An Integrated Risk Reduction Intervention can reduce body mass index in individuals being treated for bipolar I disorder: results from a randomized trial

Behavioral-Social Rhythms and Cardiovascular Disease Risk in Retired Night Shift Workers and Retired Day Workers

OBJECTIVE

Stability in the timing of key daily routine behaviors such as working/doing housework, sleeping, eating, and engaging in social interactions (i.e., behavioral-social rhythms) contributes to health. This study examined whether behavioral-social rhythms were associated with cardiovascular disease (CVD) risk factors in retired night shift workers and retired day workers and explored whether past night shift work exposure moderated this association.

METHODS

A total of 154 retired older adults participated in this study. Multiple logistic regression models were used to examine associations between behavioral-social rhythms and CVD risk factors. Independent variables included Social Rhythm Metric (SRM)-5 score and actigraphy rest-activity rhythm intradaily variability (IV) and interdaily stability (IS). Dependent variables were metabolic syndrome prevalence and its five individual components.

RESULTS

More regular behavioral-social rhythms were associated with lower odds of prevalent metabolic syndrome (SRM: odds ratio [OR] = 0.57, 95% confidence interval [CI] = 0.35-0.88; IV: OR = 4.00, 95% CI = 1.86-8.58; IS: OR = 0.42, 95% CI = 0.24-0.73) and two of its individual components: body mass index (SRM: OR = 0.56, 95% CI = 0.37-0.85; IV: OR = 2.84, 95% CI = 1.59-5.07; IS: OR = 0.42, 95% CI = 0.26-0.68) and high-density lipoprotein cholesterol (SRM: OR = 0.49, 95% CI = 0.30-0.80; IV: OR = 2.49, 95% CI = 1.25-4.96; IS: OR = 0.35, 95% CI = 0.19-0.66). Past shift work history did not moderate the association between behavioral-social rhythms and metabolic syndrome.

CONCLUSIONS

Behavioral-social rhythms were related to CVD risk factors in retired adults regardless of prior night shift work exposure. Older retired workers may benefit from education and interventions aiming to increase behavioral-social rhythm regularity.

Lessons and Untapped Potential of Smartphone-Based Physical Activity Interventions for Mental Health: Narrative Review

BACKGROUND

Physical activity has well-known and broad health benefits, including antidepressive and anxiolytic effects. However, only approximately half of Americans meet even the minimum exercise recommendations. Individuals with anxiety, depression, or related conditions are even less likely to do so. With the advent of mobile sensors and phones, experts have quickly noted the utility of technology for the enhanced measurement of and intervention for physical activity. In addition to being more accessible than in-person approaches, technology-driven interventions may uniquely engage key mechanisms of behavior change such as self-awareness.

OBJECTIVE

This study aims to provide a narrative overview and specific recommendations for future research on smartphone-based physical activity interventions for psychological disorders or concerns.

METHODS

In this paper, we summarized early efforts to adapt and test smartphone-based or smartphone-supported physical activity interventions for mental health. The included articles described or reported smartphone-delivered or smartphone-supported interventions intended to increase physical activity or reduce sedentary behavior and included an emotional disorder, concern, or symptom as an outcome measure. We attempted to extract details regarding the intervention designs, trial designs, study populations, outcome measures, and inclusion of adaptations specifically for mental health. In taking a narrative lens, we drew attention to the type of work that has been done and used these exemplars to discuss key directions to build on.

RESULTS

To date, most studies have examined mental health outcomes as secondary or exploratory variables largely in the context of managing medical concerns (eg, cancer and diabetes). Few trials have recruited psychiatric populations or explicitly aimed to target psychiatric concerns. Consequently, although there are encouraging signals that smartphone-based physical activity interventions could be feasible, acceptable, and efficacious for individuals with mental illnesses, this remains an underexplored area.

CONCLUSIONS

Promising avenues for tailoring validated smartphone-based interventions include adding psychoeducation (eg, the relationship between depression, physical activity, and inactivity), offering psychosocial treatment in parallel (eg, cognitive restructuring), and adding personalized coaching. To conclude, we offer specific recommendations for future research, treatment development, and implementation in this area, which remains open and promising for flexible, highly scalable support.

