Management of Co-morbid Anxiety in Bipolar Disorder A New Psychological Approach Steven Jones

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

The following slides present independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding scheme (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.

Consistent with Spectrum approach we wanted to ensure: – Strong service user input from the outset – Integration of evidence based approaches – Aim therapy at targets valued by service users – So Asked people about their experiences of anxiety Asked people what they wanted from treatment Developed treatment based on this input

21 individuals with bipolar disorder and anxiety. Interviewed by a research assistant or a service user researcher. Aimed to find out: – What helps to manage anxiety? – What doesn’t help? – Do people want an anxiety intervention & what might that look like? – What barriers might there be to people accessing an intervention such as this?

Knowledge as power You can’t just treat it with drugs Cognitive strategies Behavioural strategies The therapeutic experience: – Waiting lists – Therapist – Treatment delivery

Most therapy approaches split anxiety and BD. Common therapist question – which do we treat first? People’s lived experience however integrates both. “I think the thing to do would be to find out why I become so anxious, unreasonably so over little things and why I would get so anxious that...I would do something as dramatic as abandon my son, jump in my car and drive away. Why would that be a good idea? but that is driven seriously by anxiety”

Based on Phase 1 results we proposed that the intervention would be: – One to one – Delivered at home / preferred location – Flexible appointments – Accessible immediately on referral – Include general info about bipolar and anxiety. – Include cognitive and behavioural strategies to manage anxiety.

Based on current evidence-based CBT for anxiety & bipolar. Maximum 10 therapy sessions. Therapy delivered over a maximum period of 4 months. Therapy will be delivered by 2 fully trained cognitive behavioural therapists working part time. Participants would live in the Manchester, Lancashire or Cumbria area.

3 focus group sessions at the Spectrum Centre 10 individuals with bipolar disorder 3 health professionals Reviewed Phase 1 findings and our plans for the intervention.

Agreement with themes from Phase 1 Therapeutic experience: – Joint goals for treatment – Regular feedback to therapist – Including care team in outcome Requested: – Resources: colourful, accessible, portable – Website: more likely to access post-treatment

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

Clinical Outcomes Primary clinical outcomes Anxiety symptoms - HAM-AD and STAI Time to relapses of mood episodes as measured by SCID-LIFE Mood symptoms - HAM-AD and MAS

Participant Characteristics AIBDTAUTotal n Mean Age (SD) 45.5 (10.7) 42.9 (16.6) 44.2 (13.8) Sex (%) Male Female 13 (35.1) 24 (64.9) 10 (28.6) 25 (71.4) 23 (31.9) 49 (68.1) N previous episodes (%) < (10.8) 7 (18.9) 26 (70.3) 3 (8.6) 6 (17.1) 26 (74.3) 7 (9.7) 13 (18.1) 52 (72.2) HAM-Anxiety score (%) Less than More than (94.6) 1 (2.7) 29 (82.9) 4 (11.4) 2 (5.7) 64 (88.9) 5 (6.9) 3 (4.2) Ethnicity (%) White British Other white Asian other British Asian Not stated 33 (89.2) 0 2 (5.4) 32 (91.4) 1 (2.9) 0 65 (90.3) 1 (1.4) 3 (4.2) 2 (2.8) Marital Status (%) Married or cohabiting Divorced/annulled/separated Never married 17 (45.9) 9 (24.3) 11 (29.7) 7 (20.0) 13 (37.1) 15 (42.9) 24 (33.3) 22 (30.6) 26 (36.1) Number of children (%) (40.5) 7 (18.9) 8 (21.6) 7 (18.9) 0 15 (42.9) 4 (11.4) 5 (15.3) 7 (20.0) 3 (8.6) 1 (2.9) 30 (41.7) 11 (15.2) 13 (18.1) 14 (19.4) 3 (4.2) 1 (1.4)

Participant Characteristics Living with (%) Spouse / partner only Child(ren) only Spouse/partner & child(ren) Close relative no child(ren) Friends without child(ren) Alone Other 7 (18.9) 3 (8.1) 10 (27.0) 5 (13.5) 0 10 (27.0) 2 4 (11.4) 6 (17.1) 3 (8.6) 1 (2.9) 16 (45.7) 2 (5.7) 11 (15.2) 9 (12.5) 13 (18.1) 8 (11.1) 1 (1.4) 26 (36.1) 4 (5.6) Education (%) Year 7-11 (No GCSEs) GCSEs or equivalent Further education not completed Further education completed Higher education not completed Higher education completed Postgraduate not completed Postgraduate completed 3 (8.1) 6 (16.2) 4 (10.8) 8 (21.6) 3 (8.1) 8 (21.6) 0 5 (13.5) 0 8 (22.9) 2 (5.8) 7 (20.0) 2 (5.7) 9 (25.7) 1 (2.9) 6 (17.1) 3 (4.2) 14 (19.4) 6 (8.3) 15 (20.8) 5 (6.9) 17 (23.6) 1 (1.4) 11 (15.3) Working (%) No Yes 21 (56.8) 16 (43.2) 23 (65.7) 12 (34.3) 44 (61.1) 28 (38.9) Type of work (%) Employed full-time Employed part-time Voluntary Self employed Unemployed Sick/disability Retired Student 5 (13.5) 7 (18.9) 3 (8.1) 1 (2.7) 6 (16.2) 11 (29.7) 3 (8.1) 1 (2.7) 4 (11.4) 3 (8.6) 1 (2.9) 8 (22.9) 12 (34.3) 2 (5.7) 1 (2.9) 9 (12.5) 11 (15.3) 6 (8.3) 2 (2.8) 14 (19.4) 23 (31.9) 5 (6.9) 2 (2.8) AIBDTAUTotal n

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

Results

Post therapy qualitative interviews 17 participants Attended mean 8.65 session (SD = 2.91) Range of attendance female, 8 male

Intervention in general Value of treating anxiety and BD together “And it is the only therapy I have had in all my... I have had anxiety since I was what, about 15 and that is the only thing that worked for me was that CBT therapy.” “[the therapy] a real gift, and so I took it with you know both hands, 6 toes and my teeth because it was a gift.” Normally people do them separately and trying to put them together when you are ill is just... not easy at all…if you have got them separate it's like skirting round each issue, but putting them together and showing a person that deal with them all, and will go slowly over everything so you know what to expect, it is so much better, definitely.”

Brief nature of therapy Positive “it was 10 sessions, and that were it, but the 10 sessions meant that the goals that were laid out at session 1, those were the goals that were worked at, and those were the goals that were achieved by the end and that is a far better way of working” Negative “it's good when you have the sessions but once they finish you feel, I felt like lost, and CBT is ok during treatment but long term, putting it into practice day to day, you know it's difficult to remember instantly all the tips, and that”

Outcomes from Therapy “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...and I know exactly the steps that I need to take so, and it's not all about increasing dosages on drugs, and stuff like that it's about taking positive action, yourself and realising the warning signs.” “it has been crippling for me over the years I have had a number of breakdowns, and each time it's always been the anxiety that has kept me prisoner in my own home, it has stopped me from socialising, and progressing so this time, I have healed better and with coping strategies that have allowed me to do things, a lot quicker than before.”

Integrating service user views into development of therapy led to more individualised therapy Consequence – good recruitment and retention General positive experiences of therapy process and structure - – NB not everyone some felt a bit rushed Next step definitive trial – hopefully

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