Quality control in the management of bipolar disorder: tracking clinical, functional and quality of life outcomes

on May 14, 2013

I am an academic and clinical psychologist with a research interest in bipolar disorder. This post is about the challenge of measuring outcomes when we treat bipolar disorder. I think it’s an important topic, because what we measure largely determines what we try to achieve in treatment.

How do we measure whether a treatment for bipolar disorder is working? Mental health professionals (such as psychologists, psychiatrists, counsellors, social workers) need to know whether their treatments are effective.  People with bipolar disorder need to know whether they are getting what they need in terms of professional support.

In some medical and psychiatric conditions, a good measure of treatment effectiveness is decrease in current symptoms.  If I have the flu or insomnia, I will be perfectly happy if my treatment leads to a decrease in the symptoms of the acute condition.

In chronic and relapsing conditions like bipolar disorder, decrease in symptoms is a meaningful outcome to measure, but only sometimes. If I am manic, I need my symptoms of impulsivity and agitation to decrease; if I am clinically depressed, I need my symptoms of amotivation and negative thinking to decrease. Medications are the first line treatments for these features of BD, and monitoring the effect of medications often involves monitoring symptoms.  Self-report and clinician-report scales can be used to get complementary perspectives on the intensity of manic and depressive symptoms.

Of course, the other challenge of managing bipolar disorder is relapse prevention and staying well. Indeed, many professionals, patients and health systems believe that “recovery” (living well despite the disorder) is the most important goal for treatments of bipolar disorder. Recovery includes not just managing the condition, but also working toward positive goals around leading a meaningful and satisfying life.

Best practice treatment for bipolar disorder is a combination of medication and psychosocial interventions. Psychosocial interventions can be in the form of structured therapies (provided in individual or group formats) or through self-management strategies. There is a lot of overlap between these approaches, and all have the broad aim of preventing relapse and improving wellness.

An important component of all psychosocial treatments for bipolar disorder is encouraging and assisting the patient to monitor their own mood, energy, sleep and other indicators of their condition. Mood diaries in paper or electronic form are commonly used – it’s important to understand that this monitoring is primarily to develop the patient’s own expertise in noticing and addressing early signs of relapse. It is not in fact being used as a measure of the effectiveness of treatment.

So how do we measure the effectiveness of an intervention aimed at relapse prevention and staying well? Let’s take these separately. Relapse in bipolar disorder is often, unfortunately, easy to see: Severe depression or mania are very obvious events in someone’s life and we can easily count whether they’ve happened or not. Of course the challenge here is that we might need a few years to decide whether our treatment is effective – if I was having one episode every 2 years before treatment, I might need a big whack of time to know that my therapist was helping with relapse prevention. We could also use more fine-grained information – if I became hypomanic but did not progress to mania, or if I got mildly depressed but didn’t fall into a hole, I might attribute these better outcomes to the therapy I’ve been receiving.

What about measuring staying well and improving wellness?  We think a good tool for measuring this aspect of treatment is the Quality of Life in Bipolar Disorder Scale (QoL.BD – we might be a bit biased, because we developed it :)). The QoL.BD is a self-report measure of quality of life across various domains of functioning:  Physical, Sleep, Mood, Cognition, Leisure, Social, Spirituality, Finances, Household, Self-esteem, Independence, Identity, Work, and Study. We have linked this tool to our Bipolar Wellness Centre, which elaborates on these domains in the following ways: Providing easy to read information for people who have bipolar and, and listing further resources to gain and maintain wellness in each area of life.

By quantifying people’s satisfaction with these broad areas of life, we can help target the specific areas of strength, or concern that we need to address to improve wellness and continue the process of recovery. A good treatment should lead to improvements in the domains of life that are important to the person with bipolar disorder:  If improvements aren’t being made, the clinician and client should review their work together and consider changing tack.

For more information about how to use the QoL.BD, you can take a look at the following two introductory videos:
Part One, and Part Two

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