The Demonstration Site So Far – Improving Recovery for People with a

Diagnosis of Bipolar Disorder

Birmingham and Solihull Mental Health Foundation TrustAnd

The Spectrum Centre for Mental Health Research

The Team

Spectrum Centre for Mental Health Research

Professor Steven JonesDr Fiona LobbanDr Elizabeth Tyler

Rita LongProfessor

Bruce Hollingsworth

Birmingham and Solihull Mental Health Trust

(BSMHFT)

Dr Amanda GathererKaren Charles

Dr Jayne EatonChris MansellElizabeth Kyte

IAPT and Severe Mental Illness

6 demonstration sites:-• Personality Disorder (3)• Psychosis (2)• Bipolar Disorder (1)

www.iapt.nhs.uk

Background Information • A person diagnosed with bipolar disorder in their mid 20’s

loses –9 years of life –12 years normal health –14 years of working life

Prien & Potter, 1990 • Bipolar disorder (BD) has received only 1/7th of the research

spend on schizophrenia despite similar prevalence and morbidity

Mental Health Research Funders Report, 2005

How common is bipolar disorder?

• 1-2 in 100 people for DSM-IV bipolar disorder • Equate about 1 million people in UK • 4-8 in 100 for bipolar spectrum conditions

–Similar clinical and functional outcomes to BD

• Around 50% of people presenting with depression may fit in the bipolar spectrum

Negative consequences • Cost to UK £ 5.2 billion • Unemployment rates of over 50% • Completed suicide 18 times higher than general population • Elevated mortality from cardiovascular disease and accidents (x1.5-2)

Gareth Hill et al, 1996; Kupfer et al 2002; Angst et al., 1999

• High rates of drug and alcohol misuse • Lifetime prevalence rates for

-46% alcohol disorder -41% drug disorder

• 12 month rates of dependence compared to general population -10 times higher for drug -8 times higher for alcohol

Regier et al., 1990;Compton et al., 2007; Hasin et al., 2007

Key issues

• It is not good enough to offer people therapies developed for other conditions

• There are a wide range of psychological interventions available for BD

• The right intervention delivered by correctly trained therapists significantly improves functional and symptom outcomes

• Badly matched treatment delivered by inadequately trained therapists makes people worse

IAPT for Bipolar Disorder Project Objectives

1. Identify a best practice pathway across primary and secondary specialist services

2. Create a knowledge, skills and competencies framework

3. Develop a suite of resources and outcome measures

Key deliverables

1. Identify a best practice pathway across primary and secondary specialist services

Right treatment, right time, right place Review current pathway by mapping current service And speaking to service users and their families Review of unmet need and undetected case stories / missed

opportunities Explore the primary care pathway within selected GP practices

Key deliverables

2. Create a knowledge, skills and competencies framework for clinicians

Focused project in selected GP surgeries – understand awareness and educational / training needs

Develop and test education and awareness raising tools Evaluate resources to support primary care Review awareness and skill set in secondary specialist services Identify and respond to training needs

Key deliverables

3. Create a suite of resources and outcome measures Thorough evaluation of existing clinical interventions delivered

via Bipolar Disorder service in Birmingham and Solihull Formalise a minimum data set for use within Bipolar Disorder

services Review the introduction of self-management resources for

selected primary care settings Create and consult on a Charter for Good Practice Publication and dissemination of data and good practice

findings at the end of the 12 month period

BSMHFT Bipolar Disorder Service

• Psychology-led service but integrated pathway with specialist mental health care

• Provided across the whole of Birmingham and Solihull (pop. 1.2 million)

• Psychological interventions and recovery focused • 100 – 120 referrals a year (2.6 wte Clinical Psychologists, 1 wte

Assistant and full time admin)• Mood on Track – 10 group sessions (80 – 90 complete p/a)• Follow up and on-going support – individual and group

Youth and Early

Intervention for Psychosis

(EIP)

Direct Referral from

GP and Healthy Minds

(IAPT)

