressed in its Gaussian decomposition, and the diagonal matrix reparameterized using the exponential transformation. Estimation of the individual random effects is accomplished using an empirical Bayes approach. Examples illustrating usage and features of MIXREG are provided.
The treatment alliance is the arena in which psychopharmacological and other therapeutic interventions occur. The nature and quality of the treatment alliance may affect adherence to treatment and the realization of the benefits of effective pharmacological treatment in clinical practice. It is an area that has attracted little systematic study, despite the available evidence suggesting that it plays a measurable role in clinical outcomes.
A literature search was undertaken using Medline, Ovid, Psychinfo and Science Direct from 1975 to 2004. The following key words were used: bipolar disorder, patient adherence, non-adherence to medication, compliance, doctor-patient relationship, doctor-patient communication, treatment alliance, therapeutic alliance, chronic illness management, collaborative care, self-management, health beliefs, self-efficacy, self-determination, autonomy support, motivational interviewing.
Psychosocial interventions have demonstrated positive effects on adherence problems. Studies of the impact of the treatment alliance on outcomes in mental illness highlight the possibilities of fruitful research in this area in bipolar disorder. Different theoretical models of changing health related behaviour may inform approaches to the treatment alliance.
Results suggest the usefulness of a collaborative approach to the treatment alliance. Attention needs to be given to developing intervention models that target modifiable risk factors for non-adherence and address patient, clinician and illness related variables to enhance medication adherence in the treatment alliance. Refinement of these models through controlled evaluation in real world settings may lead to integration in health care delivery systems.
In a study of 18 patients with manic symptomatology and 31 patients with melancholic symptomatology the Bech-Rafaelsen Mania Scale (BRMS) and the Hamilton Depression Scale (HDS) have been compared. The results showed that the inter-observer reliability of the BRMS was adequate compared with the HDS. Both scales are constructed for assessing the severity of manic or melancholic states, and no difference was found in the total BRMS or HDS score between the various diagnostic groups, when the patients were classified by an index of the course and symptomatology otive disorder, using the Multi-axial Classificetion System for Affective Disorders (MULTI-CLAD). The homogeneity of the BRMS seemed more adequate than that of the HDS, when each item was correlated to the corresponding total score. Although the homogeneity of the BRMS needs to be evaluated by other statistical models than correlation analysis, our results seem to indicate that the improvement in assessing manic-melancholic states quantitatively is a matter of redefining items or incorporating new items in the melancholic rather than the manic part of these rating scales.
The current point and lifetime prevalence rates of affective disorders, based on the application of Research Diagnostic Criteria to a US urban community sample, are reported. The affective disorders studied included major and minor depression, mania, hypomania, bipolar I and II, primary and secondary depression, schizo-affective disorder, depressive and cyclothymic personality, and grief reactions. Epidemiologic surveys that include treated and untreated persons to obtain rates of specific psychiatric disorders are needed for scientific purposes and health care planning.
While the Hamilton Rating Scale for Depression (HRSD) has been the standard instrument for the assessment of the severity of depression for many years, this scale has a number of limitations. We developed the Modified Hamilton Rating Scale for Depression (MHRSD) to overcome some of these limitations and to enable paraprofessional research assistants to make reliable and valid assessments of depressive symptoms. The present study investigates the reliability and validity of the MHRSD. Interrater reliability among paraprofessional research assistants was excellent. The relationship between the MHRSD and expert clinician ratings on the MHRSD and the original HRSD was also high. Thus, the MHRSD appears to be a useful addition to the clinical researcher's assessment battery.
The failure rate in long-term lithium treatment of bipolar affective disorder is in the range of 20 to 30%, even with rigorous diagnostic criteria an adequate serum lithium levels. This may be due to a variety of biologic and psychosocial factors. Psychosocial factors affecting treatment outcome were studied in 60 RDC diagnosed bipolar patients treated with lithium for one year. Outcome was measured using an affective episode score, a social adjustment scale and a global assessment scale. Social support was the factor most strongly correlated with a good outcome on all three measures.
