Emotion regulation strategies in bipolar disorder: A systematic and critical review

Background Theoretical frameworks emphasise associations between interpretations and responses to affect and bipolar disorder (BD). This review (PROSPERO CRD42016043801) investigated which emotion regulation (ER) strategies have been applied to BD, are elevated in BD compared to clinical and non-clinical controls, and are associated with clinical and functional outcomes in BD Methods Search terms relating to emotion regulation, coping and bipolar disorder were entered into Embase, MedLine and PsycInfo. Quantitative studies investigating relationships between ER strategies and BD were eligible for this narrative synthesis Results A large volume of research (n = 47) investigated specific ER strategies in BD. Maladaptive strategies such as rumination and dampening were elevated in BD compared to controls and these particular strategies had a detrimental impact on outcomes such as mood symptoms. BD had a similar profile of ER strategies to unipolar depression, but there was limited comparison to other clinical groups. People with BD did not generally have deficits in using adaptive strategies, as evidenced by comparisons with controls and experimental studies Limitations Methodological heterogeneity and a lack of ecologically valid ER assessments Conclusions Empirical literature is critiqued in line with contemporary theories of BD and of emotion regulation more generally, in order to inform future research recommendations. This includes investigation of the importance of context in the impact of ER strategies, and discrepancies between trait and state use of ER strategies, particularly through experience sampling

A systematic review of policy and clinical guidelines on positive risk management

Background National policies and guidelines advocate that mental health practitioners employ positive risk management in clinical practice. However, there is currently a lack of clear guidance and definitions around this technique. Policy reviews can clarify complex issues by qualitatively synthesising common themes in the literature. Aims To review and thematically analyse national policy and guidelines on positive risk management to understand how it is conceptualised and defined. Method The authors completed a systematic review (PROSPERO: CRD42019122322) of grey literature databases (NICE, NHS England, UK Government) to identify policies and guidelines published between 1980 and April 2019. They analysed the results using thematic analysis. Results The authors screened 4999 documents, identifying 7 eligible policies and 19 guidelines. Qualitative synthesis resulted in three main themes: i) the conflicting aims of positive risk management; ii) conditional positive risk management; and iii) responsible positive risk management. Conclusions Analysis highlighted discrepancies and tensions in the conceptualisation of positive risk management both within and between policies. Documents described positive risk management in different and contradictory terms, making it challenging to identify what it is, when it should be employed, and by whom. Five policies offered only very limited definitions of positive risk management

What does it mean to age well with bipolar disorder?

Background: Bipolar disorder is characterised by episodes of mania and depression that cause significant impairment and disruptions to people’s lives. This diagnosis has been linked to increased rates of suicide, reduced lifespan, and increased mortality, although there is limited research exploring the challenges faced by people with bipolar disorder as they age. It is possible that there is an important interaction effect between ageing and bipolar disorder that exacerbates the difficulties faced by this group, meaning further attention and support is required. This thesis investigated the challenges faced by older adults with bipolar disorder and explored their preferences, priorities, and needs in later life. Knowledge gathered from four studies helped to identify potential adaptations to care that can be used to improve quality of life in this population and enable them to age well with bipolar disorder. Methods: A range of methods were used to complete this thesis. First, a systematic review and narrative synthesis of 23 papers reporting on 19 studies was completed to investigate the prevalence and predictors of physical health comorbidities in older adults with bipolar disorder. Second, a qualitative study consisting of photo elicitation interviews with 17 participants used reflexive thematic analysis to analyse data and explore what it means to age well for older adults with bipolar disorder. Third, 16 biographical narrative interviews were analysed using narrative analysis to understand the changing care and care needs of older adults with bipolar disorder. Finally, a multilevel analysis of seven waves from The English Longitudinal Study of Ageing data was completed to examine quality of life in older adults with bipolar mood states and assess the predictors of quality of life in this group. Results: Ageing with bipolar disorder was associated with an increased prevalence of certain physical health comorbidities such as cardiovascular disease and some forms of cancer. To age well, participants highlighted the importance of lifelong learning to improve their understanding and management of bipolar disorder and find balance in later life. This learning also helped participants to feel confident in taking an active role in treatment decisions which enabled them to regain agency. Finding a sense of belonging, feeling accepted and building upon strengths all supported older adults with bipolar disorder to age well. Furthermore, giving back to others, such as helping younger age groups with bipolar disorder, allowed participants to develop confidence and self-worth. Participants indicated that there was a disconnect between the care they desired and the care that they currently received from services. Older adults with bipolar disorder appeared to have unique and changing care needs that were often neglected. To improve support, services should attempt to offer care that is consistent and facilitates the development of trusting relationships with professionals. The range of issues faced by this population was found to result in poorer quality of life that appeared to be partly driven by loneliness. Conclusions: Older adults with bipolar disorder face unique challenges and changing care needs that mean treatments require adaptation to improve outcomes in this group. At present, treatments appear to focus on symptom reduction, although participants indicated that treatments prioritising connection and consistency of care are desired. Further attention is required to understand the difficulties associated with ageing whilst experiencing bipolar disorder, to improve care and reduce the inequalities currently experienced by this population