Mood On Track Programme

On-going Relapse Prevention Sessions

Assessment

Intake(via GP referral, Healthy Minds

or acute care pathway)

Referral / assessment in secondary services

- CMHT

On-going follow-up by CMHT

Referral to Bipolar Service

MOT course declined or not suitable

Discharge from CMHT to Primary

Care/ Healthy Minds

Mental Health Services for Older People

(MHSOP)

Self Referral

Current and Planned Pathway

On-going access to Bipolar service:• Newsletter• Support group• Refresher

workshops• Telephone

contact• Consultation

10 sessions of group work: ‘Mood On Track’ course

4 – 6 Individual Relapse Prevention Sessions: to develop an early warning signs and relapse prevention plan

‘Mood On Track’ Programme

Session 6: Family

therapy engagement session

Family therapy assessment / formulation / intervention

NB. Some clients will also continue to receive input from community mental health services and family interventions can be provided at any time

Assessment by Bipolar Disorder Team Psychologist(invite to session extended to family or friend)

IAPT SMI Outcome Measures for Bipolar Disorder

Generalised Anxiety Disorder-7 Questionnaire (GAD-7)

Sessional Symptoms Measure (Anxiety)

Patient Health Questionnaire-9 (PHQ-9)

Sessional Symptoms Measure (Depression)

Work and Social Adjustment Scale (WASAS) Sessional

Wellbeing and Economic

Internal State Scale (ISS)

Sessional Symptoms Measure (mood variability)

Bipolar Recovery Questionnaire (BRQ) 6 weekly throughout MoT course, 3 monthly thereafter

Recovery

Bipolar Quality of Life Scale (Bipolar QoL) 6 weekly throughout MoT course, 3 monthly thereafter

Wellbeing

EQ-5D-5L

Monthly (4 weekly) Economic

Patient Experience Questionnaire (PEQ) : Mid and End of Treatment (MET) version

After assessment, final MoT session, after Relapse Prevention sessions

Service User Experience

Outcome data• Paired samples T-Tests were carried out to determine whether there

were any significant differences between pre-therapy and end of therapy scores (week 10) on all outcome measures.

• Service user’s scores on depression (PHQ-9) and anxiety (GAD-7) scales were significantly reduced by the end of the mood on track programme.

• Scores on the ISS sub-scale – well-being, increased significantly indicating improvement in well-being.

• Scores on the WASAS significantly reduced indicating that mood difficulties were impacting less on individuals day to day functioning.

• There was also a significant increase in participant’s scores on the BRQ measure, indicating a higher subjective sense of recovery

Key ChallengesProject wide• Cross site project team (across 125 miles)

• However benefits due to applied research / clinical expertise• Both teams bring knowledge regarding national need

Pathway• Accessibility of resources and interventionsKnowledge, Skills and Competences • Didactic versus active facilitation• Understanding the agents of change within group based interventions• Practitioner and service user experience e.g. of measures• Engaging GPsResources• Deciding upon an minimum data set

Any Questions?

Measure Pre-therapy score (mean of sample)

Post-therapy score(mean of sample)

Interpretation

Generalised anxiety disorder questionnaire (GAD – 7)

9.75 7.33 Scored out of 21 - a score of 7.33 indicates ‘mild anxiety’

Patient health questionnaire (PHQ-9)

12.83 8.25 Scored out of 27 - a score of 8.25 indicates ‘mild depression’

Work and Social adjustment scale (WASAS)

20.50 13.42 Maximum score of 40 – higher score indicates higher severity of difficulties

Internal state scale• Well-being• Activation• Perceived Conflict

95.69--

A wellbeing score of 95.69 indicates depression.

142.08--

A wellbeing score of 142 indicates well being.

The guidelines for classification into different clinical status are:Depression: Well being < 125Mania/hypomania: Well being > 125 and Activation >200

Bipolar recovery questionnaire

Total: 1889.85Mood Manageable: 313.77Developing resources: 640.62

Total: 2161.77Mood Manageable: 365.15Developing resources: 755.85

Scored out of 3600 (higher score indicates a higher degree of self-rated recovery)