Note: Sign-ups for the BETTER project are now closed.
We are pleased to announce that BETTER, a new online program for people living with earlier stage bipolar disorder, is now welcoming participants from around the world to sign up!
The BETTER project
The BETTER project will explore whether our interventions are effective for earlier stage bipolar disorder, defined as having experienced fewer than ten episodes. Additionally, it will explore the benefits of these interventions for different types of outcomes (quality of life, symptoms, functioning). This comparison will expand the understanding of stage-appropriate interventions for bipolar disorder. Feedback about our site and interventions from participants in the ORBIT trial has been overwhelmingly positive. BETTER participants will have access to peer and expert videos, interactive exercises, forums to meet with other participants and access to a personal coach.
We’re looking for 70 participants aged 18–65 years with bipolar disorder who have experienced fewer than ten mood episodes in their lifetime. To participate, sufficient understanding of English and home access to the internet is required. Because BETTER isn’t meant to replace usual care, we’ll also require that participants are under the care of a medical practitioner. The interventions are fully online and participants will access one of the interventions sites at their own pace over 5 weeks. We’ll ask participants to undertake 3 research assessments over the phone and online, and participants will be reimbursed for each of these.
For more information or to sign up, visit:
Read on to learn more about the background of how the BETTER Research Program came about.
Exploring which self-management interventions work for different experiences of bipolar disorder
Clinical staging for bipolar disorder
Clinical staging revolutionised the treatment of medical conditions, and holds significant promise for mental health illnesses. A growing body of evidence indicates that bipolar disorder follows a progressive course for a proportion of individuals; with different clinical, neurological and functional features experienced earlier versus later in the disorder (Berk et al., 2014; Duffy, 2014; Kapczinski et al., 2014; Vieta, Reinares, & Rosa, 2011). There are a number of potential benefits to understanding what role, if any, staging has in interventions for bipolar disorder. Understanding which interventions are most effective at different stages may reduce delays to accessing effective interventions, including medications and psychotherapy (Berk et al., 2014; Berk et al., 2012; McGorry, Nelson, Goldstone, & Yung, 2010). Staging may also help people experiencing bipolar disorder and their professional supports select meaningful targets for intervention. For example, some evidence suggests that a focus on relief of symptoms and management of triggers may have most impact for those at earlier stages of illness, whereas quality of life or functioning may be more meaningful intervention targets in later illness stages (Berk et al., 2012; Murray et al., 2017).
Staging and treatment
Research to date has provided support for the hypothesis that stage of illness plays a role in the effectiveness of interventions for bipolar disorder. Among the first studies to support a role for stage of illness in psychotherapy for bipolar disorder was a cognitive-behaviour therapy (CBT) trial conducted by Scott and colleagues (2006). While no overall superiority of CBT to treatment as usual (TAU) was found for improving rates of recurrence, CBT was superior for individuals with fewer than 12 lifetime mood episodes. Subsequently, similar findings were reported in several psychoeducation trials, where those classified within earlier stages of illness were more likely to report benefits than those in later stages (Colom et al., 2010; Colom et al., 2003; Reinares et al., 2010; Reinares et al., 2008).
Recently, two groups of participants with bipolar disorder were identified based on likelihood of responding to either intensive psychotherapy (in this study; CBT, interpersonal and social rhythm therapy or family-focused psychoeducation), or less intensive collaborative care (Deckersbach et al., 2016). The authors concluded that the first group, earlier in the course of illness, were more likely to recover, recovered faster and were more likely to respond to the low intensity intervention than those in the later stage group.
While these studies show reduced treatment effectiveness for those at later illness stages, each focused on improving symptoms. However, it may be that as bipolar disorder progresses, different outcomes become more relevant, and a few studies have added support to this idea. Murray and colleagues (2015) conducted a pilot study of a novel intervention, Online, Recovery-oriented, Bipolar Individual Tool, ORBIT, designed to improve quality of life outcomes in those with late stage bipolar disorder (based on number of episodes experienced). Significant, moderate to large improvements were reported in participants’ quality of life, while symptoms did not significantly improve. Following on from this, we have recently wrapped up a large international randomized controlled trial of ORBIT, comparing two interventions likely to benefit individuals with late-stage bipolar disorder (outcome data is currently pending).
Similarly, Torrent and colleagues compared TAU medication with two psychosocial interventions; intensive psychoeducation and functional remediation, in a sample of individuals considered to be at a late stage of illness (Bonnin et al., 2016; Torrent et al., 2013). Participants in the functional remediation group reported large improvements in functioning scores at 12-month follow-up, significantly greater than in the psychoeducation group. Conversely, no significant differences in relapses or residual symptoms were reported between groups at follow-up. The findings support the notion that different outcomes may be relevant at different stages. However, research to date has been limited and more studies are needed to explore which interventions are likely to have most benefit at different stages of illness AND whether different outcomes should be targeted at different stages.
The ORBIT interventions are novel in multiple ways, and questions remain about their generalisability or specificity. A new study, BETTER (Bipolar ETherapy To Enhance Recovery), will explore the benefits of these interventions further, with far-reaching clinical and theoretical implications. For example, this study will expand what is known about stage-based interventions for bipolar disorder, an area of research which will ultimately allow individuals to select optimally effective interventions, and meaningful intervention targets. Put simply, BETTER in conjunction with ORBIT, will explore for whom and for what our interventions are most helpful.
