A collaborative therapeutic relationship and risk of suicidal ideation in patients with bipolar disorder

Therapeutic alliance and suicidal ideation in brief cognitive behavioral therapy for outpatients

OBJECTIVE

The therapeutic alliance is central to psychotherapy. However, research on the relationship between alliance and suicidality is scarce. We examined whether pretreatment suicidality is associated with an impaired alliance formation in brief cognitive behavioral therapy (CBT) and whether the therapeutic alliance is associated with change in suicidal ideation (difference between pretreatment and posttreatment assessment).

METHODS

N = 643 outpatients (64% female; age: M[SD] = 37.09[13.15], range: 18-73 years), received 12 sessions of manual-based short-term CBT for primary diagnosis treatment. Using self-report questionnaires, suicidal ideation and behavior were assessed before and after therapy, patient-rated therapeutic alliance was assessed after the fourth session and posttreatment. We performed correlation analyses and two hierarchical linear regressions, unadjusted and adjusted for possible confounding variables (age, gender, lifetime suicide attempts and depression).

RESULTS

Pretreatment suicidal ideation was not predictive of the quality of the early alliance. In addition, the therapeutic alliance was not predictive of change in suicidal ideation.

CONCLUSIONS

In the outpatient setting, no association was found between therapeutic alliance and suicidality. Future studies should investigate therapeutic alliance as a predictor of prospective suicidal behavior in different clinical settings.

The Influence of Treatment Latency on Suicide-Specific Treatment Outcomes

INTRODUCTION

The Attempted Suicude Short Intervention Program (ASSIP) provides an effective and cost-effective treatment option for people who have attempted suicide. Studies suggest that longer treatment latency is associated with poorer response to therapy, more severe symptomatology, and more suicide attempts This study examined the influence of treatment latency (time between suicide attempt and initiation of therapy) on the number of suicide attempts over the long-term course of ASSIP and the influence of treatment relationship on the extent of suicidal ideation.

METHOD

Survival and regression analyses were performed on 60 participants who had recently attempted suicide and received ASSIP at an outpatient psychiatric clinic. 60% were women and 40% were men.

RESULTS

The results found no significant association between treatment outcome in ASSIP and treatment latency (HR = 1.06; 95% CI: 0.92- 1.21, p = .44). Treatment relationship significantly influenced suicidal ideation at time t4 (B = - .35, t(55) = -3.21, p = .002), but treatment latency was not significantly associated with suicidal ideation (B = .02, t(55) = 0.87, p = .39).

CONCLUSION

No relationship between treatment latency and treatment outcome could be found, suggesting that ASSIP can be implemented at any time after the last suicide attempt. In contrast, the treatment relationship plays a central role in ASSIP.

Mental Health First Aid crisis role-plays between pharmacists and simulated patients with lived experience: a thematic analysis of debrief

PURPOSE

Healthcare professionals, including pharmacists, can recognise and assist people experiencing mental health crises. Despite this, little is known about how pharmacists assist and engage with people presenting with signs and symptoms of mental health crises. This study aimed to (i) examine pharmacists' mental health crisis assessment language during simulated patient role-plays (SPRPs) and (ii) explore participants' experiences of participating in SPRPs of Mental Health First Aid (MHFA) scenarios.

METHODS

Fifty-nine MHFA-trained pharmacy staff participated in audio-recorded SPRPs of three crisis scenarios enacted by a mental health consumer educator (MHCE). Post-SPRP, pharmacy staff members (including role-playing and observing participants), engaged in reflective debrief discussions with the facilitator and MHCEs. Debrief discussions were transcribed verbatim and analysed using inductive thematic analysis and suicide assessment language was explored.

RESULTS

The majority of role-playing pharmacists asked about suicidal ideation using appropriate, direct language (n = 8). Qualitative analyses of debrief discussions yielded four themes: (i) Relationship with the consumer, (ii) Verbal and non-verbal communication, (iii) Challenges with crisis assessment, which included difficulties associated with initiating conversations about suicide and mania, and (iv) Reflective learning.