Liraglutide in Obese or Overweight Individuals With Stable Bipolar Disorder

BACKGROUND

Obesity is common among persons with bipolar disorder (BD). Liraglutide 3.0 mg/d subcutaneous injection is indicated for chronic weight management and associated with minimal adverse neuropsychiatric effects. This study evaluated whether liraglutide 3 mg/d reduced body weight, improved metabolic factors and eating psychopathology, and was safe and well tolerated in persons with stable BD who were obese (body mass index [BMI] >30 kg/m 2 ) or overweight (BMI ≥27 kg/m 2 ) with at least one weight-related comorbidity.

METHODS

This was a 40-week, randomized (1:1 ratio), placebo-controlled, double-blind, parallel-group, 2-arm clinical trial of liraglutide targeted to 3.0 mg/d (in combination with a reduced-calorie diet and increased physical activity) in 60 participants with stable BD who were obese or overweight. Primary outcome was percent change in body weight from baseline to study end. Secondary outcomes included percentage of patients who lost ≥5% of baseline body weight, and changes in metabolic variables and measures of eating psychopathology.

RESULTS

There were no significant baseline differences between the 29 liraglutide recipients and the 31 placebo recipients, except that liraglutide recipients had higher levels of binge eating and lower levels of high-density lipoprotein cholesterol. Compared with placebo, liraglutide was associated with significantly greater reductions in percent change in body weight, percentage of participants who lost at least 5% of body weight, and reductions in weight, BMI, hemoglobin A 1c levels, binge eating, and hunger. Liraglutide was well tolerated.

CONCLUSIONS

Liraglutide 3 mg/d may be efficacious and safe for weight loss in individuals with stable BD and obesity or overweight.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03158805).

Lifestyle interventions for bipolar disorders: A systematic review and meta-analysis

This review and meta-analysis aimed to describe the existing literature on interventions for bipolar disorder (BD) targeting the 6 pillars of Lifestyle Psychiatry: diet, physical activity (PA), substance use (SU), sleep, stress management, and social relationships (SR). Randomized Controlled Trials that examined the efficacy of lifestyle interventions targeting improvement in depressive/(hypo)manic symptom severity, lifestyle patterns, functioning, quality of life, and/or circadian rhythms were included. The systematic review included 18 studies, while the meta-analysis included studies targeting the same lifestyle domains and outcomes. Sleep (n = 10), PA (n = 9), and diet (n = 8) were the most targeted domains, while SU, SM and SR were least targeted (n = 4 each). Combined diet and PA interventions led to significant improvements in depressive symptoms (SMD: -0.46; 95%CI: -0.88, -0.04; p = 0.03), and functioning (SMD: -0.47; 95%CI: -0.89, -0.05; p = 0.03). Sleep interventions also led to significant improvements in depressive symptoms (SMD: -0.80; 95%CI: -1.21, -0.39; p < 0.01). Future research should focus on developing more multidimensional lifestyle interventions for a potentially greater impact on clinical and functional outcomes of BD.

Introducing Braining-physical exercise as adjunctive therapy in psychiatric care: a retrospective cohort study of a new method

BACKGROUND

Patients with severe mental disorders suffer from higher rates of poor somatic health and have shorter life expectancy than the average population. Physical activity can treat and prevent several diseases, e.g. cardiovascular and metabolic disorders as well as psychiatric symptoms. It is therefore of utmost importance to develop effective methods to integrate physical activity into psychiatric care. To meet this need, the physical activity intervention Braining was developed. This study aims to describe Braining, to assess the number of patients reached during the first years of pilot testing, to analyze clinical data in the group of patients participating in Braining 2017-2020 and to assess the intervention.

METHODS

In this descriptive retrospective study we analyzed data from all patients participating in Braining training sessions ≥ 3 times (n = 239), the Braining Participants. Regular patients at the clinic served as a comparison. Furthermore, medical records were studied for a smaller cohort (n = 51), the Braining Pilot Cohort. Data was analyzed using Chi-square and Fisher's tests.