A guide to behavioural experiments in bipolar disorder

Behavioural experiments are an important component of cognitive-behavioural therapy. However, there exists little up-to-date guidance on how to conduct these in people with a diagnosis of bipolar disorder. This paper provides recommendations on how to conduct behavioural experiments in this population. The aim is to upskill and empower clinicians to conduct behavioural experiments. The paper combines the expertise of senior clinicians working in the United Kingdom. The article starts by providing general advice on conducting behavioural experiments in people with bipolar disorder. It then offers specific examples of behavioural experiments targeting cognitions around the uncontrollability and danger of affective states, and related behavioural strategies, which have been implicated in the maintenance of bipolar mood swings. The article finishes by providing examples of behavioural experiments for non-mood related difficulties that commonly occur with bipolar experiences including perfectionistic thinking, need for approval, and intrusive memories. Behavioural experiments offer a useful therapeutic technique for instigating cognitive and behavioural change in bipolar disorder. Conducted sensitively and collaboratively, in line with people's recovery-focused goals, behavioural experiments can be used to overcome mood- and non-mood related difficulties

Quality of life in older adults with mood states associated with bipolar disorder: A secondary analysis of the English longitudinal study of ageing data.

ObjectivesTo investigate: (i) whether mood states associated with bipolar disorder are associated with poorer quality of life in older adults, and (ii) what are some of the predictors of quality of life in older adults with mood states associated with bipolar disorder.MethodsThe authors completed a cross-sectional multilevel analysis of panel data from seven waves of The English Longitudinal Study of Ageing dataset. The main analysis included 567 participants who reported experiencing mood states associated with bipolar disorder. Some participants reported this in more than one wave, resulting in 835 observations of mood states associated with bipolar disorder across the seven waves. Quality of life was assessed using the Control, Autonomy, Self-realization, and Pleasure-19 (CASP-19) measure.ResultsThe presence of mood states associated with bipolar disorder was significantly associated with poorer quality of life, even after controlling for multiple covariates (age, sex, social isolation, loneliness, alcohol use, education level, and economic status). Loneliness significantly predicted poorer quality of life in older adults with mood states associated with bipolar disorder. In contrast, higher educational attainment and being female predicted better quality of life in this group.ConclusionsOlder adults with mood states associated with bipolar disorder have potentially worse quality of life compared to the general population, which may be partly driven by loneliness. This has ramifications for the support offered to this population and suggests that treatments should focus on reducing loneliness to improve outcomes

A systematic review of the effects of psychosocial interventions on social functioning for middle-aged and older-aged adults with severe mental illness