CONCLUSION

While pharmacists demonstrated the appropriate suicide assessment language post-MHFA training, pharmacists felt uncomfortable initiating conversations around suicide and lacked confidence during crisis assessments. SPRPs provided pharmacists with opportunities to reflect on and practice MHFA skills in a safe learning environment. Future research exploring how MHFA training and SPRPs impact pharmacists' ability to provide MHFA in real-world settings is warranted.

Therapeutic alliance and change in suicide ideation among psychiatric inpatients at risk for suicide

BACKGROUND

Therapeutic alliance is thought to be essential in the treatment of suicidality. Surprisingly, studies about the association between therapeutic alliance and change in suicide ideation over the course of treatment are sparse and reported inconsistent results. Furthermore, theoretically important moderators were rarely explored empirically.

METHODS

We investigated the association between therapeutic alliance and change in suicide ideation (difference between intake and discharge), unadjusted and adjusted for potential confounding variables (diagnoses, sociodemographics etc.) in a sample of 351 inpatients treated in a psychiatric department specialized in crisis intervention and suicide prevention. We also explored if the association was moderated by suicide ideation at intake, history of suicide attempts, and borderline personality disorder (BPD). We ran sensitivity analyses for different diagnostic subgroups, history of suicide attempts, and a quantitative measure of BPD symptoms.

RESULTS

We found a moderate association between therapeutic alliance and change in suicide ideation (r = 0.30, p < 0.01). This association remained robust after accounting for potentially confounding variables. Suicide ideation at intake, history of suicide attempts, and BPD were not statistically significant moderators. Sensitivity analyses led to similar results.

LIMITATIONS

Therapeutic alliance was assessed only at the end of treatment and causality cannot be inferred from our study method.

CONCLUSIONS

Therapeutic alliance was a robust correlate of improvement in suicide ideation among psychiatric inpatients at risk for suicide, independent from diagnostic groups and other patient characteristics. Our results support the crucial role of therapeutic alliance in the treatment of patients at risk for suicide.

Medical students' knowledge of and attitudes towards LGBT people and their health care needs: Impact of a lecture on LGBT health

Objectives

Lesbian, gay, bisexual, and transgender (LGBT) adolescents have specific health care needs and are susceptible to health care disparities. Lack of skills and knowledge on the part of health care providers have a negative effect on their access to care and health outcomes. This study 1) explores the knowledge and attitudes of medical students regarding LGBT people, and 2) assesses the impact of a one-hour lecture targeting adolescent LGBT health needs.

Methods

Fourth-year medical students attended a compulsory one-hour lecture on sexual orientation and gender identity development in adolescence, highlighting health issues. We created a questionnaire with items to elicit students’ knowledge and attitudes about LGBT health issues. Students were invited to complete this questionnaire online anonymously one week before the lecture and one month after the lecture.

Results

Out of a total of 157 students, 107 (68.2%) responded to the pre-intervention questionnaire and 96 (61.1%) to the post-intervention questionnaire. A significant proportion—13.7% of all respondents—identified as LGBT or questioning. Our results show that most medical students already show favorable attitudes towards LGBT people and a certain degree of knowledge of LGBT health needs. They demonstrated a large and significant increase in knowledge of LGBT health issues one month after the lecture.

Discussion

A single one-hour lecture on sexual orientation and LGBT health issues may increase knowledge among medical students. Medical students and professionals should receive such training to increase their knowledge about LGBT patients as it, together with favorable attitudes, has the potential to improve health outcomes among this vulnerable population.

Randomized Controlled Trial of a Collaborative Care Intervention for Mood Disorders by a National Commercial Health Plan

OBJECTIVE

Few individuals with mood disorders have access to evidence-based collaborative chronic care models (CCMs) because most patients are seen in small-group practices (<20 providers) with limited capacity to deliver CCMs. In this single-blind randomized controlled trial, we determined whether a CCM delivered nationally in a U.S. health plan improved 12-month outcomes among enrollees with mood disorders compared with usual care.

