Think Effectively About Mood Swings (TEAMS): a case series of cognitive-behavioural therapy for bipolar disorders

How to study psychological mechanisms of mania? A systematic review on the methodology of experimental studies on manic mood dysregulation of leading theories on bipolar disorder

INTRODUCTION

Although there are several psychological theories on bipolar disorders (BD), the empirical evidence on these theories through experimental studies is still limited. The current study systematically reviews experimental methods used in studies on the main theories of BD: Reward Hypersensitivity Theory (RST) or Behavioral Activation System (BAS), Integrative Cognitive Model (ICM), Positive Emotion Persistence (PEP), Manic Defense theory (MD), and Mental Imagery (MI). The primary aim is to provide an overview of the used methods and to identify limitations and suggest areas of improvement.

METHODS

A systematic search of six databases until October 2023 was conducted. Study selection involved two independent reviewers extracting data on experimental study design and methodology.

RESULTS

A total of 84 experimental studies were reviewed. BAS and RST were the most frequently studied theories. The majority of these experimental studies focus on mechanisms of reward sensitivity. Other important elements of the reviewed theories, such as goal setting and-attainment, situation selection (avoidance or approach), activation, affective/emotional reactivity, and regulatory strategies, are understudied. Self-report and neuropsychological tasks are most often used, while mood induction and physiological measures are rarely used.

CONCLUSION

There is a need for more consensus on the operationalization of psychological theories of mania. Standardization of test batteries could improve comparability among studies and foster a more systematic approach to experimental research. Research on affective (activated) states is still underrepresented in comparison with studies on trait vulnerabilities.

A Brief Cognitive Analytic Therapy-Informed Approach for Young People That Have Self-Injured (CATCH-Y): A Case Series

BACKGROUND

Non-suicidal self-injury (NSSI) presents an increasingly prevalent problem for young people; however, there remains a scarce evidence base for effective, scalable treatments for adolescents. This study aimed to assess the feasibility and acceptability of a brief, cognitive analytic therapy (CAT)-informed intervention for young people who engage in NSSI (CATCH-Y).

METHODS

A case series design recruited 13 young people who met the inclusion and exclusion criteria to participate in the five-session intervention. Eligible participants were aged 13-17 years (M = 15.15, SD = 1.28) and had engaged in NSSI at least once in the previous 6 months. Feasibility and acceptability were measured via recruitment, retention, qualitative feedback and missing data. The secondary outcome measures of personal recovery and motivation were administered pre- and post-assessment, with measures of depressive symptoms and urges to self-injure.

RESULTS

The intervention was found to be largely feasible and acceptable with high rates of recruitment, retention and pre-/post-assessment data completeness. Measures showed preliminary support for positive change in rates of NSSI, urges to self-harm, low mood and personal recovery, although results were mixed. Completion rates for remote assessments were low.

CONCLUSIONS

The findings of this study support further evaluation of the CATCH-Y intervention on a larger scale. In-person assessments may be preferable to remote to ensure good completion rates.

Exploring aspects of self-reported emotional mental imagery in patients with bipolar disorder

BACKGROUND AND OBJECTIVES

CBT for patients with bipolar disorder has modest effects. Across disorders, mental imagery has been used to update CBT to increase effectiveness. In order to enhance CBT for bipolar disorder with imagery techniques, research is needed into emotional imagery quality and, related appraisals of imagery and their relationships with mood instability and subsequent behaviour in bipolar disorder.

METHODS

Patients with bipolar disorder (n = 106), unipolar depression (n = 51), creative imagery prone participants (n = 53) and participants without a history of a mood disorder (n = 135) completed the Dutch Imagery Survey (DImS), an online imagery survey, adapted from the Imagery Interview, assessing self-reported emotional imagery aspects. Imagery quality, appraisals and their self-perceived effects on emotion and behaviour were compared between groups. As unexpected differences within the bipolar group appeared, these were additionally explored.

RESULTS

Imagery appraisals but not imagery quality discriminated between the patient groups and non-patient groups Imagery was perceived as an emotional amplifier in all groups, but this was specifically apparent in bipolar manic and bipolar depressed groups. Only in the bipolar group imagery was experienced to amplify behavioural tendencies.

