24/04/2012 NICE guidance and best practice in psychological care for “bipolar disorder” Dr Graeme Reid, Consultant Clinical Psychologist, Step 5, Central Lancashire Liz Baines, Practice Development Nurse, Step 5 North Lancashire Network Name

Context to this workshop Local implementation issues (including resources & training needs) – gaps between recommendations and capacity to deliver? Rise of stepped & matched care models and developing evidence base (e.g. BPS “Understanding Bipolar Disorder”). NICE in initial stages of updating bipolar guidance – stakeholder scoping exercise this Friday. IAPT SMI DoH workstream – includes bipolar

NICE clinical guideline 38 (2006) Main focus on pharmacological treatments, with psychological and psychosocial care seen as adjunctive. However wider recommendations worth considering prior to looking at “high intensity” psychological interventions (formal CBT).

Psychological and psychosocial care recommended in NICE guidance: Recommendations refer specifically to CBT, FI, psychoeducation & relapse prevention, sometimes in combination (e.g. RP as component of CBT). Terminology: “individual structured psychological interventions” used interchangeably with CBT.

Working with patients and families Engage families and carers in care with client Give information Encourage joining of self-help groups Advise patients on self-management, triggers, early warning signs and importance of sleep hygiene Advance directives esp for people who have many episodes and MHA

Families continued… Healthcare professionals should consider needs of patient’s family members and be sensitive to the impact of the illness on relationships and other family members Be accessible in times of crisis Healthcare professionals should consider offering a focused family intervention to people with bipolar disorder in regular contact with their families, if a focus for the intervention can be agreed. The intervention should take place over 6–9 months, and cover psychoeducation about the illness, ways to improve communication and problem solving.

Advice re lifestyle & activity Patients with depressive symptoms should be advised about techniques such as a structured exercise programme, activity scheduling, engaging in both pleasurable and goal-directed activities, ensuring adequate diet and sleep, and seeking appropriate social support, and given increased monitoring and formal support.

Rapid cycling Adopt a psychoeducational approach and encourage patients to keep a regular mood diary to monitor changes in severity and frequency of symptoms, and the impact of interventions.

Befriending Healthcare professionals should consider offering befriending to people who would benefit from additional social support, particularly those with chronic depressive symptoms. Befriending should be in addition to drug and psychological treatments, and should be by trained volunteers providing, typically, at least weekly contact for between 2 and 6 months.

When should CBT (“individual structured psychological therapy”) be considered? 1 People with bipolar disorder who are relatively stable, but may be experiencing mild to moderate affective symptoms. People with “treatment resistant” depression (including those who have declined an antidepressant) with no recent history of rapid cycling (focus therapy on depression).

When should CBT (“individual structured psychological therapy”) be considered? 2 Comorbid anxiety disorders (focus therapy on anxiety) During pregnancy (computerised or brief CBT for mild depression, CBT for moderate depression). Children and adolescents experiencing depression.

“Individual structured psychological interventions “ (CBT) 1 The therapy should be in addition to prophylactic medication, should normally be at least 16 sessions (over 6–9 months) and should: include psychoeducation about the illness, and the importance of regular daily routine and sleep and concordance with medication

“Individual structured psychological interventions “ (CBT) 2 include monitoring mood, detection of early warnings and strategies to prevent progression into full-blown episodes enhance general coping strategies.

Who should provide “structured psychological interventions”? Structured psychological interventions should be delivered by people who are competent to do this and have experience of patients with bipolar disorder.”

Discussion 1 What (if any) value have you found in the current (2006) nice guidance? What recommendations were most helpful? If you could write the next NICE guidance, what are the main questions you would want it to address?

Discussion 2 From your perspective, what sorts of psychological care should be routinely available for people who meet bipolar diagnostic criteria? Consider “low-intensity” (e.g. self-help, group psychoeducation, RP etc) as well as high-intensity (e.g. individual CT provided by “expert” therapists, FI). What would an ideal service look like?

Discussion 3 What are the 3 main things you could do to improve the psychological care for people with bipolar disorder / mood swings? (homework task?)

Thank you Feedback on the workshop, reports of any changes you have implemented following the workshop, or general questions all welcome. Email: graeme.reid@lancashirecare.nhs.uk