METHODS

Aetna insurance enrollees (N=238), mostly females (66.1%) with a mean age of 41.1 years, who were recently hospitalized for unipolar major depression or bipolar disorder provided informed consent, completed baseline assessments, and were randomly assigned to usual care or CCM. The CCM included 10 sessions of the Life Goals self-management program and brief contacts by phone by a care manager to determine symptom status. Primary outcomes were changes over 12 months in depression symptoms (nine-item Patient Health Questionnaire [PHQ-9]) and mental health-related quality of life (Short Form-12).

RESULTS

Adjusted mean PHQ-9 scores were lower by 2.34 points (95% confidence level [CL]=-4.18 to -0.50, p=0.01), indicating improved symptoms, and adjusted mean SF-12 mental health scores were higher by 3.21 points (CL=-.97 to 7.38, p=0.10), indicating better quality of life, among participants receiving CCM versus usual care.

CONCLUSIONS

Individuals receiving CCM compared with usual care had improved clinical outcomes, although substantial attrition may limit the impact of health plan-level delivery of CCMs. Further research on the use of health plan-level interventions, such as CCMs, as alternatives to practice-based models is warranted.

Shared decision making in pharmacotherapy decisions, perceived by patients with bipolar disorder

Background

Shared decision making has been promoted as standard care, but there has been debate on the possible types. On the one hand, there is a more ‘instrumental’/objective approach focused on the exchange of information, but an ‘interpersonal’/subjective patient involvement has been suggested as well. In this study we aim to investigate this further by assessing both actual and perceived patient involvement in medical decisions.

Methods

Eighty-one consultations between patients with bipolar disorder and their clinicians were observed and scored using the OPTION scale. Afterwards, the patients’ experienced involvement was explored with the SDM-Q-9. Furthermore, several patient characteristics were gathered. Correlations between the scores were examined.

Results

The clinicians scored on average 34.6 points on the OPTION scale. In contrast, patients scored on average 77.5 points on the SDM-Q-9, suggesting that patients felt more involved in the consultation than was observable.

Conclusion

Our patients with bipolar disorder feel involved in pharmacotherapy decisions, but this is not scored in objective observations. Our data suggest that there are implicit, interpersonal aspects of patient involvement in shared decision making, a concept that deserves further attention and conceptualisation.

The relationship between therapeutic alliance and patient's suicidal thoughts, self-harming behaviours and suicide attempts: A systematic review

BACKGROUND

Suicidality is a common concern for people with mental health problems. The interpersonal nature of suicidality suggests that therapeutic alliance may be important when working clinically with suicidal patients. This paper is a systematic review of studies investigating the association between alliance and treatment outcome relating to suicidal ideation and behaviours.

METHODS

Systematic searches of PsychINFO, MEDLINE, AMED, EMBASE, Web of Science and CINAHL were completed using words that captured the concepts of alliance and suicidality. Eligible studies: involved participants aged 18-years-old or over; used a validated measure of therapeutic alliance; and reported associations between alliance and suicidality. Abstracts, qualitative studies and articles not written in English were excluded.

RESULTS

Twelve studies were included. Findings indicated that alliance is associated with suicidality. Alliance was related to suicidality in eleven of the papers. Self-harming behaviours had the strongest association with patient-rated alliance. Suicide attempts had the weakest association, possibly due to the infrequency of suicide attempts in the studies reviewed.

LIMITATIONS

The twelve studies were heterogeneous in terms of the measure of alliance used, method of assessing suicidality, clinical setting and professional-type. This variability limited the degree to which findings could be synthesised.

CONCLUSION

Therapists, care-coordinators and mental health teams should recognise the importance of building a strong therapeutic alliance with suicidal patients. Researchers should use consistent methods of measuring alliance and assessing suicidality in future studies. Clinicians and researchers should note that suicidal thoughts, self-harm and suicide attempts may be related to alliance in different ways and therefore should be assessed as separate constructs.