LIMITATIONS

Results need to be replicated using a larger sample of patients with BD who are currently manic or depressed.

CONCLUSIONS

Not only quality of imagery, but especially appraisals associated with imagery are differentiating between imagery prone people with and without mood disorder. Imagery amplifies emotion in all groups, but only in those patients with bipolar disorder currently manic or depressed did this influence behaviour.

"It felt very special, it felt customised to me"-A qualitative investigation of the experiences of participating in a clinical trial of CBT for young people at risk of bipolar disorder

OBJECTIVES

The Bipolar at Risk Trial (BART) was a feasibility randomized controlled trial investigating cognitive behavioral therapy (CBT) compared with treatment as usual (TAU) in young people at high risk of developing bipolar disorder (BD). This qualitative study aimed to investigate participants' experiences of trial involvement, and the acceptability of CBT for this population.

DESIGN

Participants were those identified as being at risk of bipolar disorder, determined by current symptoms or family history. A purposive sample of twenty-one participants from both the intervention and TAU arms of the trial was recruited.

METHODS

Twenty-one semi-structured interviews were conducted by service user researchers (13 participants had received therapy and 8 TAU). Interviews were audio recorded with consent from participants and transcribed verbatim. NVivo 11 Pro software was used to conduct an inductive thematic analysis.

RESULTS

Super-ordinate themes were "adaptability and flexibility," "feeling understood and valued," and "relevance of study and intervention" which had two sub-themes-"value of the trial therapy" and "acceptability of trial processes." Participating in the trial and having therapy enabled participants to feel understood and valued by research assistants (RAs) and therapists. Participants viewed therapy as relevant to their current concerns and valued adaptability and flexibility of RAs and therapists.

CONCLUSIONS

Findings highlight the importance and value of flexibility, adaptability, and understanding in relationships between participants and trial staff. Findings also indicate that the trial processes and CBT focusing on mood swings are acceptable and relevant to participants from this at risk population.

PRACTITIONER POINTS

Young people at risk of bipolar disorder value a flexible approach to assessments and therapy, developing a rapport with research assistants and therapists and opening up to them when they feel comfortable to do so. CBT focusing on coping with mood swings was acceptable to the majority of participants who received it and it was perceived as helpful in ways that were personal to each participant.

A cognitive behavioural group therapy for bipolar disorder using daily mood monitoring

BACKGROUND AND AIM

This study investigated the effects of group cognitive behavioural therapy (CBT) for patients with bipolar disorder. The development of CBT for this disorder is relatively under-explored.

METHOD

Participants with bipolar I or II disorder were treated with group CBT in addition to treatment as usual. The effectiveness of the protocol was explored through sequence analysis of daily mood monitoring prior to, during and after the intervention. Also, a repeated measures design was used assessing symptomatology, dysfunctional attitudes, sense of mastery, psychosocial functioning, and quality of life at start and end of intervention, and at follow-up 2 and 12 months later.

RESULTS

The results indicate that variation in mood states diminished over the course of the intervention. Also, there was a change from depressive states to more euthymic states. Greater number of reported lifetime depressive episodes was associated with greater diversity of mood states. There was an increase in overall psychosocial functioning and self-reported psychological health following the intervention. Improvement continued after treatment ended until follow-up at 2 months, and measured 1 year later, for outcomes representing depression, general psychosocial functioning and self-reported psychological health. Due to small sample size and the lack of a control group the results are preliminary.

CONCLUSIONS

The results of this pilot study suggest that both offering CBT in group interventions and sequence analysis of time series data are helpful routes to further explore when improving standard CBT interventions for patients suffering from bipolar disorder.