Over the last decade, our clinical research team has evolved effective methods for forming a strong treatment alliance with mood disorder patients. These methods, in turn, have been associated with very low rates of patient dropout (< 10%) and high rates of objectively measured medication compliance (> 85%) over multiyear treatment trials. We have every reason to believe that our technique for alliance building would be equally effective in general clinical practice. The cornerstones of our methods are education of, information for, and active participation by the patient in the treatment process. We begin by educating the patient about his or her disorder and its treatment, giving patients as much information as their clinical condition will allow them to absorb. As patients begin to improve, we provide additional information. We continuously inform patients about what to expect in treatment and when, both with respect to amelioration of symptoms and with respect to the medication side effects they may experience. We present the treatment experience as an experiment in which clinician and patient are coinvestigators, each with his or her own expertise. The clinician is the expert on the disorder and its treatment in general; the patient is the expert on his or her own disorder and his or her own experience of the treatment. We try to keep the experiment interesting and, whenever possible, to inject some humor into it. We work to engage family members as adjunct members of the experimental team by educating them as well and keeping them informed throughout the treatment process.(ABSTRACT TRUNCATED AT 250 WORDS)
The authors assessed insight on admission on the 15th, 30th and discharge day in 77 female inpatients (42 schizophrenic, 13 manic, 22 depressives) using McEvoy's Insight and Treatment Attitude Questionnaire (ITAQ) and studied its relation to psychopathology, which was assessed by completion of the Brief Psychiatric Rating Scale (18-item version). The data suggest that depressives had good initial (on admission) insight, schizophrenics the poorest, followed shortly by manics. Insight (ITAQ total score) improved significantly after treatment in both mania and schizophrenia. Moreover a constantly significant negative correlation existed between ITAQ and BPRS in mania but not in schizophrenia, indicating that other factors besides psychopathology might influence insight in schizophrenia.
Structural equation modeling with latent variables was used to test whether negative affectivity, or the cross-situational tendency to experience and express negative thoughts and feelings, correlates with spouses' attributions for relationship events and accounts for the association between attributions and satisfaction. Eighty married couples completed measures of marital satisfaction, attributions, and negative affectivity. Spouses high in negative affectivity tended to make maladaptive attributions, but spouses' attributions were unrelated to the level of negative affectivity reported by the partner. Attributions and marital satisfaction remained associated among husbands and wives after controlling for negative affectivity. These findings clarify the link between attributions and marital satisfaction and raise the possibility that negative affectivity contributes to the attributions that spouses make for negative events in marriage.
A total of 21 recovered bipolar patients on prophylactic treatment were prospectively followed up for a period of 1 year. Data for major recurrences were retrospectively collected for an additional 3-year period. During the entire 4-year period, over half of the patients (52%) had no major affective recurrences. Eight patients experienced a major depressive episode, while only two experienced a manic one. Psychosocial and clinical variables were assessed at entry to the study. The effect of these variables on the subsequent 4-year illness course was analysed using survivorship curves. The results show that the following psychosocial variables significantly predicted the occurrence of a major affective episode: low level of social support, maladjustment in social and leisure activities, and poor quality of relationships with extended family. In contrast, clinical variables which characterize illness history were not significantly associated with major recurrences.
Unipolar and bipolar patients with a chronic illness pattern were investigated to evaluate the relevance of clinical and psychosocial risk factors to predict subsequent recurrence. Self-esteem, social adjustment, social support and attributional style were assessed in 27 recovered bipolar patients, 24 recovered unipolar patients maintained on lithium or antidepressant prophylaxis and 26 healthy controls. They were further interviewed every 2 months in a 1-year period in order to diagnose affective episodes according to Research Diagnostic Criteria. Survival analyses and Cox's regressions demonstrated that being a unipolar patient and showing poor social adjustment were the strongest predictors of the occurrence of affective episodes. Self-esteem, social support, attributional style and clinical characteristics, such as age at illness onset, number of previous episodes or of previous hospitalizations and presence of affective disorder in first-degree relatives, were not found to be risk factors for further recurrence. This study stresses the importance of social adjustment in evaluating the outcome of affectively ill patients maintained on medication prophylaxis.
Studies of compliance with pharmacologic treatment in patients with bipolar disorder have primarily involved outpatients receiving lithium. To date, very little data addresses the rates of noncompliance in patients with bipolar disorder treated with other available mood stabilizers (e.g. divalproex, carbamazepine). One hundred and forty patients initially hospitalized for a bipolar disorder, manic or mixed episode, were evaluated prospectively over 1 year to assess their compliance with pharmacotherapy. Compliance was assessed by a clinician-administered questionnaire, using information from the patient, treaters, and significant others. Seventy-one patients (51%) were partially or totally noncompliant with pharmacologic treatment during the 1-year followup period. Noncompliance was significantly associated with the presence of a comorbid substance use disorder. Denial of need was the most common reason cited for noncompliance. Compliance was associated with being male and Caucasian and with treatment with combined lithium and divalproex or with this combination and an antipsychotic. Noncompliance with pharmacotherapy remains a substantial problem in the treatment of patients with bipolar disorder.
