Lynere Wilson

Disorder-specific psychosocial interventions for bipolar disorder—A systematic review of the evidence for mental health nursing practice

AIMS To systematically review the evidence for the efficacy of psychosocial interventions for bipolar disorder and examine the implications for mental health nursing practice. BACKGROUND Bipolar disorder is associated with significant psychosocial impairment and high use of mental health services. Generally medication is effective in the treatment of acute episodes but there is increasing evidence that while a large majority of patients recover from these episodes of mania and/or depression, many do not achieve a functional recovery. In response a range of psychotherapies have either been adapted or developed. DESIGN An extensive review of the literature was performed using Medline, Cinahl and PsycINFO databases and 35 relevant research studies were chosen that met inclusion criteria. FINDINGS All the identified psychosocial interventions were structured, adhered to manualized protocols and had solid evidence demonstrating their effectiveness when used as an adjunct to psychopharmacology. The identified psychosocial interventions all incorporated some features of a psycho-education including developing an acceptance of the disorder, awareness of its prodromes and signs of relapse, and communication with others; and several emphasise regular sleep and activity habits. CONCLUSION Mental health nurses have an important role to play in integrating psychosocial interventions into their clinical practice settings and in conducting high quality trials of their clinical effectiveness. Nurses are well-positioned to lead pragmatic trials of the clinical effectiveness of these psychosocial interventions in mental health services because of their experience and expertise in working with patients with bipolar disorder.

Parenting with a diagnosis bipolar disorder.

AIM This paper is a report of a study of the ways in which bipolar disorder is constructed in the DSM-IV and popular texts, and how parents who have been diagnosed as having a bipolar disorder construct their role as parent. BACKGROUND Research into parenting and mental illness has typically taken a deficit-based approach that focuses on the risks to children when a parent has a mental illness. Literature that considers parenting specifically in the context of bipolar disorder retains a focus on the increased risk to their children of psychopathology or psychosocial difficulties. METHOD A critical discourse analysis was conducted using interviews with five parents who had received a diagnosis of bipolar disorder. These interviews were examined in relation to the text that constructs the diagnosis of bipolar disorder (DSM-IV) and the popular texts from which the parents drew their understandings of parenting. FINDINGS The need to monitor and moderate emotions was a dominant theme that emerged from the analysis. For these parents this also involved teaching moderation to their children and monitoring it in their childrens development. The consequence of this for these parents was a heightened sense of the need for self-surveillance. CONCLUSION The challenge for people working with parents who have been diagnosed with a bipolar disorder is to support them to feel confident in the management of their bipolar disorder and their ability to parent effectively.

Effectiveness of interventions to improve medication adherence in bipolar disorder

Objective: To identify interventions that improve medication adherence in bipolar disorder. Method: A review of the literature from 2004 to 2011 was conducted using Medline and manual searching. Results: Eleven studies were identified as meeting inclusion criteria. Five studies demonstrated improved medication adherence. No characteristics of the interventions, clinical characteristics of the groups or methodological factors distinguished those psychosocial interventions that demonstrated improvement from those that did not. Conclusions: While only a few interventions improved adherence, most improved clinical outcomes. Issues were also identified about the way in which adherence is defined. It is proposed that incorporating patient preferences into measures of adherence within the context of a disorder-specific psychosocial intervention may provide an approach that demonstrates both improved adherence and improved clinical outcomes. However this requires further research.

Feeling out of control: a qualitative analysis of the impact of bipolar disorder

Bipolar disorder is a chronic and recurrent disorder with fluctuating symptoms. Few patients with bipolar disorder experience a simple trajectory of clear-cut episodes, with recovery typically occurring slowly over time. The chronic and disabling course of the disorder has a marked impact on the persons functioning and relationships with others. The objectives of this study were to investigate the impact of bipolar disorder on the lives of people diagnosed with this disorder. The method used was a general inductive qualitative approach. Twenty-one participants were interviewed between 2008 and 2009 about how they had experienced the impact of bipolar disorder. The interviews were audio-taped and transcribed. The core theme that emerged was the participants were feeling out of control. Their own reactions and the reactions of others to the symptoms of bipolar disorder contributed to this core theme. The core theme was constituted by feeling overwhelmed, a loss of autonomy and felling flawed. Mental health nurses can help facilitate a sense of personal control for people with bipolar disorder by exploring what the symptoms mean for that person and implementing strategies to manage the symptoms, address social stigma and facilitate active involvement in treatment.

Learning to live well with chronic fatigue: the personal perspective

BACKGROUND Persistent fatigue is recognized as an integral and significantly disabling aspect of the experience of living with a long-term health condition. Acute medical care models have limited applicability when seeking to provide health care to meet the needs of those living with chronic fatigue. AIMS This article is a report of a study that sought to understand how people can live well in spite of the presence of chronic fatigue. METHODS A thematic analysis was conducted on 43 narratives provided by people living with chronic fatigue during 2007 as part of an internet-based study. FINDINGS This report focuses on the two themes that appeared of most relevance to participants: managing energy and redefining self. Two particular approaches to energy management were noted. In the first, the focus is upon moderating and avoiding excess to manage energy. In the second approach, the body was conceptualized as a machine so that energy becomes a limited resource to be managed. Work to redefine the sense of self appeared to be focused upon the desire to seek normality, to see oneself as rational and come to terms with change. CONCLUSION People can and do find ways to live well with chronic fatigue. Understanding how the person with chronic fatigue has come to conceptualize his/her experiences will be a more fruitful starting point than providing recipes for successful living if nurses are to work effectively with this group of people.