A preliminary study of group therapy intervention for bipolar disorder based on the integrative cognitive model

The main aim of this research was to investigate the effect of the 8-week group therapy intervention based on the integrative cognitive model (ICM) of bipolar disorder. The sample was composed of 10 patients with bipolar I and bipolar II diagnoses. The group sessions were held once a week for 1.5 hours. For the quantitative measures, the group participants were assessed during pre-test, post-test and 3-month follow-up using the Turkish versions of the Beck Depression Inventory, the Hypomanic Attitudes and Positive Predictions Inventory, the Psychological Well-being Scale and the Satisfaction with Life Scale. Quantitative analyses revealed that a reliable change was seen only in pre-test and post-test depression scores. However, this change could not be maintained at 3-month follow-up. For the qualitative analyses, data collected during semi-structured interviews were used. The thematic analyses results showed that the 8-week ICM-based group therapy was found to help participants make sound observations about their behaviors, decrease their feelings of loneliness and increase self-acceptance, and acceptance of the role of mood swings in their lives. Moreover, the results showed that participants found the following activities very beneficial: describing their emotions, evaluating the intensity of their emotions, identifying their life goals, coping with interpersonal conflicts, evaluating resources and going over strengths. In conclusion, the 8-week ICM-based group therapy had a positive impact on participants’ self-awareness, self-acceptance and self-perception.

Key learning aims

(1)

Improving functional outcomes in early-stage bipolar disorder: The protocol for the REsearch into COgnitive and behavioural VERsatility trial

AIM

Young people with bipolar disorder (BD) commonly experience reduced quality of life, persistent symptoms and impaired functional recovery despite often superior school performance. Compromised long-term functioning can ensue. There is evidence that psychological therapies alongside pharmacology may be more efficacious earlier in the course of the disorder. Intervention in the early stages may thus reduce the burden and risk associated with BD and mitigate the impact of the disorder on normal developmental trajectories. To date, however, the availability of evidence-based psychological therapies for young people with early BD is limited. Furthermore, there are no large-scale randomized controlled trials (RCTs) of such interventions.

METHODS

The study is a prospective, single-blind, RCT examining the effectiveness of an adjunctive individualized and manualized psychological intervention, compared with treatment as usual within youth-specific early intervention services. The REsearch into COgnitive and behavioural VERsatility (RECOVER) intervention is delivered over a 6-month period. About 122 young people in the early stages of BD-I (at least one manic episode in the previous 2 years, with no more than five lifetime treated/untreated manic or hypomanic episodes) will be recruited. The assessments will occur at baseline, 3, 6 (primary endpoint, end of treatment), 9, 12, 15 and 18 months.

RESULTS

Recruitment will commence in January 2019 and is anticipated to occur over a 3.5-year period.

CONCLUSIONS

To date, there are no evidence-based psychological therapies tailored to young people with early BD. We will test whether early psychological intervention in the course of BD can reduce the symptomatic, psychological, vocational and social impacts that are seen in entrenched disorder.

Cognitive Analytic Therapy for psychosis: A case series

OBJECTIVES

Cognitive Analytic Therapy (CAT) is an effective psychological intervention for several different mental health conditions. However, whether it is acceptable, safe, and beneficial for people with psychosis remains unclear, as is the feasibility of providing and evaluating it within a research context. The aim of this study was to begin to address these questions and to obtain for the first time a rich and detailed understanding of the experience of receiving CAT for psychosis.

DESIGN

A mixed-methods case series design.

METHOD

Seven individuals who experienced non-affective psychosis received CAT. They completed assessments at the start of CAT, 16 weeks, and 28 weeks post-baseline. Qualitative interviews were completed with four individuals following completion of or withdrawal from therapy.

RESULTS

Six participants attended at least four sessions of therapy and four went on to complete therapy. There were no serious adverse events, and self-reported adverse experiences were minimal. Qualitative interviews suggested CAT is acceptable and provided a way to understand and work therapeutically with psychosis. There was limited evidence of change in psychotic symptoms, but improvement in perceived recovery and personality integration was observed.

CONCLUSIONS

The results suggest that CAT is a safe and acceptable intervention for psychosis. Personality integration, perceived recovery, and functioning are relevant outcomes for future evaluations of CAT for psychosis.