Non-compliance is the most frequent cause of recurrence during prophylactic lithium treatment and is associated with poor response and high levels of suicidality. Non-compliance is a complex phenomenon and may have a number of causes. When manic-depressive patients fare badly under the conditions of so-called 'naturalistic' trials, this usually indicates that such conditions are inadequate for long-term maintenance treatment. Prophylactic lithium treatment must be accompanied by measures to sustain compliance and counteract drop-out, and these measures build on three cornerstones, namely information, support and supervision.
In an epidemiologic sample of female-female twin pairs, we previously reported analyses of lifetime major depression. Because lifetime mania was not assessed, we could not differentiate unipolar from bipolar illness. Having completed such an evaluation in this sample, we now examine three questions: (i) does removing bipolar cases from our cohort substantially alter estimates for the heritability of major depression?; (ii) does our epidemiologic data support a familial relationship between major depression and mania?; and (iii) do our results for major depression and mania suggest that the two disorders are caused by the same underlying liability? We find that (i) the heritability of major depression declines only trivially if cases with a history of mania are removed; (ii) mania in one twin predicts major depression in her cotwin-suggesting a familial/genetic relationship between major depression and mania; and (iii) a multiple threshold model fits our data well, consistent with the hypothesis that unipolar and bipolar disorders are points on a continuum of a single liability of illness. The validity of these results are tempered by the small number of bipolar cases detected, as expected from the low base rate of mania in general population samples.
The association between social adjustment and recurrent affective episodes was examined in 27 recovered bipolar patients and 24 recovered unipolar patients who had been receiving maintenance treatment for at least 1 year. Social adjustment variables and psychiatric status were assessed by bimonthly interviews over the 1-year period using the Social Adjustment Scale (SAS) and the Research Diagnostic Criteria (RDC). Variations in the social adjustment scores were analyzed in the 2 months preceding the onset of a recurrent affective episode. Furthermore, social adjustment variables at entry into the study were assessed to investigate whether there was any association between these and the potential timing of a recurrent episode. Results revealed no significant deterioration in social adjustment during the 2 months preceding a recurrent affective episode. However, it was demonstrated that there was a relationship between a patient's overall social adjustment score at entry into the study and the onset of recurrent affective episodes, independent of any residual depressive symptomatology. Specifically, impaired work adjustment in bipolar and unipolar patients was associated with recurrent episodes. Impaired social and leisure activities adjustment in bipolar patients was also associated with recurrent episodes, and impaired marital adjustment in unipolar patients was associated with recurrent episodes. These results suggest that social maladjustment could be a risk factor for both unipolar and bipolar recurrent affective episodes and that impairment in specific areas of social functioning could be used to predict outcome.
The purpose of the study was to examine the outcome of long-term lithium treatment in consecutively admitted affective disorder patients assigned to high and low serum lithium levels. A total of 91 patients were diagnosed according to DSM-III criteria and randomly allocated to two open treatment groups in which prophylactic lithium was administered in high (serum lithium 0.8-1.0 mmol L-1) and low (serum lithium 0.5-0.8 mmol L-1) doses, respectively. The patients were followed for 2 years or until discontinuation of lithium treatment or readmission to hospital for recurrence of affective illness. The main outcome of the treatment groups was compared with Kaplan-Meier survival curves and by Cox regression analysis. A total of 31 patients (34%) completed 24 months of prophylactic lithium treatment without recurrence and readmission to hospital. In total, 18 patients (20%) suffered a recurrence on lithium, and 42 patients (46%) discontinued lithium or were lost to follow-up. No effect of treatment group was seen, either for the total patient group or for the large subgroup of bipolar patients when analysed separately. A number of patients did not maintain their original assignment to the high serum lithium levels group. The results were analysed both according to assignment and according to actual serum lithium levels. Abuse of alcohol or medication was associated with a poor outcome. Only one third of the patients completed 2 years of lithium prophylaxis successfully. No difference in the protection against recurrences was observed between patients maintained on high and low serum lithium levels.
Discrepancy between efficacy of prophylactic lithium and its effectiveness in ordinary clinical practice necessitates long-term follow-up data from specialised lithium clinics. Also, role of psychosocial factors in influencing the outcome is unclear.
One hundred and eighteen patients of bipolar affective disorder attending a lithium clinic were followed-up for approximately 11 years (range 2-27 years). Demographic and clinical data, measures of social support and psychosocial stress were obtained at the intake in 1989-1990. Study design combined retrospective chart-review (till the time of intake) with prospective follow-up till July 1995.