Sexual orientation differences in treatment expectation, alliance, and outcome among patients at risk for suicide in a public psychiatric hospital

BACKGROUND

Sexual minority (SM) individuals (gay, lesbian, bisexual, or otherwise nonheterosexual) are at increased risk for mental disorders and suicide and adequate mental healthcare may be life-saving. However, SM patients experience barriers in mental healthcare that have been attributed to the lack of SM-specific competencies and heterosexist attitudes and behaviors on the part of mental health professionals. Such barriers could have a negative impact on common treatment factors such as treatment expectancy or therapeutic alliance, culminating in poorer treatment outcomes for SM versus heterosexual patients. Actual empirical data from general psychiatric settings is lacking, however. Thus, comparing the treatment outcome of heterosexual and SM patients at risk for suicide was the primary aim of this study. The secondary aim was to compare treatment expectation and working alliance as two common factors.

METHODS

We report on 633 patients from a suicide prevention inpatient department within a public psychiatric hospital. Most patients were at risk for suicide due to a recent suicide attempt or warning signs for suicide, usually in the context of a severe psychiatric disorder. At least one indicator of SM status was reported by 21% of patients. We assessed the treatment outcome by calculating the quantitative change in suicide ideation, hopelessness, and depression. We also ran related treatment responder analyses. Treatment expectation and working alliance were the assessed common factors.

RESULTS

Contrary to the primary hypothesis, SM and heterosexual patients were comparable in their improvement in suicide ideation, hopelessness, or depression, both quantitatively and in treatment responder analysis. Contrary to the secondary hypothesis, there were no significant sexual orientation differences in treatment expectation and working alliance. When adjusting for sociodemographics, diagnosis, and length of stay, some sexual orientation differences became significant, indicating that SM patients have better outcomes.

CONCLUSIONS

These unexpected but positive findings may be due to common factors of therapy compensating for SM-specific competencies. It may also be due to actual presence of SM competencies - though unmeasured - in the department. Replication in other treatment settings and assessment of SM-specific competencies are needed, especially in the field of suicide prevention, before these findings can be generalized.

Communication and decision-making in mental health: A systematic review focusing on Bipolar disorder

OBJECTIVES

To systematically review studies of communication and decision-making in mental health-based samples including BP patients.

METHODS

Qualitative systematic review of studies using PsychINFO, MEDLINE, SCOPUS, CINAHL, and EMBASE (January 2000-March 2015). One author assessed study eligibility, verified by two co-authors. Data were independently extracted by two authors, and cross-checked by another co-author. Two independent raters assessed eligible studies using a validated quality appraisal.

RESULTS

Of 519 articles retrieved, 13 studies were included (i.e., 10 quantitative/1 qualitative/1 mixed-methods). All were cross-sectional; twelve were rated good/strong quality (>70%). Four inter-related themes emerged: patient characteristics and patient preferences, quality of patient-clinician interactions, and influence of SDM/patient-centred approach on patient outcomes. Overall BP patients, like others, have unmet decision-making needs, and desire greater involvement. Clinician consultation behaviour influenced patient involvement; interpersonal aspects (e.g., empathy, listening well) fostered therapeutic relationships and positive patient outcomes, including: improved treatment adherence, patient satisfaction with care, and reduced suicidal ideation.

CONCLUSIONS

This review reveals a paucity of studies reporting bipolar-specific findings. To inform targeted BP interventions, greater elucidation of unmet decision-making needs is needed.

PRACTICE IMPLICATIONS

Eliciting patient preferences and developing a collaborative therapeutic alliance may be particularly important in BP, promoting improved patient outcomes.

Prospective rates of suicide attempts and nonsuicidal self-injury by young people with bipolar disorder participating in a psychotherapy study

OBJECTIVE

Bipolar disorder is a chronic relapsing disorder associated with high rates of suicide, suicide attempts and nonsuicidal self-injury. The study aimed to prospectively identify the rates of suicide attempts and nonsuicidal self-injury in young people participating in an adjunctive randomised controlled psychotherapy for bipolar disorder and to identify differences in individuals who engaged in nonsuicidal self-injury, made suicide attempts or did both.

METHOD

In all, 100 participants aged 15-36 years with bipolar disorder received 78 weeks of psychotherapy and were followed up for a further 78 weeks. Data were collected using the Longitudinal Interval Follow-up Evaluation.

