The Demonstration Site So Far – Improving Recovery for People with a Diagnosis of Bipolar Disorder Birmingham and Solihull Mental Health Foundation Trust And The Spectrum Centre for Mental Health Research

The Team Spectrum Centre for Mental Health Research Professor Steven Jones Dr Fiona Lobban Dr Elizabeth Tyler Rita Long Professor Bruce Hollingsworth Birmingham and Solihull Mental Health Trust (BSMHFT) Dr Amanda Gatherer Karen Charles Dr Jayne Eaton Chris Mansell Elizabeth Kyte

IAPT and Severe Mental Illness 6 demonstration sites:- Personality Disorder (3) Psychosis (2) Bipolar Disorder (1)

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 : t o 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 Challenges Project 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 interventions Knowledge, 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 GPs Resources 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) Scored out of 21 - a score of 7.33 indicates ‘mild anxiety’ Patient health questionnaire (PHQ-9) Scored out of 27 - a score of 8.25 indicates ‘mild depression’ Work and Social adjustment scale (WASAS) Maximum score of 40 – higher score indicates higher severity of difficulties Internal state scale Well-being Activation Perceived Conflict A wellbeing score of indicates depression A wellbeing score of 142 indicates well being. The guidelines for classification into different clinical status are: Depression: Well being < 125 Mania/hypomania: Well being > 125 and Activation >200 Bipolar recovery questionnaire Total: Mood Manageable: Developing resources: Total: Mood Manageable: Developing resources: Scored out of 3600 (higher score indicates a higher degree of self-rated recovery)