Sue Lauder

Group-based psychosocial intervention for bipolar disorder: randomised controlled trial

BACKGROUND Psychosocial interventions have the potential to enhance relapse prevention in bipolar disorder. AIMS To evaluate a manualised group-based intervention for people with bipolar disorder in a naturalistic setting. METHOD Eighty-four participants were randomised to receive the group-based intervention (a 12-week programme plus three booster sessions) or treatment as usual, and followed up with monthly telephone interviews (for 9 months post-intervention) and face-to-face interviews (at baseline, 3 months and 12 months). RESULTS Participants who received the group-based intervention were significantly less likely to have a relapse of any type and spent less time unwell. There was a reduced rate of relapse in the treatment group for pooled relapses of any type (hazard ratio 0.43, 95% CI 0.20-0.95; t(343) = -2.09, P = 0.04). CONCLUSIONS This study suggests that the group-based intervention reduces relapse risk in bipolar disorder.

A randomized head to head trial of MoodSwings.net.au: An internet based self-help program for bipolar disorder

BACKGROUND Adjunctive psychosocial interventions are efficacious in bipolar disorder, but their incorporation into routine management plans are often confounded by cost and access constraints. We report here a comparative evaluation of two online programs hosted on a single website (www.moodswings.net.au). A basic version, called MoodSwings (MS), contains psychoeducation material and asynchronous discussion boards; and a more interactive program, MoodSwings Plus (MS-Plus), combined the basic psychoeducation material and discussion boards with elements of Cognitive Behavioral Therapy. These programs were evaluated in a head-to-head study design. METHOD Participants with Bipolar I or II disorder (n=156) were randomized to receive either MoodSwings or MoodSwings-Plus. Outcomes included mood symptoms, the occurrence of relapse, functionality, Locus of Control, social support, quality of life and medication adherence. RESULTS Participants in both groups showed baseline to endpoint reductions in mood symptoms and improvements in functionality, quality of life and medication adherence. The MoodSwings-Plus group showed a greater number of within-group changes on symptoms and functioning in depression and mania, quality of life and social support, across both poles of the illness. MoodSwings-Plus was superior to MoodSwings in improvement on symptoms of mania scores at 12 months (p=0.02) but not on the incidence of recurrence. LIMITATIONS The study did not have an attention control group and therefore could not demonstrate efficacy of the two active arms. There was notable (81%) attrition by 12 months from baseline. CONCLUSION This study suggests that both CBT and psychoeducation delivered online may have utility in the management of bipolar disorder. They are feasible, readily accepted, and associated with improvement.

A brief review of exercise, bipolar disorder, and mechanistic pathways

Despite evidence that exercise has been found to be effective in the treatment of depression, it is unclear whether these data can be extrapolated to bipolar disorder. Available evidence for bipolar disorder is scant, with no existing randomized controlled trials having tested the impact of exercise on depressive, manic or hypomanic symptomatology. Although exercise is often recommended in bipolar disorder, this is based on extrapolation from the unipolar literature, theory and clinical expertise and not empirical evidence. In addition, there are currently no available empirical data on program variables, with practical implications on frequency, intensity and type of exercise derived from unipolar depression studies. The aim of the current paper is to explore the relationship between exercise and bipolar disorder and potential mechanistic pathways. Given the high rate of medical co-morbidities experienced by people with bipolar disorder, it is possible that exercise is a potentially useful and important intervention with regard to general health benefits; however, further research is required to elucidate the impact of exercise on mood symptomology.

Development of an online intervention for bipolar disorder: www.moodswings.net.au

We describe the development process and completed structure, of a self-help online intervention for bipolar disorder, known as MoodSwings (www.moodswings.net.au). The MoodSwings program was adapted as an Internet intervention from an efficacious and validated face-to-face, group-based psychosocial intervention. The adaptation was created by a psychologist, who had previously been involved with the validation of the face-to-face program, in collaboration with website designers. The project was conducted under the supervision of a team of clinician researchers. The website is available at no cost to registered participants. Self-help modules are accessed sequentially. Other features include a mood diary and a moderated discussion board. There has been an average of 1,475,135 hits on the site annually (2008 and 2009), with some 7400 unique visitors each year. A randomised controlled trial based on this program has been completed. Many people with bipolar disorder are accepting of the Internet as a source of treatment and, once engaged, show acceptable retention rates. The Internet appears to be a viable means of delivering psychosocial self-help strategies.

