March 30, 2021
By Sophie Parker
Today on March 30th World Bipolar Day we asked Dr. Sophie Parker, Consultant Clinical Psychologist, Youth Mental Health Research Unit, Greater Manchester Mental Health NHS Foundation Trust (GMMH) UK, to share with us an update on early intervention for bipolar disorder.
Bipolar disorder (BD) is characterised by fluctuations in mood from depression to mania and can be severe and potentially disabling. BD is a leading worldwide cause of disability adjusted life years in people aged 10-24 years. Disability adjusted life years represents the burden of a ‘disease’, as the number of years lost due to ill-health, disability or early death. The World Health Organisation states BD is one of the main reasons for loss of life and health in young adults. It is clear that misdiagnosis and a lengthy time to treatment is common, and people often wait years for the correct diagnosis and access to treatment. With a reported average wait of around six years, although we know this can be much longer when symptoms begin under age 21. This is a significant finding as approximately two thirds of individuals with BD experience their first symptoms before age 19 and this lack of access to timely treatments can result in worse outcomes. The serious personal and societal costs of BD, especially when treatment is delayed, suggests that intervening in early symptoms to prevent more severe illness should be a clinical priority.
We have seen the early intervention model used internationally to support people with first episode psychosis and those at high risk of developing psychosis, with important clinical and economic benefits. Consequently, researchers have proposed extending early detection and intervention services to provide support and interventions for other mental health problems in young people, including BD and those at-risk of developing BD. With limited evidence to draw upon, unfortunately there is no current guide for clinical services on the identification and treatment for people considered to be at-risk of developing BD. These guidelines will be crucial as our experience has also shown us that the early stages of BD are often poorly recognised by clinicians, partly because many people initially present with depressed mood and very few services provide specialised BD care where additional assessment of other aspects of mood are assessed.
Applying early detection and intervention approaches used for people with subthreshold psychosis experiences such as the “close-in strategy” could be a useful approach. Informed by Yung and colleagues’ ultra-high risk of psychosis criteria, a group led by Andreas Bechdolf brought together key evidence about the family risk of BD, peak age of onset, and early symptoms that seem to come before the onset of BD, to develop the Bipolar At Risk (BAR) criteria. This criteria has shown to be able to predict those who go on to develop BD later and is reliable and valid.
An important next step is to identify useful treatments for people at-risk of BD. Clinical guidelines recommend offering psychological interventions to individuals with BD, particularly young people. Cognitive behavioural therapy (CBT) has been found by multiple studies to improve functioning, symptoms of mania and depression and relapse rates in adults with BD. CBT has also been found to significantly improve recovery outcomes in recent-onset BDand mood symptoms and functioning for children with BD. Additionally, CBT is an evidence-based and recommended intervention for people at-risk of psychosis so could form part of the widening of early detection teams as we have seen pioneered within one such team at Greater Manchester Mental Health NHS Foundation Trust (GMMH).
Based on this our group were funded by the NIHR to conduct a study comparing CBT (CBTBAR) with treatment as usual (TAU) for individuals who meet criteria for Bipolar at risk (BAR).
The Bipolar at Risk Trial (BART; ISRCTN10773067), sponsored by GMMH, was a feasibility randomised controlled trial testing the acceptability of CBTBAR, a CBT treatment focusing on how people make sense of low and high moods. CBTBAR is based on an Integrative Cognitive Model (ICM) that suggests people hold extreme and contradictory ideas about internal states leading to recurrent styles of thinking, behaving, and feeling that maintain and escalate mood episodes. The CBTBAR approach uses an individualised approach taken from this model to reduce experiences of mood swings by targeting important appraisal change, enabling people to have a better quality of life, independently of mood state.
Participants spoke positively about their experiences and the impact the trial overall and the treatment had on their life e.g. the chance to open up to an understanding research assistant about distressing experiences, the perceived helpfulness of flexible, personally tailored CBTBAR sessions, and development of a close therapeutic relationship. This help-seeking population stated the trial was valuable even for those who did not receive CBTBAR as they felt listened to and had the opportunity to open up with research assistants to discuss their experience of both low and high moods. Participants who received CBTBAR appreciated aspects of therapy such as feeling comfortable with the therapist and not feeling patronised. CBTBAR seems an acceptable and feasible treatment option and a larger trial of CBTBAR focusing on mood swings for this group is needed.
It is clear from our discussions with young people at risk of BD that they want access to services for mood swings and additional trials are needed to understand which treatments could be beneficial to this group. The importance of developing interventions with a focus on health promotion and prevention has long been recognised.
Navigating this path will require further investment if we are to achieve the benefits for service users and their family members alongside the potential economic and societal benefits. This could be life changing for a young person and may provide hope for a different future than they feel could otherwise be possible:
“I just like …. to say thank you to everyone involved because it’s been probably one of the most biggest experiences in my life that’s impacted me in the best way possible, so I couldn’t thank you guys enough for giving me a future” [BART participant]
You can follow Dr. Sophie Parker on Twitter @ParkerSpophs
You can follow the work of BART on Twitter @BipolarAtRisk
You can connect with the Youth Mental Health Research Unit @YMHRU_UK