A NXIETY AND ALCOHOL USE IN BIPOLAR DISORDER S TEVEN J ONES Treatment development and feasibility studies Some of the slides in this talk present independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (RP-PG & RP-PG ). Further support was received from primary care trusts, mental health trusts, the Mental Health Research Network and Comprehensive Local Research Networks in North West England. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

93% of people with a bipolar diagnosis have lifetime experience of anxiety. 32% of people have current anxiety difficulties Co-morbid anxiety and bipolar are associated with poor treatment response increased suicidality earlier age of onset greater risk of relapse Effective interventions exist for anxiety and bipolar separately. No definitive research into psychological treatment of bipolar and anxiety together. McIntyre, et al., 2006 Otto et al., 2006 Feske, et al., 2000 Frank, et al., 2002 Henry, et al., 2003 Ouimet et al, 2009 A NXIETY

A LCOHOL USE IN BIPOLAR DISORDER Most commonly used substance 30-35% prevalence alcohol use Linked to More severe mood disturbance Higher subsyndromal symptoms Great risk of suicide and violence DiFlorio et al 2014 Goldstein et al 2006 Bellivier et al 2011 Elbogen & Johnson 2008

C AN W E T ARGET C OMORBID I SSUES IN BD? Anxiety Alcoho l Both common, worsen clinical outcome, cause distress

S OME I NTERESTING D EVELOPMENTS Lack of RCT trials specifically designed for anxiety or alcohol in BD

PARADES programme 2 streams devoted to development of integrated approaches to Anxiety Alcohol Both based on qualitative interviews and focus groups with people with bipolar disorder to develop Focus, structure Support materials Timing W AYS F ORWARD

F EASIBILITY S TUDIES

Based on current evidence-based CBT for anxiety & Bipolar disorder Therapy Up to 4 months Up to 10 therapy sessions Cognitive behavioural therapists (2 nurses, 1 CP) P RACTICALITIES - A NXIETY

Recruitment = 72 participants (37 intervention/35 control). Bipolar disorder & anxiety (HADS 8+) 18+ English speaking No episode in the past 4 weeks No current suicidal intent Not taking part in any other intervention study RCT

Primary clinical outcomes Anxiety symptoms - HAM-AD and STAI Time to relapses of mood episodes as measured by SCID-LIFE C LINICAL O UTCOMES

122 potential participants screened N = 72 randomised 76% retention to final 20 month follow-up Mean session attendance 7.7 ( ) F EASIBILITY O UTCOMES

STAI-S HAM-A C LINICAL O UTCOMES

T IME TO ANY MOOD RELAPSE

17 participants Attended mean 8.65 session (SD = 2.91) Range of attendance female, 8 male Q UALITATIVE I NTERVIEWS

It's good when you have the sessions but once they finish you feel, I felt like lost… you know it's difficult to remember instantly all the tips, and that If you have got them separate it's like skirting round each, ….but putting them together and showing a person how to deal with them all….it is so much better, definitely I have had anxiety since I was what, about 15 and that is the only thing that worked for me was that CBT therapy It was 10 sessions, and that were it, but the 10 sessions meant that the goals that were laid out at session 1, …and those were the goals that were achieved …that is a far better way of working I have healed better and with coping strategies that have allowed me to do things, a lot quicker than before I do have my bad periods, I am not going to lie, I have had a bad period recently but when those bad periods happen I know what to do to quickly turn them into a good period...00 ANXIETYANXIETY

MI-CBT Individual therapy Up to 20 sessions over 6 months Based on case series Primary focus on alcohol and links to bipolar mood experiences Where not ready to change address other client led issues Link back to alcohol using MI

Recruitment = 44 participants (24 intervention/20 control). Bipolar disorder 1 or 2 Alcohol use >21 units for mem/ >14 for women or At least one alcohol binge per fortnight over past 3 months Score >8 on AUDIT 18+ English speaking No episode in the past 4 weeks No current suicidal intent Not taking part in any other intervention study RCT

C LINICAL O UTCOMES Primary clinical outcomes Frequency and severity of alcohol use (Time Line Follow Back) Time to relapses of mood episodes as measured by SCID-LIFE

F EASIBILITY O UTCOMES 76 referred by trusts or self 74 consented to screening N = 44 randomised 75% retention to final 12 month follow-up Mean session attendance 17.6 (range 1-20) Recruitment was challenging – partly clinicians unaware of client alcohol use – improved when self referral option was offered

A LCOHOL U NITS PER DAY

P ERCENTAGE DAYS ABSTINENT

P ERCENTAGE B INGE D AYS

T IME TO A NY B IPOLAR R ELAPSE

P OST THERAPY QUALITATIVE INTERVIEWS 15 participants Attended from 15 – 20 sessions 10 men, 5 women

I really hope that this gets commissioned as a therapeutic process because for me it was, it was brilliant The therapy without wanting to sound melodramatic I would probably say it was fairly life changing for me to be honest I thought it was going to be a bit of a finger wagging erm... because I can't give up alcohol, I can't, because by giving up alcohol I would give up my whole social existence it was good, it was clear…I knew what exactly what coming up, and also I felt I was in control of it as well I wasn’t just kind of spieling off answers to questions that I didn’t really want to know myself I feel it’s much more manageable it is not my go-to place, so it is not the first thing that I go right I need a drink…because always there is a reason to drink… The conversation was therapeutic because it’s always nice to be involved in a conversation but you know apart from that you know I couldn’t say it was a therapy ALCOHOLALCOHOL

C ONCLUSIONS Feasibility and acceptability demonstrated People want help They will attend integrated therapy Some people report very +ve outcomes Overall quantitative outcomes NS Review Therapy content and thresholds for intervention Consider different models of delivery