Pilot of group intervention for bipolar disorder

Objective. This pilot study aimed to determine whether a group based psychosocial intervention reduced rates of relapse, improved function and quality of life in people with bipolar disorder. Method. Patients with a diagnosis of bipolar disorder, types I and II were recruited in the Geelong Region of Victoria. Patients were assessed at baseline for psychiatric status, mood episode, function, and medication adherence. They were randomly assigned to either the intervention arm, a 12-week, structured group-based therapy as an adjunct to treatment as usual or the control arm, which consisted of treatment as usual, plus weekly phone calls. Participants were then followed up for a period of 3 months and assessed by a researcher blinded to treatment and control interventions. Results. Functioning as measured by the Global Assessment of Functioning (GAF) was significantly improved in the intervention group (P=0.008). The social relationships subscale on the (WHOQoL-BREF) showed significant results (P<0.05 level). There was also a positive trend in reduction of relapses in the intervention group. Conclusion. The use of a group intervention for bipolar disorder as an adjunct to usual treatment has potential benefits, both in reduction of relapse and improvement in functionality, and may be a cost effective way of delivering psychosocial treatments.

Psychosocial interventions for bipolar disorder

Aim: To provide a selected overview of the literature on psychosocial treatments for bipolar disorder Method: Selective literature review Results: Randomised controlled trials of psychosocial interventions in bipolar disorder fall largely into five categories, namely: psychoeducation, integrated treatments, family based therapy, cognitive behavioural therapy and interpersonal social rhythm therapy. Most studies have shown some benefit in terms of relapse prevention, but have tended to be effective for either the depressed or the manic pole, and not both. Broader outcome parameters such as quality of life have not been reported consistently. The mechanisms whereby treatments might exert their effects have not been clearly delineated. Many studies have excluded patients with bipolar II and other variants, and those with psychiatric and substance use comorbidities, reducing their generalisability. Discussion: Whilst psychosocial treatments show promise in the area of bipolar disorder, more work is required to delineate the effective elements of such interventions, and to ensure generalisability to individuals with bipolar II and other forms of bipolar disorder, as well as those with psychiatric and substance use comorbidities. Other forms of delivery, such as via the internet, deserve further exploration.