RESULTS

Suicide attempts reduced from 11% at baseline to 1% at the end of follow-up (week 156). Similarly, self-harm reduced from 15% at baseline to 7% at the end of follow-up. Individuals who engaged in both nonsuicidal self-injury and made suicide attempts differed from those with who only made suicide attempts, engaged in nonsuicidal self-injury or did neither. They were characterised by a younger age of illness onset and higher comorbidity.

CONCLUSION

Adjunctive intensive psychotherapy may be effective in reducing suicide attempts and nonsuicidal self-injury and warrants further attention. Particular attention needs to be paid to individuals with early age of onset of bipolar disorder.

The Working Alliance Between Patients With Bipolar Disorder and the Nurse: Helpful and Obstructive Elements During a Depressive Episode From the Patients' Perspective

Despite treatment, many patients with bipolar disorder experience impaired functioning and a decreased quality of life. Optimal collaboration between patient and mental health care providers could enhance treatment outcomes. The goal of this qualitative study, performed in a trial investigating the effect of collaborative care, was to gain more insight in patients' experiences regarding the helpful and obstructive elements of the working alliance between the patient recovering from a depressive episode and their nurse. Three core themes underpinned the nurses' support during recovery: a safe and supportive environment, assistance in clarifying thoughts and feelings, and support in undertaking physical activities.

Overgenerality memory style for past and future events and emotions related in bipolar disorder. What are the links with problem solving and interpersonal relationships?

This study investigated patients with Bipolar Disorder's abilities to generate specific past and future events in response to positive and negative cues words as well as emotional intensity related to these ones. The relationships between the number of generated specific events cognitive functioning, interpersonal problems and the ability to problem solving were investigated. Nineteen BD and nineteen healthy controls completed a French version of the AMT to evaluate the past and future events recall, in function of their valence, and emotions related. Furthermore, they completed the Optional Thinking Test, the Inventory of Interpersonal Problems and the neuropsychological measures. Compared to healthy controls, BD recollected (1) fewer specific past negative events and (2) fewer future specific positive and negative events furthermore, (3) they felt more emotional intensity related to future events. These results were explained in the light of theoretical models. Finally, specific past memories deficits in BD were linked with issues in problem solving but not with levels of distress arising from interpersonal problems. In view of AM functions in everyday life, all types of deficits should be taken into consideration, and AM remediation envisaged.

Subtypes of antipsychotics and suicidal behavior in bipolar disorder

OBJECTIVE

Antipsychotics are commonly used in bipolar disorder, with newer (SGA) agents increasingly replacing FGA antipsychotics, particularly in bipolar depression. There are few data on differences between FGA and SGA antipsychotics in terms of their relationship to suicidal behavior in bipolar disorder.

METHOD

This was a retrospective chart review of 161 bipolar veterans treated naturalistically with antipsychotics at a university-affiliated VA hospital and clinics for up to 8 years. Charts were reviewed to determine monthly antipsychotic use and occurrence of suicidal behavior: completed suicide, attempted suicide or hospitalization to prevent suicide. Suicidal behavior events were compared across patients during treatment with individual antipsychotics and FGAs or SGAs as a class.

RESULTS

Non-lethal suicide events were more common during FGA than SGA monotherapy (9 events/110 months of exposure vs. 6 events/381 months of exposure; χ(2)=9.65, p=0.002). Suicide event rates did not differ between FGAs and SGAs when used in conjunction with mood stabilizers. Event rates were lower with lithium than anticonvulsants when used in conjunction with antipsychotics. No differences were found between olanzapine, risperidone and quetiapine.

LIMITATIONS

The retrospective chart review methodology may have led to confounding by indication and diagnostic inaccuracy. No completed suicides occurred. Study participants were primarily male veterans. Results may not be generalizable to SGAs marketed since 2003.

CONCLUSIONS

FGA antipsychotic monotherapy may be associated with higher suicidal behavior risk than SGA antipsychotic monotherapy. Antipsychotics used in conjunction with mood stabilizers, particularly lithium, are associated with lower rates, independent of antipsychotic subtype.