PRACTITIONER POINTS

It is feasible to conduct research evaluating CAT for people with psychosis. Within this case series, CAT appears acceptable and safe to individuals with psychosis. Within this case series, clients reported that CAT was a positive and helpful experience. There is a mixed picture with regard to secondary outcomes, but the design and aims of this case series limit conclusion that can be drawn from this data.

Bipolar Disorder: Its Etiology and How to Model in Rodents

Characterized by the switch of manic and depressive phases, bipolar disorder was described as early as the fifth century BC. Nevertheless up to date, the underlying neurobiology is still largely unclear, assuming a multifactor genesis with both biological-genetic and psychosocial factors. Significant process has been achieved in recent years in researching the causes of bipolar disorder with modern molecular biological (e.g., genetic and epigenetic studies) and imaging techniques (e.g., positron emission tomography (PET) and functional magnetic resonance imaging (fMRI)). In this chapter we will first summarize our recent knowledge on the etiology of bipolar disorder. We then discuss how several factors observed to contribute to bipolar disorder in human patients can be manipulated to generate rodent models for bipolar disorder. Finally, we will give an overview on behavioral test that can be used to assess bipolar-disorder-like behavior in rodents.

Imagery-Focused Cognitive Therapy (ImCT) for Mood Instability and Anxiety in a Small Sample of Patients with Bipolar Disorder: a Pilot Clinical Audit

BACKGROUND

Despite the global impact of bipolar disorder (BD), treatment success is limited. Challenges include syndromal and subsyndromal mood instability, comorbid anxiety, and uncertainty around mechanisms to target. The Oxford Mood Action Psychology Programme (OxMAPP) offered a novel approach within a cognitive behavioural framework, via mental imagery-focused cognitive therapy (ImCT).

AIMS

This clinical audit evaluated referral rates, clinical outcomes and patient satisfaction with the OxMAPP service.

METHOD

Eleven outpatients with BD received ImCT in addition to standard psychiatric care. Mood data were collected weekly from 6 months pre-treatment to 6 months post-treatment via routine mood monitoring. Anxiety was measured weekly from start of treatment until 1 month post-treatment. Patient feedback was provided via questionnaire.

RESULTS

Referral and treatment uptake rates indicated acceptability to referrers and patients. From pre- to post-treatment, there was (i) a significant reduction in the duration of depressive episode relapses, and (ii) a non-significant trend towards a reduction in the number of episodes, with small to medium effect size. There was a large effect size for the reduction in weekly anxiety symptoms from assessment to 1 month follow-up. Patient feedback indicated high levels of satisfaction with ImCT, and underscored the importance of the mental imagery focus.

CONCLUSIONS

This clinical audit provides preliminary evidence that ImCT can help improve depressive and anxiety symptoms in BD as part of integrated clinical care, with high patient satisfaction and acceptability. Formal assessment designs are needed to further test the feasibility and efficacy of the new ImCT treatment on anxiety and mood instability.

"When my Moods Drive Upward There Is Nothing I Can Do about It": A Review of Extreme Appraisals of Internal States and the Bipolar Spectrum

The integrative cognitive model provides a comprehensive account of bipolar disorder (BD) that, if empirically supported, has important potential implications for psychological therapies. This article is the first to review the evidence for this model. We evaluate the evidence (up to 2017) for four hypotheses derived uniquely from the model: extreme positive and negative appraisals of internal states are associated with (1) risk of developing BD; (2) BD diagnosis; (3) relevant clinical and functional outcomes including hypomanic and depressive mood symptoms; and (4) outcomes over time. Research involving individuals with diagnosed mood disorders as well as non-clinical populations is reviewed. The hypotheses were broadly supported and several consistent findings were not accounted for by alternative psychological models of BD. The evidence base is limited by a relative paucity of prospective studies; only 6 of the 31 studies identified. Implications for theory, research and clinical practice are discussed.

Extreme cognitions are associated with diminished ability to use disconfirming evidence

OBJECTIVES

An Integrative Cognitive Model of mood swings and bipolar disorder proposes that cognitive styles characterized by extreme self-referent appraisals of internal states (e.g., 'If I have a bad night's sleep it means that I am about to have a breakdown') interfere with mood regulation. The aim of this study is to determine whether strong endorsement of such appraisals is predicted by a diminished ability to access disconfirming counterexamples.