Nurse‐led delivery of specialist supportive care for bipolar disorder: a randomized controlled trial

The aim of the study is (1) to assess the feasibility of delivering nurse-led specialist supportive care as an adjunct to usual care in the clinical setting; (2) to examine the relationship between the delivery of specialist supportive care and improved self-efficacy and functioning and reduced depressive symptoms. A randomized controlled trial of the clinical effectiveness of specialist supportive care as an adjunct to usual care was conducted in community mental health services at one site. Participants were randomized to either usual care or usual care and the adjunctive intervention. Self-report measures of depression, general functioning and self-efficacy were completed by participants in both groups at baseline and 9 months. The intervention was delivered parallel to usual treatment arrangements. While recruitment numbers were sufficient, a low rate of engagement meant we were unable to show significant differences in depressive symptoms or self-efficacy between the usual care group and the specialist supportive care plus usual care group. This study demonstrated that it was difficult to engage patients with bipolar disorder in specialist supportive care when they were currently in a mood episode and under the care of community mental health services.

Self-management for bipolar disorder and the construction of the ethical self

The promotion of the self-managing capacities of people has become a marker of contemporary mental health practice, yet self-management remains a largely uncontested construct in mental health settings. This discourse analysis based upon the work of Foucault investigates self-management practices for bipolar disorder and their action upon how a person with bipolar disorder comes to think of who they are and how they should live. Using Foucaults framework for exploring the ethical self and transcripts of interviews with people living with bipolar disorder, this discourse analysis finds that the discursive practices of self-management for bipolar disorder are prescribing a restricted regime for living based upon the quintessential neo-liberal subject using practices that are focused upon managing an unreliable and problematic self. The article concludes with the proposition that the problem of bipolar disorder (for which self-management is an answer) is less about the object itself and more about how we construct the nature of the self. A Māori indigenous ontology is used here as an example of an alternative discursive resource through which people make sense of the self and which allows ways of thinking about self-management that engage with ambivalence and ambiguity rather than restriction and regulation.

Clinical response to treatment in inpatients with depression correlates with changes in activity levels and psychomotor speed

Background: Monitoring clinical response to treatment in depressed inpatients, particularly identifying early improvement, may be sub-optimal. This may impact adversely on patients through longer admissions and sub-optimal pharmacotherapy. Psychomotor speed is a prominent neuropsychological function which changes as recovery occurs. This study examines simple techniques used to quantify psychomotor change and their potential to contribute to monitoring recovery. Methods: Activity levels were continuously monitored in patients diagnosed with a major depressive episode from four acute psychiatric wards using two actigraphs (commercial and scientific) for 3 weeks and linear regression used to calculate a gradient to express rate of change. Psychomotor speed was assessed using the simple Coin Rotation Task. Mood and functioning were rated using the Quick Inventory of Depressive Symptoms, Clinical Global Impression Scale and Functioning Assessment Short Test. The assessments were completed at baseline and follow-up (3 weeks), and correlations were calculated for all change measures. Results: In all, 24 inpatients were recruited but not all completed baseline and follow-up measures. Change in activity count (N = 16) and psychomotor speed (N = 13) correlated significantly with improvement in clinical measures of depressive symptoms. Actigraphs were acceptable to hospital inpatients. Limitations: The limited size of this pilot study precludes the analysis of predictive power or the influence of other variables such as depression subtypes, age, gender or variations related to medications. Conclusion: Early change in simple activity and psychomotor speed warrant further investigation for utility in measuring treatment response in depressed inpatients.

Using Discourse Analysis to Investigate How Bipolar Disorder Is Constructed as an Object

The experiences now known as bipolar disorder have a long history as a focus of attention for psychiatry; from la folie circulaire (circular disorder) to manic depressive insanity to present day bipolar disorder (Goodwin & Jamison, 2007) psychiatry has worked hard to know, define, and claim expertise in the treatment of the disorder. As with many other health conditions which are understood to be incurable and relapsing, in contemporary mental healthcare there is an expectation that people can learn to live a life that is conducive to limiting relapse and, when a relapse does happen, an expectation that the person can learn to see the early signs of impending illness and take appropriate action (Colom & Vieta, 2006; Suto, Murray, Hale, Amari, & Michalak, 2010). As part of this movement towards greater self-management by individuals with long-term health conditions, mental health clinicians have led the development of psycho-education as an intervention. Psycho-education seeks to integrate a psychotherapeutic and educational approach to the way information is shared with people living with long-term conditions so that they learn more about the condition they are understood to have and how best to live with it (Ryglewicz, 1991). It is an intervention that is now recognised as an essential part of mental healthcare for people with bipolar disorder (Poole, Simpson, & Smith, 2012; Stern & Sin, 2012) to the point where it seems ‘common sense’ to expect that a person can learn to manage their own condition and to do so offers the possibility of a greater sense of control over one’s own life. Who would not want this?