Steve Jones

1. National Initiatives in the Development and Delivery of Psychological Approaches to Bipolar Disorder Steve Jones

2. Introductions • Spectrum Centre for mental health research • www.spectrumcentre.org

3. Overview • What psychological approaches are there out there? • What is the mechanism for getting these into practice? • Shortfall between aspiration and reality • IPT SMI programme • Core competencies programme • Hopes for the future • NB. There are probably new developments I have not heard of yet – if I miss anything please get in touch!

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

5. Psychosocial Factors in Bipolar • Life events – both positive and negative associated with triggering episodes • Cognitive styles – • Dysfunctional beliefs • Positive self appraisal • Depression avoidance • Johnson & Fingerhut, 2006 • Mansell & Scott, 2006 • Jones, 2006 • Bentall et al, 2006

6. Psychosocial Factors in Bipolar • Activity and sleep patterns • Approach to early warning signs • Family environment and communication styles • Jones, 2006 • Lam & Wong, 2006 • Morris & Miklowitz, 2006

7. Psychosocial Factors in Bipolar • All of these factors are potentially amendable to psychological interventions

8. Where do people sit within services? • Key feature of bipolar is its fluctuating course • Care needs fluctuate similarly • Many people with bipolar often not in mental health services • Many receive care in primary care or from third sector

9. Diagnostic Issues • Average 10 years from first contact with services to bipolar diagnosis • Evidence for misdiagnosis even for those within mental health services • Many people have bipolar features without meeting full BD criteria • Bipolar relevant therapies are potentially relevant to around 5% of population! Hirschfeld et al., 2000 Perlis, et al., 2005 Smith et al., 2011

10. Psychosocial Interventions • Aims – traditionally symptom focused but becoming more recovery orientated • Meta-analysis of psychological therapies as adjunct to medication (Scott et al 2007) • significant reduction in relapse rates (of about 40%) compared to standard treatment alone. • most effective in preventing relapses in people who were euthymic when recruited into the treatment trial • less effective in those with a high number of previous episodes (>12) NB – Scott CBT trial 2006– no benefit

11. Psychological Interventions are effective (for some people) Established interventions (there are more) • Cognitive Behaviour Therapy • Lam et al., 2003/2005 • Scott, 2006 • Ball, 2006 • Interpersonal and social rhythm therapy • Frank et al.,2005, 2008 • Family focussed therapy • Miklowitz et al., 2003 • Group psychoeducation • Colom et al., 2003, 2005,2009 • Castle 2010 • Enhanced relapse prevention • Lobban et al., 2010 • Mindfulness-based Cognitive Therapy (MBCT) • Williams et al (2008)

12. Access issues • High level of demand for psychological services in bipolar (MDF etc) • Access restricted by lack of training, poor detection, lack of specialist knowledge and stigma about use of services • Many people not in MH services so even less likely to access bipolar specific help

13. Risk of Wrong Treatment • Inappropriate treatments can: • trigger mania • be ineffective and increase resistance to more appropriate care • trigger severe anxiety problems • fail to recognise common comorbidity issues • fail to recognise risk factors including risk taking and suicidality • Surveys at IoP and Manchester indicate access rates to CBT for psychosis around 7-8%. Probably lower for BD as services less configured for them.

14. Wrong Treatments • Pharmacological interventions focussed solely on depression • Psychosocial approaches focussed only on depressive episodes or psychotic experiences • EWS interventions done badly

15. NICE Guidelines 2006 • National Institute for Clinical Excellence 2006 guideline “Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care” Recommends: • Structured psychological therapy for relapse prevention and enhanced coping • Delivered by clinician trained in CBT or similar • Although there are strengths to NICE it reflects current focus on medical over psychological perspectives • i.e. 159 pages on medication • 25 pages on psychological support • Important because • it affects the messages people receive on diagnosis • It affects the ways in which care is delivered • It affects the types of care that are prioritised and offered

16. NICE Guideline Rewrite • Bipolar guidelines currently being updated • Substantial increase in volume of psychosocial intervention trials since last guideline • Level of evidence assigned is a potential issue (psychological trials less common than drug trials as therapy costs much higher) • Reports in 2014

17. Key challenges with bipolar clients • High needs for autonomy • Treatment ambivalence – many value their bipolar experience (not just mania) • Varying mood states from depression through euthymia to mania • High levels of comorbidity including anxiety, substance use and self harm/suicidality

18. Key challenges • CBT informed psychological approaches ideally placed to address these challenges • But requires clinicians with appropriate training, support and supervision • Range of needs of clients means that good psychological care can range from self management to intensive psychological therapy

19. What was happening before IAPT SMI? • Informal survey of IAPT colleagues and of BABCP Bipolar SIG nationally • “CMHT practitioners highlighted that psychological therapy specific for clients with Bi-Polar are not routinely offered in secondary care” • “IAPT workers could be seen as useful to bridge the gap between primary/secondary care” • “What should I do with people referred to IAPT for depression treatment who have bipolar disorder? I am not trained in BD interventions so do I just treat as unipolar?”

20. What was happening before IAPT SMI? • Modern matron delivering inpatient care to individuals recovering from mania (adapted EWS approach) (Tees) • Pilot care pathway BD and psychotic symptoms (East Anglia) • Psychology services delivering 10 session group psychoeducation intervention to recent diagnosis clients (Swindon) • CBT in primary care for bipolar clients currently stable ? Training? Supervision? Based on own reading? (Preston)

21. Service developments • Some great individual initiatives • Not a consistent picture nationally • Types of intervention not necessarily based on current evidence for what is effective • Lack of infrastructure, training, support and supervision

22. IAPT SMI • Process began in Nov 2011 with national stakeholder event • Since then work has been driven forward by an expert advisory group and a series of task and finish groups • In parallel a separate expert group has developed core competencies for SMI therapies

24. IAPT SMI • Demonstration site programme is intended to provide model for good practice and for future development • Our demonstration site is evaluating current good practice, exploring ways of improving access and considering the incorporation of new therapy initiatives

26. Core Competencies • G • roup

29. New Therapy Developments to Inform IAPT SMI • At Spectrum current RCTs include • Group psychoeducation delivered by service users and clinicians (Lobban) • CBT for anxiety in bipolar disorder (Jones) • CBT for alcohol use (Barrowclough & Jones) • Recovery informed CBT for early bipolar disorder (Jones)

30. New Therapy Developments • Self management approaches • Self management intervention for relatives (psychosis including BD: Lobban) • Web psychoeducation intervention for adults with BD • Web intervention to relapse in adults with BD • Web intervention for bipolar parents

31. Other Developments (Not exhaustive) • Manchester • Mansell – TEAMS approach based on Mansell’s appraisal model (RCT) • Exeter • Wright – Physical activity and bipolar disorder • Glasgow/Edinburgh • Gumley, Schwannuer et al. – Integrated psychological therapy approach (RCT) • Cambridge • Holmes – Development of imagery related approaches to BD • Oxford • Williams & Miklowitz – Mindfulness for BD

32. Challenges • Funding fundingfunding … • Big challenge is to use the outcomes of demonstration sites to extend support for programme • This would include setting up appropriate training in line with competencies • No chance of the same level of funding for IAPT 1 • Changes in line with IAPT SMI will be ‘within existing resources’

33. Thanks for your attention • Contact for further information: s.jones7@lancaster.ac.uk www.spectrumcentre.org