DESIGN

We examined whether the ability to access two different categories of counterexample (known as Disabling Conditions and Alternative Causes) would predict endorsement of extreme appraisals (measured by the Hypomanic Attitudes and Positive Predictions Inventory; HAPPI) and mania risk (measured by the Hypomanic Personality Scale; HPS).

METHOD

A non-clinical sample of 150 students completed the HAPPI, the HPS and a conditional reasoning task that indexed the ability to access Disabling Conditions and Alternative Causes. Current mood was controlled for using the Internal States Scale.

RESULTS

The ability to make use of disabling counterexamples during the reasoning task was inversely related with scores on the HAPPI (r = -.19, p < .05); participants that were less able to make use of disabling counterexamples endorsed extreme self-referent appraisals to a greater extent. There was no association between the use of alternative cause counterexamples and the HAPPI, and no association between either measure of counterexample generation and the HPS.

CONCLUSIONS

A diminished ability to use disconfirming evidence when reasoning about the world may reinforce problematic cognitive styles such as extreme, personalized appraisals of experience, which can interfere with mood regulation.

PRACTITIONER POINTS

Problematic cognitive styles such as extreme, personalized appraisals of experience may be reinforced by the inability to produce or access evidence that disconfirms these maladaptive beliefs. This reasoning bias may be associated with cognitive styles underlying psychopathology. There may be clinical utility in exploring the use of disabler generation in psychological interventions, to help disconfirm maladaptive beliefs.

The Turkish Adaptation, Validity, and Reliability of the Internal States Scale

INTRODUCTION

The Internal State Scale (ISS) was developed to simultaneously assess manic and depressive symptoms in bipolar disorder. In the present study, the validity and reliability of the Turkish version of ISS (ISS-TR) were examined. The present study aimed to present the psychometric properties of this scale.

METHODS

The sample consisted of 200 outpatients with bipolar disorder and 49 healthy controls. Participants completed the Turkish Internal State Scale (ISS-TR), the Brief Psychiatric Rating Scale (BPRS), the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS).

RESULTS

Reliability analyses revealed that the Cronbach alfa coefficient of ISS was 0.88 for the whole sample. Item-total correlations ranged from 0.15 to 0.78. Two factors emerged as a result of factor analysis: "mania" and "depression-well-being." Test-retest correlations were determined for the mania subscale as r=0.654, p<0.01 and for the depression-well-being subscale as r=0.356, p<0.01. The correlations between BPRS and both subscales were quite high. The correlation between HDRS and the depression-well-being subscale was higher (r=0.475) than that between HDRS and the mania subscale, whereas the correlation between YMRS and the mania subscale was higher (r=0.818) than that between YMRS and the depression-well-being subscale. It was seen that ISS could discriminate between the clinical and healthy control samples. In addition, it was observed that the mania subscale predicted a manic period more strongly, while the depression-well-being subscale predicted a depressive period better.

CONCLUSION

ISS is a valid and reliable scale that can be used to simultaneously assess manic and depressive symptoms. It is thought that ISS will be useful in the recognition of prodromal symptoms and in the process of maintenance treatment.

An evidence map of psychosocial interventions for the earliest stages of bipolar disorder

Depression, schizophrenia, and bipolar disorder are three of the four most burdensome problems in people aged under 25 years. In psychosis and depression, psychological interventions are effective, low-risk, and high-benefit approaches for patients at high risk of first-episode or early-onset disorders. We review the use of psychological interventions for early-stage bipolar disorder in patients aged 15-25 years. Because previous systematic reviews had struggled to identify information about this emerging sphere of research, we used evidence mapping to help us identify the extent, distribution, and methodological quality of evidence because the gold standard approaches were only slightly informative or appropriate. This strategy identified 29 studies in three target groups: ten studies in populations at high risk for bipolar disorder, five studies in patients with a first episode, and 14 studies in patients with early-onset bipolar disorder. Of the 20 completed studies, eight studies were randomised trials, but only two had sample sizes of more than 100 individuals. The main interventions used were family, cognitive behavioural, and interpersonal therapies. Only behavioural family therapies were tested across all of our three target groups. Although the available interventions were well adapted to the level of maturity and social environment of young people, few interventions target specific developmental psychological or physiological processes (eg, ruminative response style or delayed sleep phase), or offer detailed strategies for the management of substance use or physical health.