Net‐effect? Online psychological interventions

Psychosocial interventions are effective in the treatment of a range of psychiatric disorders (1). Supply constraints, however, mean that access to specialist interventions is extremely limited (2). This is particularly salient for those in regional and rural areas that have limited contact with specialist services (3). Access is further compounded by a reticence of some to seek help from service providers (4), and the stigma associated with mental illness (5). It seems the Internet has become a place for people to seek help. The use and acceptability of the Internet as a medium for information on a range of physical and mental health issues iswell documented (6). This is supported by the Harris poll of 2000 adults in the United States, which found that depression, anxiety and bipolar disorder accounted for 42%ofhealth issues searched for on the web (7). While men are more likely go online on a typical day than women (61% of men, compared with 57% of women) (8), it is women who are more likely to seek help online (9). Increasingly physicians report of patients taking Internet printouts to their consultations (10). It seems the Internet has indeed been embraced as an information tool. More recently, the use of the Internet has extended beyond information. It has also become a vehicle in which psychological assessment can be conducted and treatment can be delivered (11). Compared with face-to-face treatment for psychological disorders, on-line interventions provide a less inhibiting communication method (12), which may be more appealing to those withmental illness (13). Online interventions are accessible, costeffective and enable 24-h access; the Internet has been described as a place where many who need services are’ (14). A range of therapy formats currently exist online, including the provision of synchronous or asynchronous online therapy through chat platforms or e-mail. A recent study by Chester and Glass (15) explored the burgeoning field of online counseling and found that online therapists reported an increasing number of online clients each year. Predominately clients were female andwith a broader and older age demographic predominating (25–44 years) than is reflected in the Internet use data. Adjunctive service management models also exist with usual care supplemented with access to computer-based psychoeducation, progress monitoring and some online consultations (16). Such programs, as described by Roberston et al. (17), provide a broad integrative package with clinicians able to monitor patient progress. The limited access to efficacious psychological treatments, particularly in rural areas (5) has also given rise to their online application. The highly structured approach of Cognitive Behavioural Therapy (CBT), with clearly defined processes and concepts is particularly well suited to an online format (18) and predominates the current pool of online interventions (19). The acceptance of the online modality is reflected in the number of people who register for such programs as MoodGYM, an open access preventative and treatment intervention for unipolar depression that received more than 800 000 hits over a 6-month period (20). The targets of online interventions are diverse, ranging from smoking cessation programs [eg (21, 22)], diabetes (23), tinnitus (24), encopresis (25), insomnia (26), headache (27), weight (28) and eating disorders (29). A number of studies evaluating the effectiveness of online interventions in the area ofmental health have been conducted, particularly in the area of unipolar depression and anxiety disorders. Since 2001, some 20 randomised controlled trials have been published that target symptoms of depression and anxiety. A little more than half of these studies (57%) have been published in the last 2 years, highlighting this as a new and fast growing area of research. Overall, the results of these studies support their effectiveness and show the ability of online interventions to significantly improve health outcomes (30). An additional appeal of these interventions is how the technology enables complex information to be conceptualised succinctly. Typically this is via a range of multimediamediums such as flash objects, video and audio clips. Often as part of the interventions, some automated feedback regarding progress is provided, such a through feedback from questionnaires (eg MoodGYM http://www.moodgym. anu.edu.au/), and can include strategies that enable participants to monitor and watch their own progress through the use of specifically tailored monitoring tools. At the back-end, the technology provides a range of data helpful in quantifying how engaged someone is with the intervention in general and which specific elements in particular. Most typically, this data include the length of time someone spent on the intervention, what areas of the site did they look at (and for how long) and what they download. In some ways, this level of detail is greater than what is collected in face-to-face interventions and enables the opportunity for the dose effect of an intervention to be assessed. While online interventions may be considered the way of the future (11), these interventions face a number of challenges

www.moodswings : The highs and lows of an online intervention for bipolar disorder - preliminary findings

Advances in understanding recovery and effective communitybased and balanced care leave a dilemma. A significant subgroup of people treated for psychosis in affluent countries remain severely disabled, take little part in community life and are socially isolated, as illustrated by recent work in Australia and the UK. Most of those with psychosis in poorly resourced countries receive no formal care despite successful demonstration of community rehabilitation approaches. What can be done to make better use of community resources and the hospital and other components of balanced care, and to avoid reinstitutionalisation in any form?Aims: Although the age-dependent neurobiological processes leading to cognitive decline in the elderly remains to be fully understood, there is now growing evidence to suggest that age-dependent increases in pro-inflammatory cytokines, such as tumour necrosis factor alpha (TNF), might play a role in such age-associated cognitive decline. The aim of this work was to examine, using a mouse model, the effect of a deficiency of TNF (TNF−/−) on cognitive function throughout aging. Methods: A standardized survey on cognition-like behaviour assessing learning and retention, spatial learning/memory, and cognitive flexibility was used to measure the cognitive-behavioural profile of TNF knockout and wildtype mice, across three age periods; 3, 6 and 12 months of age, respectively. Results: All studied mice strains demonstrated successful exploration and learning processes during the training phases of the tests, which made the specific cognition like tests valid in these mice strains. In the specific cognition-like tests, the B6.TNF−/− mice demonstrated, at 3 months of age, significantly poorer learning and retention in the novel object test as compared to B6.WT mice. In addition, spatial learning and learning effectiveness were significantly poorer in B6.TNF−/− mice, at 3 months of age, as compared to B6.WT mice. While the absence of TNF was correlated with poor cognitive functioning in early adulthood, over time the deletion of TNF resulted in better cognitive performance compared to B6.WT mice. Conclusion: Low-levels of TNF under non-inflammatory immune conditions appear essential for normal cognitive function. Moreover, the absence of TNF with age appears to protect against age-associated cognitive decline. Collectively, these findings suggest a possible role for TNF in the molecular and cellular mechanisms subserving age-related changes in learning, memory and cognition.

Online ethics: where will the interface of mental health and the internet lead us?