RESULTS

During the introduction period of Braining, 580 patients attended an information meeting about Braining, or at least one training session. 239 patients participated in ≥ 3 training sessions, considered to be participants of Braining. These Braining Participants (n = 239), ages 19 to 82, males 23.4%, attended between 3 and 308 training sessions (median 9). The main diagnoses were affective and anxiety disorders. Number of diagnoses ranged from 0 to 10 (median = 2). For the subsample, the Braining Pilot Cohort (n = 51), participants attended between 3 and 208 training sessions (median = 20). Twelve percent were working full-time, and symptom severity of depression and general anxiety was moderate. Two thirds had ≥ 3 different classes of medication. Regarding metabolic morbidity, 28 had been diagnosed with hypertension, though blood lipids, blood glucose as well as blood pressure were within the normal range. Thirty-seven percent were prescribed Physical Activity on Prescription during 2017-2020. One severe adverse event was reported.

CONCLUSIONS

The Braining intervention reached all age-groups and patients with a wide and representative diagnostic panorama, suggesting that Braining could be a promising and safe method for implementing physical activity in a psychiatric patient population.

Nurse-Led Physical Health Interventions for People with Mental Illness: A Scoping Review of International Literature

People with mental illness have a higher prevalence of co-occurring physical health conditions and poor health behaviors, leading a mortality gap of up to 16 years, compared with the general population. Nurses working in mental health settings play an important role in addressing factors influencing sub-optimal physical health. Therefore, this scoping review aimed to identify nurse-led physical health interventions and align interventions to eight recognized physical healthcare priority areas (i.e. Equally Well in Victoria Framework). A systematic search strategy was used to identify relevant literature. Data extraction included alignment to the Equally Well priority areas, research design, and indication of co-design (meaningful and collaborative involvement of consumers and significant others) and recovery-oriented practice (focusing on needs and goals of a consumer's recovery journey). All included papers (n = 74) were aligned to at least one of eight Equally Well priority areas. Papers were predominately quantitative (n = 64, 86%), with the remainder mixed methods (n = 9, 9%) or qualitative (n = 4, 5%). Most papers were aligned to improving metabolic health and support to quit smoking. One study focused on nurse-led intervention designed to reduce falls. Recovery-oriented practice was evident in six papers. No paper described evidence of co-design. A research gap was identified for nurse-led intervention to reduce falls and improve dental/oral care. Relative to mental healthcare policy, there is a need for future nurse-led physical health research to be co-designed and include recovery-oriented practice. Evaluation and description of future nurse-led physical interventions should seek to report perspectives of key stakeholders as these remain relatively unknown.

Randomized controlled trials of mental health nurse-delivered interventions: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Well conducted randomized controlled trials provide the highest level of evidence of effectiveness of healthcare interventions, including those delivered by mental health nurses. Trials have been conducted over the years but there has not been a comprehensive review since 2005, and never one including studies conducted outside the UK. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides a comprehensive overview of results from randomized controlled trials of mental health nurse-delivered interventions conducted in the UK, Ireland, US, Australia, New Zealand, or Canada and reported 2005 to 2020. It highlights that the trial evidence is limited and offers only partial evidence for interventions that are central to mental health nursing practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Much mental health nursing practice is not supported by the highest level trial evidence. Mental health nurses need to carefully select evidence on which to base their practice both from the mental health nursing literature and beyond. Mental health nurses and other stakeholders should demand greater investment in trials to strengthen the evidence base.

ABSTRACT

INTRODUCTION: Nurses are the largest professional disciplinary group working in mental health services and have been involved in numerous trials of nursing-specific and multidisciplinary interventions. Systematic appraisal of relevant research findings is rare.

AIM

To review trials from the core Anglosphere (UK, US, Canada, Ireland, Australia, New Zealand) published from 2005 to 2020.

METHOD

A systematic review reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Comprehensive electronic database searches were conducted. Eligible studies were randomized controlled trials of mental health nurse-delivered interventions conducted in relevant countries. The risk of bias was independently assessed. Synthesis involved integration of descriptive statistics of standardized metrics and study bias.