Appraisals of Internal States and their Consequences: Relationship to Adolescent Analogue Bipolar Symptoms

BACKGROUND

Extreme appraisals of internal states correlate with and prospectively predict mood symptoms in adults, and discriminate individuals with bipolar disorder from individuals with unipolar depression and non-clinical controls.

AIMS

These findings required replication in adolescents. This study sought to investigate the relationships between appraisals of internal states, mood symptoms and risk for bipolar disorder in an adolescent sample.

METHOD

A non-clinical sample (n = 98) of adolescents completed measures of mood symptoms, appraisals, and mania risk, alongside covariates.

RESULTS

Appraisals of internal states were associated with analogue bipolar symptoms, independently of impulsivity and responses to positive affect. Positive appraisals of activated mood states were uniquely associated with hypomania, whilst negative appraisals were uniquely associated with depression and irritability symptoms. Individuals who appraised activated states as both extremely positive and extremely negative were more likely to score at high or moderate risk for future mania.

CONCLUSIONS

This study is the first to demonstrate associations between appraisals of internal states, analogue mood symptoms and mania risk in adolescents. Clinical implications are discussed.

Appraisals to affect: Testing the integrative cognitive model of bipolar disorder

OBJECTIVE

Cognitive models have suggested that extreme appraisals of affective states and maladaptive affect regulation strategies are important in the development of bipolar symptomatology. Little is known about the pathway by which these appraisals and behaviours interact in the formation of activated and depressed affective states. This study tested the predictions that (1) ascent behaviours mediate the relationship between positive appraisals of activated mood and activation; and (2) descent behaviours mediate the relationship between negative appraisals of activated mood and depression.

METHOD

A total of 52 individuals with a DSM-IV diagnosis of bipolar I or II disorder (confirmed by structured interview) completed biweekly assessments of affect regulation behaviours and mood for 4 weeks. Positive and negative appraisals of affective states were assessed at baseline through the Hypomanic Attitudes and Positive Prediction Inventory. Multilevel mediation analysis was used to explore the data.

RESULTS

Ascent behaviours partially mediated the relationship between positive appraisals of activated mood and activation. Descent behaviours, but not negative appraisals of activated mood, predicted levels of depression indicating the absence of a mediation effect.

CONCLUSION

The results suggest that positive appraisals of activated mood can escalate activation in individuals with bipolar disorder. Such appraisals may be inherently rewarding and reinforcing directly elevating levels of activation, whilst increasing individuals' use of ascent behaviours. The results are consistent with the view that appraisals and behaviours should be targeted during cognitive behavioural therapy for bipolar disorder.

PRACTITIONER POINTS

It may be beneficial to target positive appraisals of activated mood in cognitive behavioural therapy for mania. Cognitive behavioural therapists may also wish to focus on identifying and targeting individuals' use of ascent behaviours to reduce highly activated states.

Combined treatment: impact of optimal psychotherapy and medication in bipolar disorder

OBJECTIVES

The current study investigated the longitudinal course of symptoms in bipolar disorder among individuals receiving optimal treatment combining pharmacotherapy and psychotherapy, as well as predictors of the course of illness.

METHODS

A total of 160 participants with bipolar disorder (bipolar I disorder: n = 115; bipolar II disorder: n = 45) received regular pharmacological treatment, complemented by a manualized, evidence-based psychosocial treatment - that is, cognitive behavioral therapy or psychoeducation. Participants were assessed at baseline and prospectively for 72 weeks using the Longitudinal Interval Follow-up Evaluation (LIFE) scale scores for mania/hypomania and depression, as well as comparison measures (clinicaltrials.gov identifier: NCT00188838).

