Innovations in adjunctive psychosocial interventions for bipolar disorder

Over the past decade, psychosocial interventions have been shown to be effective adjuncts to pharmacotherapy for bipolar disorder (BD). However, effect sizes are not large, mechanisms are poorly understood, and more research is urgently required to improve outcomes for people with BD.  Our international group has sought to innovate in this space, building on theory and research in two broad areas: quality of life (QoL) as an outcome measure, and the potential importance of ‘staging’ psychosocial interventions for BD. These streams of research share an emphasis on recovery, which is commonly defined as,  “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles . . . a way of living a satisfying, hopeful and contributing life even with the limitations caused by illness” [1, p.15].

Recovery in mental health

Initially driven by the mental health consumer movement, the recovery perspective has been adopted in mental health policies and guidelines worldwide, and has  rapidly become the expressed goal of treatment for persons with persistent mental disorders [2]. Indeed, recovery has so rapidly become instantiated in mental health guidelines throughout the western world that practice has arguably outpaced research [3].

Personal recovery (contrasted with clinical and functional recovery) is commonly defined as the process of individual psychological adaptation to a disorder, contrasted with the reduction of psychiatric symptoms, relapse prevention or addressing functional difficulties [4]. There is a clear focus on social justice in the recovery movement, and its implications for stigma, social inclusion and traditional health power structures are frequently  discussed [5, 6].

Measuring Outcomes of Psychosocial Interventions for Bipolar Disorder

Commonly recognised elements of recovery are connectedness, hope and optimism, identity, meaning in life and empowerment (giving the acronym CHIME, [7], and there are consumer calls for the aims of psychosocial interventions to be more congruent with these humanistic values [8]. Growing interest in recovery-congruent aims has, in turn, encouraged focus on outcome measures that capture broader subjective experiences of the individual. To date, QoL has received the most research attention [9].

The World Health Organization defines QoL as: “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” [10]. Importantly, QoL variables are not merely the inverse of symptom variables. That is, some patients maintain role functioning despite severe symptoms, while others report significant functional and QoL decrements in the context of relatively few symptoms. Indeed, QoL measures have only small to moderate negative correlations with symptom measures [e.g., 11]. Trajectories of symptom and QoL outcomes also diverge over time, whether measured naturalistically [12] or in response to treatment [13]. Finally, patients see QoL and other foci that are broader than symptoms as core treatment targets [14].

The recovery perspective on mental health elevates QoL measurement, consistent with its prioritising of personal agency, context, meaning-making and lived experience [e.g., 5]. QoL outcome measures emphasise individual experience across important life domains in the context of an individual’s culture and values system [9].

In sum, there is growing consensus that symptom measures alone do not capture clients’ or therapists’ aims and clinical outcome measures in BD should be augmented. Future investigations of recovery-focussed interventions may choose to prioritise measures of subjective QoL if these are in fact the primary aims of psychosocial treatment.

Clinical Staging of Bipolar Disorder

Stage-sensitive treatment approaches are common outside mental health. In cardiac health, for example, the ischaemic heart disease model contrasts at-risk individuals, those whose illness is showing signs of progression (symptoms of hypertension, metabolic syndrome etc.) and those with overt cardiac disease [e.g., angina, 15].

The staging approach is less well developed in psychiatry than other areas of medicine. In BD, the staging approach has overlap with the notion of neuroprogression, around which many empirical questions remain: A recent review concludes that neuroprogression is not a general rule in BD, but that a proportion of patients show this unfavourable course [16]. To avoid unwarranted demoralisation, then, it is important to stress to clients and clinicians that progression in BD is not universal and can potentially be reversed with optimal treatment and support.

Staging models generate a number of testable predictions. First, earlier stages tend to have a better treatment response, a more favourable risk-benefit ratio and respond to more benign and potentially transdiagnostic therapeutic interventions. Second, if staging is aetiologically meaningful, earlier intervention should impact the course of the disorder. Third, to the extent that stage progression is underpinned by neurobiological changes, biomarkers should be discernible. Finally, and perhaps most critically, treatments that are tailored to disorder stage should be more effective than solely diagnosis-driven interventions due to their more personalised characterisation of the disorder [17, 18].

The notion of BD staging is consistent with the recovery approach in prioritising interactions between person and disorder. In contrast to a narrow diagnosis-driven approach, stage tailoring aims to guide interventions according to the experiences and needs common to individuals at particular stages of their disorder. For example, individuals in the early stages of BD appear more likely to benefit from psychoeducation and traditional CBT [18], while it has been suggested that acceptance-based interventions might be more beneficial in later stages [19]. Indeed, there is some post hoc evidence that people in the later stages of BD may be harmed by existing psychosocial interventions [20]. One mechanism of this apparent iatrogenic effect might be people’s unproductive self-appraisals when relapse prevention efforts prove ineffective.

Quality of life focused online intervention for late stage bipolar disorder

One example of innovation in this space is the ORBIT project, an ongoing clinical trial comparing two brief online self-management interventions aimed at improving QoL  amongst people who have had at least 10 episodes of BD.   The programs (accessible via personal computer, tablet and mobile phone) are brief (4 modules delivered over 5weeks), self-paced, interactive and tailored to late stage BD. They incorporate a range of multi-media components to maximise engagement and motivation: videos of consumers with lived experience and clinicians, audio files for practicing learned concepts, interactive exercises, quizzes, static images and hyperlinks to PDF content for further learning opportunities.  Guided support is offered via once-weekly asynchronous messages (from trained coaches); peer support is offered via moderated forums and the ability for users to connect privately with each other via a secure-messaging system embedded in the program. The programs are intended to be highly interactive: users are encouraged to track and monitor well-being via an embedded tracking tool, complete interactive exercises and reflect on their participation as they complete each module, contribute to forums, connect with other users (fostering social support) and message their coach for assistance. Engagement and adherence is encouraged via coach messages, seeded forum posts and cognitive behavioural principles to facilitate practice of skills in everyday life.

Feedback from ORBIT participants has been very positive, and recruitment into the trial has progressed much more quickly than expected.  The final few spots in the trial are now open, and recruitment will close in November 2018. To express interest in participating, people – worldwide – who have experienced 10 or more episodes of BD are welcome to visit www.orbitonline.org

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