RESULTS

Outcomes from 348 between-group comparisons were extracted from K = 51 studies (N = 11,266 participants), Standardized effect sizes for 68 (39 very small/small, 29 moderate/large) statistically significant outcomes from 30 studies were calculable. All moderate/large effect sizes were at risk of bias.

DISCUSSION

Trial evidence of effective mental health nurse-delivered interventions is limited. Many studies produced few or no measurable benefits; none demonstrated improvements related to personal recovery.

IMPLICATIONS FOR PRACTICE

Mental health nurses should look beyond gold standard RCT evidence, and to evidence-based interventions that have not been trialled with mental health nurse delivery.

Effectiveness of nutrition and dietary interventions for people with serious mental illness: systematic review and meta-analysis

OBJECTIVE

To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors.

STUDY DESIGN

Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies.

DATA SYNTHESIS

Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms found statistically significant intervention effects on weight, ten of 24 on BMI, and seven of seventeen on waist circumference. The pooled effects of nutrition interventions on metabolic syndrome risk factors were statistically non-significant. However, we identified small size effects on weight for interventions delivered by dietitians (five studies; 262 intervention, 258 control participants; standardised mean difference [SMD], -0.28; 95% CI, -0.51 to -0.04) and interventions consisting of individual sessions only (three studies; 141 intervention, 134 control participants; SMD, -0.30; 95% CI, -0.54 to -0.06).

CONCLUSIONS

We found only limited evidence for nutrition interventions improving metabolic syndrome risk factors in people with serious mental illness. However, they may be more effective when delivered on an individual basis or by dietitians.

PROSPERO REGISTRATION

CRD42021235979 (prospective).

Physical Activity Monitoring Preferences in Adults With Bipolar Disorder

This report investigated physical activity (PA) monitoring preferences and problems among adults with bipolar disorder (BD). Methods: PARC2 study was conducted at the Western Psychiatric Institute and Clinic at the University of Pittsburgh. This secondary data analysis assessed three PA monitors; Body Media SW Pro Armband, Actigraph AM-7164, and Pedometer Omron HJ-720IT. PA monitors were worn simultaneously for 1 week. Participants reported preferences and problems (irritating, cumbersome, movement of the activity monitor, technical difficulties, and impaired functioning) encountered with each activity monitor. Results: Approximately 70% of the participants (n = 66) were middle-aged Caucasian women with a diagnosis of BD I and overweight. Sixty-six adults with BD wore all 3 monitors simultaneously. Twelve (18%) participants had no PA monitoring preference, 28 (42%) preferred the armband, 17 (26%) preferred the pedometer and 9 (14%) preferred the Actigraph. Activity monitoring preferences did not statistically differ by age, gender, race, BMI, diagnosis, or depressive and mania symptoms (p > 0.25). Two-thirds of the participants (64%) had at least one problem with at least one activity monitor. As far as problem categories, more than a quarter of participants reported irritation with the Armband (26%, n = 17) and movement of the pedometer (32%, n = 21). No statistically significant association was observed between activity monitoring preferences and problems (p = 0.72). Discussion: Adults with BD were willing to wear activity monitors even though problems were reported. Preference of physical activity monitors, in descending order, was the armband, pedometer, and Actigraph. One fifth of the adults with BD reported no preferences in activity monitors. The activity monitors selected for investigation included the "gold standard" in activity monitoring (Actigraph) worn at the waist as well as a research grade pedometer that is considerably more affordable, provides activity feedback in real-time, and may be a more feasible option for large scale studies.

Trajectories of functioning in bipolar disorders: A longitudinal study in the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort

OBJECTIVE

We aimed at identifying distinct trajectories of functioning and at describing their respective clinical characteristics in a cohort of individuals with bipolar disorders.

METHODS

We included a sample of 2351 individuals with bipolar disorders who have been followed-up to 3 years as part as the FondaMental Advanced Centers of Expertise in Bipolar Disorders cohort. Global functioning was measured using the Functioning Assessment Short Test. We used latent class mixed models to identify distinct longitudinal trajectories of functioning over 3 years. Multivariable logistic regression models were used to identify the baseline factors that were associated with the membership to each trajectory of functioning.