On lithium, the patients had a mean of 0.43 relapses per year (manic, 0.26; depressive, 0.17) which was significantly less (p < 0.01) than the pre-lithium episode frequency. The figure for entirely relapse-free patients was 24%, and 62% had relapses up to one episode per year (median = 0.3 per year). Fifty-eight (49%) patients were good responders to lithium (relapses < or = 0.30 per year). In comparison to good responders, partial/poor responders had a significantly greater number of pre-lithium depressive episodes, poor lithium compliance, more psychosocial stress and lower social support at intake. These variables correlated well with relapses and explained 32% of the variance of the data.
Lithium had a definite prophylactic effect on long-term outcome. Social support and stressful life events are significant correlates of response to lithium.
Lithium prophylaxis of bipolar affective disorders seems justified though psychosocial factors appear to modulate its effectiveness.
Other psychotropic medications were used during relapse and the assessment of psychosocial factors was cross-sectional.
In a retrospective 6-year follow-up, we assessed the reasons for and the frequency and consequences of non-adherence in 76 affectively ill patients receiving lithium prophylaxis in two lithium clinics. Thirty-eight bipolar (50%), 21 unipolar (27.6%) and 17 schizoaffective patients (22.4%) diagnosed according to DSM-III-R, were investigated with a specialized follow-up documentation. Of the patients 53.9% discontinued prophylaxis at some time; 43.2% of the discontinuations occurred during the first 6 months. In contrast to other studies the main reason reported for non-adherence was resistance against long-term treatment. According to the Lithium Attitudes Questionnaire non-adherent patients showed significantly less acceptance of the prophylaxis in general, of the effectiveness of lithium and of the severity of their illness than adherent patients. In a multivariate analysis of various parameters, only the negative attitude to prophylaxis correlated significantly with non-adherence. Significant correlation was found between treatment outcome and duration of initial prophylaxis. During the 6-year follow-up only the adherent patients showed a significant reduction of the number and duration of admissions. Our findings confirmed non-adherence as a major problem in the effectiveness of lithium prophylaxis. The authors recommend prospective investigations of attitudes and the impact of psychoeducation on long-term adherence.
Noncompliance with medication is a very common feature among bipolar patients. Rates of poor compliance may reach 64% for bipolar disorders, and noncompliance is the most frequent cause of recurrence. Knowledge of the clinical factors associated with noncompliance would enhance clinical management and the design of strategies to achieve a better outcome for bipolar patients. Although most patients withdraw from medication during maintenance treatment, compliance studies in euthymic bipolar samples are scarce.
Compliance treatment and its clinical correlates were assessed at the end of 2-year follow-up in 200 patients meeting Research Diagnostic Criteria for bipolar I or bipolar II disorder by means of compliance-focused interviews, measurements of plasma concentrations of mood stabilizers, and 2 structured interviews: the Schedule for Affective Disorders and Schizophrenia and the Structured Clinical Interview for DSM-III-R Axis II disorders. Well-compliant patients and poorly compliant patients were compared with respect to several clinical and treatment variables.
The rate of mildly and poorly compliant patients was close to 40%. Comorbidity with personality disorders was strongly associated with poor compliance. Poorly compliant patients had a higher number of previous hospitalizations, but reported fewer previous episodes. The type of treatment was not associated with compliance.
Clinical factors, especially comorbidity with personality disorders, are more relevant for treatment compliance than other issues such as the nature of pharmacologic treatment. Compliant patients may have a better outcome in terms of number of hospitalizations, but not necessarily with respect to the number of episodes. Bipolar patients, especially those with personality disorders, should be monitored for treatment compliance.
This study investigated the relationship between psychotherapeutic interventions and pharmacologic measures of pharmacotherapy treatment adherence in patients with bipolar I disorder, as well as the relationship between these measures and treatment outcome. Subjects were participating in an ongoing maintenance treatment study. Audiotaped therapy sessions were rated for frequency of psychotherapeutic interventions related to pharmacotherapy treatment adherence. Pharmacologic measures of medication adherence were compared to the tape ratings as well as to treatment outcome. Variability in log erythrocyte (RBC) lithium-a marker of probable nonadherence to the pharmacotherapy regimen-for individual patients correlated significantly with treatment adherence interventions scale ratings. This marker of nonadherence was significantly related to maintenance treatment outcome, as was variability of the serum lithium level/dose (L/D) ratio; however, no relationship was found between treatment adherence interventions scale ratings and outcome.