Maree Inder

Conducting qualitative research in mental health: Thematic and content analyses

Objective: The objective of this paper is to describe two methods of qualitative analysis – thematic analysis and content analysis – and to examine their use in a mental health context. Method: A description of the processes of thematic analysis and content analysis is provided. These processes are then illustrated by conducting two analyses of the same qualitative data. Transcripts of qualitative interviews are analysed using each method to illustrate these processes. Results: The illustration of the processes highlights the different outcomes from the same set of data. Conclusion: Thematic and content analyses are qualitative methods that serve different research purposes. Thematic analysis provides an interpretation of participants’ meanings, while content analysis is a direct representation of participants’ responses. These methods provide two ways of understanding meanings and experiences and provide important knowledge in a mental health context.

I Actually Don't Know Who I Am : The Impact of Bipolar Disorder on the Development of Self

Abstract The majority of patients with bipolar disorder have onset prior to twenty years with early onset associated with increased impairment. Despite this, little attention has been given to the psychosocial developmental impact of this disorder. This qualitative study explored the impact of having bipolar disorder on the development of a sense of self and identity. Key findings from this qualitative study identified that for these participants, bipolar disorder had a significant impact in the area of self and identity development. Bipolar disorder created experiences of confusion, contradiction, and self doubt which made it difficult for these participants to establish continuity in their sense of self. Their lives were characterized by disruption and discontinuity and by external definitions of self based on their illness. Developing a more integrated self and identity was deemed possible through self-acceptance and incorporating different aspects of themselves. These findings would suggest that it is critical to view bipolar disorder within a psychosocial developmental framework and consider the impact on the development of self and identity. Afocus on the specific areas of impact and targeting interventions that facilitate acceptance and integration thus promoting self and identity development would be recommended.

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.

Randomized, controlled trial of Interpersonal and Social Rhythm Therapy for young people with bipolar disorder

This randomized, controlled clinical trial compared the effect of interpersonal and social rhythm therapy (IPSRT) to that of specialist supportive care (SSC) on depressive outcomes (primary), social functioning, and mania outcomes over 26–78 weeks in young people with bipolar disorder receiving psychopharmacological treatment.

''I Really Don't Know Whether it is Still There'': Ambivalent Acceptance of a Diagnosis of Bipolar Disorder

Questioning a diagnosis of bipolar disorder is not surprising given the chronic and fluctuating nature of the illness. Qualitative research using thematic analysis was used to derive an understanding of the process patients used to make sense of their diagnosis of bipolar disorder. The findings suggested that receiving a diagnosis was an active process. Factors such as fluctuating moods, changing diagnoses or misdiagnosis, difficulties patients have differentiating self from illness, mistrust in mental health services, and experiences of negative side effects of medication can contribute to ambivalence about the diagnosis and lead to relapse. These findings highlight the need for clinicians to focus on patients’ perceptions of bipolar disorder and work with the ambivalence in the process of facilitating greater acceptance. This has the potential for reducing relapses through increased adherence with treatment.

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.

Further evidence for slow binocular rivalry rate as a trait marker for bipolar disorder

Objective: Binocular rivalry refers to a situation where contradictory information is presented simultaneously to the same location of each eye. This leads to the alternation of images every few seconds. The rate of alternation between images has been shown to be slower in euthymic participants with bipolar disorder than in healthy controls. The alternation rate is not uniformly slowed in bipolar disorder patients and may be influenced by clinical variables. The present study examined whether bipolar disorder patients have slower alternation rates, examined the influence of depression and explored the role of clinical variables and cognitive functions on alternation rate. Method: Ninety-six patients with bipolar disorder and 24 control participants took part in the study. Current mood status and binocular rivalry performance were analysed with nonparametric tests. A slow and a normal alternation group were created by median split. We subsequently explored the distribution of several clinical variables across these groups. Further, we investigated associations between alternation rate and various cognitive functions, such as visual processing, memory, attention and general motor speed. Results: The median alternation rate was significantly slower for participants with bipolar disorder type I (0.39 Hz) and for participants with bipolar spectrum disorder (0.43 Hz) than for control participants (0.47 Hz). Depression had no effect on alternation rate. There were no differences between participants with bipolar disorder type I and type II and in regard to medication regime and predominance of one rivalry image. There were also no differences in regard to the clinical variables and no significant associations between alternation rate and the cognitive functions explored. Conclusion: We replicated a slowing in alternation rate in some bipolar disorder participants. The alternation rate was not affected by depressed mood or any of the other factors explored, which supports views of binocular rivalry rates as a trait marker in bipolar disorder.

Social rhythm interventions for bipolar disorder: a systematic review and rationale for practice

INTRODUCTION Three interconnected pathways to relapse have been identified as stressful life events, medication non-adherence and disruptions in social rhythms (daily activity and routine). The role of medication and stressful life events is generally better understood than the role of social rhythms. There is no previous review of interventions that target social rhythms. AIM To identify the evidence for the effectiveness of interventions that target social rhythms for improving mood symptoms. METHOD A quantitative systematic review was conducted. Results Seven studies were included in the review: four reporting interpersonal and social rhythm therapy (IPSRT) interventions and three sleep/light interventions. DISCUSSION The results suggest that IPSRT may have a potential benefit in improving mood symptoms and relapse, but it is not clear whether this is of greater benefit than an intensive supportive care intervention of similar duration. The sleep/light interventions demonstrated rapid mood improvements; however, it was not clear how long this improvement was sustained. IMPLICATIONS FOR PRACTICE Attention to social rhythms and the implementation of interventions that target these could be useful for mental health nursing practice may provide people with BD a clinically effective adjunctive intervention to medication.

A developmental approach to the treatment of bipolar disorder: IPSRT with an adolescent

AIM This case study explains how a psychotherapy previously used with adults can be used with adolescents by focusing on the specific developmental issues associated with adolescence. BACKGROUND Bipolar disorder is a damaging disorder to experience during the developmental phase of adolescence. Interpersonal social rhythm psychotherapy has been developed as an adjunct to medication for managing bipolar disorder and shows some promising outcomes in adults. DESIGN This is a single case study design drawn from a larger randomised control trial of two psychotherapies for bipolar disorder. The case study addressed the question: How can Interpersonal social rhythm therapy be applied with adolescents who have bipolar disorder? METHOD This study used a purposeful sampling process by selecting the youngest adolescent participating in the randomised control trial. All the subjects sessions of Interpersonal social rhythm therapy were taped, transcribed and analysed. The analysis involved describing the process of psychotherapy as it occurred over time, mapping the process as a trajectory across the three phases of psychotherapy experience and focusing the analysis around the impact of bipolar disorder and IPSRT on adolescent developmental issues, specifically the issue of identity development. RESULTS Interpersonal social rhythm therapy allowed the therapist to address developmental issues within its framework. As a result of participation in the psychotherapy the adolescent was able to manage her mood symptoms and develop a sense of identity that was age-appropriate. CONCLUSION Interpersonal social rhythm therapy provided the adolescent in the case study the opportunity to consider what it meant to have bipolar disorder and to integrate this meaning into her sense of self. RELEVANCE TO CLINICAL PRACTICE Bipolar disorder is a chronic and recurring disorder that can have a serious impact on development and functioning. Interpersonal social rhythm therapy provides an approach to nursing care that enables adolescents to improve social functioning.