Berk, M., Berk, L., Dodd, S., Cotton, S., Macneil, C., Daglas, R., . . . Malhi, G. S. (2014). Stage managing bipolar disorder. Bipolar Disorders, 16(5), 471-477. doi:10.1111/bdi.12099
Berk, M., Berk, L., Udina, M., Moylan, S., Stafford, L., Hallam, K., . . . McGorry, P. D. (2012). Palliative models of care for later stages of mental disorder: maximizing recovery, maintaining hope, and building morale. Australian and New Zealand Journal of Psychiatry, 46(2), 92-99. doi:10.1177/0004867411432072
Bonnin, C. M., Torrent, C., Arango, C., Amann, B. L., Sole, B., Gonzalez-Pinto, A., . . . Group, C. F. R. (2016). Functional remediation in bipolar disorder: 1-year follow-up of neurocognitive and functional outcome. British Journal of Psychiatry, 208(1), 87-93. doi:10.1192/bjp.bp.114.162123
Colom, F., Reinares, M., Pacchiarotti, I., Popovic, D., Mazzarini, L., Martinez-Aran, A., . . . Vieta, E. (2010). Has number of previous episodes any effect on response to group psychoeducation in bipolar patients? A 5-year follow-up post hoc analysis. Acta Neuropsychiatrica. Officieel Wetenschappelijk Orgaan van Het IGBP (Interdisciplinair Genootschap voor Biologische Psychiatrie), 22(2), 50-53. doi:10.1111/j.1601-5215.2010.00450.x
Colom, F., Vieta, E., Martinez-Aran, A., Reinares, M., Goikolea, J. M., Benabarre, A., . . . Corominas, J. (2003). A randomized trial on the efficacy of group psychoeducation in the prophylaxis of recurrences in bipolar patients whose disease is in remission. Archives of General Psychiatry, 60(4), 402-407. doi:10.1001/archpsyc.60.4.402
Deckersbach, T., Peters, A. T., Sylvia, L. G., Gold, A. K., da Silva Magalhaes, P. V., Henry, D. B., . . . Miklowitz, D. J. (2016). A cluster analytic approach to identifying predictors and moderators of psychosocial treatment for bipolar depression: Results from STEP-BD. Journal of Affective Disorders, 203, 152-157. doi:10.1016/j.jad.2016.03.064
Duffy, A. (2014). Toward a comprehensive clinical staging model for bipolar disorder: integrating the evidence. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 59(12), 659-666.
Kapczinski, F., Magalhaes, P. V., Balanza-Martinez, V., Dias, V. V., Frangou, S., Gama, C. S., . . . Berk, M. (2014). Staging systems in bipolar disorder: an International Society for Bipolar Disorders Task Force Report. Acta Psychiatrica Scandinavica, 130(5), 354-363. doi:10.1111/acps.12305
McGorry, P. D., Nelson, B., Goldstone, S., & Yung, A. (2010). Clinical Staging: A Heuristic and Practical Strategy for New Research and Better Health and Social Outcomes for Psychotic and Related Mood Disorders. Can. J. Psychiat.-Rev. Can. Psychiat., 55, 486-497.
Murray, G. (2015). You say you want a revolution: Recovery, biomedicine and muddling through. Australian and New Zealand Journal of Psychiatry, 49(12), 1085-1086. doi:10.1177/0004867415610200
Murray, G., Leitan, N. D., Thomas, N., Michalak, E. E., Johnson, S. L., Jones, S., . . . Berk, M. (2017). Towards recovery-oriented psychosocial interventions for bipolar disorder: Quality of life outcomes, stage-sensitive treatments, and mindfulness mechanisms. Clinical Psychology Review, 52, 148-163. doi:10.1016/j.cpr.2017.01.002
Reinares, M., Colom, F., Rosa, A. R., Bonnin, C. M., Franco, C., Sole, B., . . . Vieta, E. (2010). The impact of staging bipolar disorder on treatment outcome of family psychoeducation. Journal of Affective Disorders, 123(1-3), 81-86. doi:10.1016/j.jad.2009.09.009
Reinares, M., Colom, F., Sanchez-Moreno, J., Torrent, C., Martinez-Aran, A., Comes, M., . . . Vieta, E. (2008). Impact of caregiver group psychoeducation on the course and outcome of bipolar patients in remission: a randomized controlled trial. Bipolar Disorders, 10(4), 511-519. doi:10.1111/j.1399-5618.2008.00588.x
Scott, J., Paykel, E., Morriss, R., Bentall, R., Kinderman, P., Johnson, T., . . . Hayhurst, H. (2006). Cognitive-behavioural therapy for severe and recurrent bipolar disorders: randomised controlled trial. British Journal of Psychiatry, 188(4), 313-320. doi:10.1192/bjp.188.4.313
Torrent, C., Bonnin Cdel, M., Martinez-Aran, A., Valle, J., Amann, B. L., Gonzalez-Pinto, A., . . . Vieta, E. (2013). Efficacy of functional remediation in bipolar disorder: a multicenter randomized controlled study. American Journal of Psychiatry, 170(8), 852-859. doi:10.1176/appi.ajp.2012.12070971
Vieta, E., Reinares, M., & Rosa, A. R. (2011). Staging bipolar disorder. Neurotoxicity Research, 19(2), 279-285. doi:10.1007/s12640-010-9197-8