OBJECTIVES: The number of older adults with severe mental health problems such as schizophrenia is likely to double in the next 20 years. The needs of this patient group change across the life course, but difficulties with social functioning persist into older age. Poorer social functioning is associated with poorer outcomes and has been identified as a priority for intervention by patients themselves. This paper systematically reviews studies examining the effectiveness of psychosocial interventions on social functioning for people with severe mental health problems in later life. METHODS: A systematic review of peer-reviewed journal articles was conducted and databases were searched from inception to December 2017. The review was limited to psychosocial interventions, for mid to older aged adults (≥40 years of age) with severe mental illness that included a validated measure of social functioning. RESULTS: Fifteen studies (17 papers) met inclusion criteria. There was evidence to support skills training interventions that primarily focused on social skills training or integrated mental and physical health interventions. There was not sufficient evidence to recommend any other interventions. CONCLUSIONS: The results highlight the limited nature of interventions designed specifically for older people with severe mental health problems that target social functioning and the need for more robust, large-scale studies in the area. Current evidence suggests that cognitive behaviour therapy can be effective in targeting social functioning in younger age groups, but, as yet, there is insufficient evidence to recommend this intervention for an older population

Integrating mobile-phone based assessment for psychosis into people\u27s everyday lives and clinical care: a qualitative study

Background: Over the past decade policy makers have emphasised the importance of healthcare technology in the management of long-term conditions. Mobile-phone based assessment may be one method of facilitating clinically- and cost-effective intervention, and increasing the autonomy and independence of service users. Recently, text-message and smartphone interfaces have been developed for the real-time assessment of symptoms in individuals with schizophrenia. Little is currently understood about patients\u27 perceptions of these systems, and how they might be implemented into their everyday routine and clinical care. Method: 24 community based individuals with non-affective psychosis completed a randomised repeated-measure cross-over design study, where they filled in self-report questions about their symptoms via text-messages on their own phone, or via a purpose designed software application for Android smartphones, for six days. Qualitative interviews were conducted in order to explore participants\u27 perceptions and experiences of the devices, and thematic analysis was used to analyse the data. Results: Three themes emerged from the data: i) the appeal of usability and familiarity, ii) acceptability, validity and integration into domestic routines, and iii) perceived impact on clinical care. Although participants generally found the technology non-stigmatising and well integrated into their everyday activities, the repetitiveness of the questions was identified as a likely barrier to long-term adoption. Potential benefits to the quality of care received were seen in terms of assisting clinicians, faster and more efficient data exchange, and aiding patient-clinician communication. However, patients often failed to see the relevance of the systems to their personal situations, and emphasised the threat to the person centred element of their care. Conclusions: The feedback presented in this paper suggests that patients are conscious of the benefits that mobile-phone based assessment could bring to clinical care, and that the technology can be successfully integrated into everyday routine. However, it also suggests that it is important to demonstrate to patients the personal, as well as theoretical, benefits of the technology. In the future it will be important to establish whether clinical practitioners are able to use this technology as part of a personalised mental health regime

Social recovery therapy: a treatment manual

Social Recovery Therapy is an individual psychosocial therapy developed for people with psychosis. The therapy aims to improve social recovery through increasing the amount of time individuals spend in meaningful structured activity. Social Recovery Therapy draws on our model of social disability arising as functional patterns of withdrawal in response to early socio-emotional difficulties and compounded by low hopefulness, self-agency and motivation. The core components of Social Recovery Therapy include using an assertive outreach approach to promote a positive therapeutic relationship, with the focus of the intervention on using active behavioural work conducted outside the clinical room and promoting hope, values, meaning, and positive schema. The therapy draws on traditional Cognitive Behavioural Therapy techniques but differs with respect to the increased use of behavioural and multi-systemic work, the focus on the development of hopefulness and positive self, and the inclusion of elements of case management and supported employment. Our treatment trials provide evidence for the therapy leading to clinically meaningful increases in structured activity for individuals experiencing first episode and longer-term psychosis. In this paper, we present the core intervention components with examples in order to facilitate evaluation and implementation of the approach