RESULTS

Over a 72-week period, patients spent a clear majority (about 65%) of time euthymic. Symptoms were experienced more than 50% of the time by only a quarter of the sample. Depressive symptoms strongly dominated over (hypo)manic symptoms, while subsyndromal symptoms were more common than full diagnosable episodes for both polarities. Mixed symptoms were rare, but present for a minority of participants. Individuals experienced approximately six significant mood changes per year, with a full relapse on average every 7.5 months. Participants who had fewer depressive symptoms at intake, a later age at onset, and no history of psychotic symptoms spent more weeks well over the course of the study.

CONCLUSIONS

Combined pharmacological and adjunctive psychosocial treatments appeared to provide an improved course of illness compared to the results of previous studies. Efforts to further improve the course of illness beyond that provided by current optimal treatment regimens will require a substantial focus on both subsyndromal and syndromal depressive symptoms.

A novel cognitive behaviour therapy for bipolar disorders (Think Effectively About Mood Swings or TEAMS): study protocol for a randomized controlled trial

Background

Existing psychological therapies for bipolar disorders have been found to have mixed results, with a consensus that they provide a significant, but modest, effect on clinical outcomes. Typically, these approaches have focused on promoting strategies to prevent future relapse. An alternative treatment approach, termed ‘Think Effectively About Mood Swings’ (TEAMS) addresses current symptoms, including subclinical hypomania, depression and anxiety, and promotes long-term recovery. Following the publication of a theoretical model, a range of research studies testing the model and a case series have demonstrated positive results. The current study reports the protocol of a feasibility randomized controlled trial to inform a future multi-centre trial.

Methods/Design

A target number of 84 patients with a diagnosis of bipolar I or II disorder, or bipolar disorder not-otherwise-specified are screened, allocated to a baseline assessment and randomized to either 16 sessions of TEAMS therapy plus treatment-as-usual (TAU) or TAU. Patients complete self-report inventories of depression, anxiety, recovery status and bipolar cognitions targeted by TEAMS. Assessments of diagnosis, bipolar symptoms, medication, access to services and quality of life are conducted by assessors blind to treatment condition at 3, 6, 12 and 18 months post-randomization. The main aim is to evaluate recruitment and retention of participants into both arms of the study, as well as adherence to therapy, to determine feasibility and acceptability. It is predicted that TEAMS plus TAU will reduce self-reported depression in comparison to TAU alone at six months post-randomization. The secondary hypotheses are that TEAMS will reduce the severity of hypomanic symptoms and anxiety, reduce bipolar cognitions, improve social functioning and promote recovery compared to TAU alone at post-treatment and follow-up. The study also incorporates semi-structured interviews about the experiences of previous treatment and the experience of TEAMS therapy that will be subject to qualitative analyses to inform future developments of the approach.

Discussion

The design will provide preliminary evidence of efficacy, feasibility, acceptability, uptake, attrition and barriers to treatment to design a definitive trial of this novel intervention compared to treatment as usual.

Trial registration

This trial was registered with Current Controlled Trials (ISRCTN83928726) on registered 25 July 2014.

Bipolar disorder in children

Although bipolar disorder historically was thought to only occur rarely in children and adolescents, there has been a significant increase in children and adolescents who are receiving this diagnosis more recently (Carlson, 2005). Nonetheless, the applicability of the current bipolar disorder diagnostic criteria for children, particularly preschool children, remains unclear, even though much work has been focused on this area. As a result, more work needs to be done to further the understanding of bipolar symptoms in children. It is hoped that this paper can assist psychologists and other health service providers in gleaning a snapshot of the literature in this area so that they can gain an understanding of the diagnostic criteria and other behaviors that may be relevant and be informed about potential approaches for assessment and treatment with children who meet bipolar disorder criteria. First, the history of bipolar symptoms and current diagnostic criteria will be discussed. Next, assessment strategies that may prove helpful for identifying bipolar disorder will be discussed. Then, treatments that may have relevance to children and their families will be discussed. Finally, conclusions regarding work with children who may have a bipolar disorder diagnosis will be offered.