While e-health initiatives are poised to revolutionize delivery and access to mental health care, conducting clinical research online involves specific contextual and ethical considerations. Face-to-face psychosocial interventions can at times entail risk and have adverse psychoactive effects, something true for online mental health programs too. Risks associated with and specific to internet psychosocial interventions include potential breaches of confidentiality related to online communications (such as unencrypted email), data privacy and security, risks of self-selection and self-diagnosis as well as the shortcomings of receiving psychoeducation and treatment at distance from an impersonal website. Such ethical issues need to be recognized and proactively managed in website and study design as well as treatment implementation. In order for online interventions to succeed, risks and expectations of all involved need to be carefully considered with a focus on ethical integrity.

To E or not to E? The case for electronic health records

Medicine lags behind business in the adoption of electronic processes generally and client records in particular. Banks, travel agencies, insurance companies and others have changed business processes and adopted electronic automation to serve larger numbers of customers more efficiently and effectively and to create business advantage. Information is aggregated across industry sectors, e.g. supply chain aggregation; e-procurement, etc to support this, and drive improved standards accordingly. Delay in developing and adopting the electronic health record (EHR) may reflect a tendency for health to lag behind industry in its ability to change processes and its customer awareness. This is despite the evidence that EHRs offer increased accuracy, risk reduction, quality improvement, ease of audit and research, and lowered cost. EHR is defined as a longitudinal collection of electronic health information about individual patients and populations. It is a mechanism for integrating health care information currently collected in both paper and electronic medical records (EMR) for the purpose of improving quality of care’ (1). There are many forces pushing the development and adoption of EHRs in healthcare settings. A major driver is reduction in error and increased safety. Errors in paper-based systems can arise because of inaccuracy in transcription and handwriting and loss or misfiling of laboratory and other records. Electronic processes such as electronic prescribing can increase safety by linking to the EHR, thus ensuring that the file has a record of current medications and by detecting and alerting clinicians to drug interactions if agents are prescribed or dispensed by different practitioners. It is often forgotten just how unreliable paper records are. In a comparison of paper records to that of EHRs, the latter were found to be 40% more complete in medication documentation than their hard copy contemporaries (2). In addition, difficulties with timely access to paper records can also impede care. In many emergency departments, where records of patients not seen within a defined period, of say 2 years, are held off-site, are in effect unavailable in 10%of emergency situations (2). It is also potentially difficult to access key data within an extensive written record. An important driver, particularly in mental health services, which are often responsible for care across the continuum of in-patient and community-based settings, is the potential for the EHR to support the integration of provision of care by different providers. Each practitioner is often one element of a far wider network of health delivery, and the value of the total data set is greater than the sum of its individual components. In an era of increasing specialisation, swathes of relevant data are unavailable to an individual practitioner. This can result in error through data absence, and frequently results in inefficiency through duplication. With EHRs, data is potentially immediately available and comprehensive. The shift from in-patient to community-based and episodic care has further amplified the need for accurate and efficient transfer of patient information between organisationally and geographically discrete providers (1). This is especially true of shared care models of health delivery. An evidence base to support the role of EHRs in improving the quality of ambulatory care is being developed, albeit with ambiguous results (3,4). However, the place of EHRs is highlighted by the current national projects being instituted around the globe to develop EHR systems (5). Ownership of such records is becoming an issue of increasing complexity, and needs to be seen in the context that the data and system are separate. Themove to EHRs is occurring concurrently with a shift towards the notion that ownership of the data is, and can be, shared rather than owned by one or other parties, including the patient. Some components of practice recognise this, with radiology reports, for example inmany systems being held by the patient rather than the system, although other drivers such as cost-shifting and practicality make it simpler to have the patient responsible for a hard to manage’ physical film that is needed acrossmultiple providers. EHRs offer the potential of a centralised, patient-held medical record system. Such a system highlights tensions related to issues of confidentiality, where the needs of providers, third party payers and regulators of health care may conflict with the principles of privacy and confidentiality. EHRs are fundamental to the movement towards personalised health, and are tailor-made for internet-based models of information archival and access (6). The ability of EHRs to offer a range of additional components is already in play including online clinical support, education materials, monitoring and outcome tools as part of an integrative disease management tool. It is suggested that these multifunctional systems will ultimately offer the most benefit to patients (7). Surveys suggest that consumers are broadly supportive of the notion of EHR, with the major caveat being that security issues are addressed, and that consumers