RESULTS

Three distinct trajectories of functioning were identified: (1) a majority of individuals (72%) had a stable trajectory of mild functional impairment, (2) 20% of individuals had a stable trajectory of severe functional impairment and (3) 8% of individuals had a trajectory of moderate functional impairment that improved over time. The membership to a trajectory of stable severe versus stable mild functional impairment was associated with unemployment, a higher number of previous hospitalizations, childhood maltreatment, a higher level of residual depressive symptoms, higher sleep disturbances, a higher body mass index and a higher number of psychotropic medications being prescribed at baseline. The model that included these seven factors led to an area under the curve of 0.85.

CONCLUSION

This study enabled to stratify individuals with bipolar disorders according to three distinct trajectories of functioning. The results regarding the potential determinants of the trajectory of severe functional impairment needs to be replicated in independent samples. Nevertheless, these potential determinants may represent possible therapeutic targets to improve the prognosis of those patients at risk of persistent poor functioning.

A systematic scoping review of interventions to integrate physical and mental healthcare for people with serious mental illness and substance use disorders

Integrated care approaches have been recommended to remove barriers to healthcare and improve the physical health outcomes of people living with serious mental illness (SMI) and/or substance use disorders (SUDs). The aim of this systematic scoping review was to describe empirical investigations of interventions designed to integrate physical, mental, and addiction healthcare for this population. An iterative and systematic search of five electronic databases (Medline (Ovid), PsycINFO, CINAHL, Embase (Ovid) and Scopus) was conducted to identify peer-reviewed articles published between January 2000 and April 2019. Two reviewers independently screened publications in two successive stages of title and abstract screening, followed by full-text screening of eligible publications. Data from each included publication were extracted independently by two reviewers using a standardised spreadsheet. A total of 28 eligible publications were identified, representing 25 unique studies. Over half of the included studies investigated the use of case managers to provide self-management skills or to coordinate mental and physical healthcare (n = 14). Other interventions examined the co-location of services (n = 9) and the implementation of screening and referral pathways to specialist treatment (n = 2). Less than half of the included studies described a framework, theory or model that was underpinning the intervention tested. While some aspects of integrated care have been identified and addressed by interventions, other key dimensions have not been considered, such as shared decision-making. Identification of a comprehensive model of integrated care is recommended to inform the development and evaluation of future interventions for people with SMI/SUDs.

Interventions for the management of obesity in people with bipolar disorder

BACKGROUND

Bipolar disorder is one of the most common serious mental illnesses, affecting approximately 60 million people worldwide. Characterised by extreme alterations in mood, cognition, and behaviour, bipolar disorder can have a significant negative impact on the functioning and quality of life of the affected individual. Compared with the general population, the prevalence of comorbid obesity is significantly higher in bipolar disorder. Approximately 68% of treatment seeking bipolar patients are overweight or obese. Clinicians are aware that obesity has the potential to contribute to other physical health conditions in people with bipolar disorder, including diabetes, hypertension, metabolic syndrome, cardiovascular disease, and coronary heart disease. Cardiovascular disease is the leading cause of premature death in bipolar disorder, happening a decade or more earlier than in the general population. Contributing factors include illness-related factors (mood-related factors, i.e. mania or depression), treatment-related factors (weight implications and other side effects of medications), and lifestyle factors (physical inactivity, poor diet, smoking, substance abuse). Approaches to the management of obesity in individuals with bipolar disorder are diverse and include non-pharmacological interventions (i.e. dietary, exercise, behavioural, or multi-component), pharmacological interventions (i.e. weight loss drugs or medication switching), and bariatric surgery.

OBJECTIVES

To assess the effectiveness of interventions for the management of obesity in people with bipolar disorder.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and the Cochrane Central Register for Controlled Trials (CENTRAL) to February 2019. We ran additional searches via Ovid databases including MEDLINE, Embase, and PsycInfo to May 2020. We searched the World Health Organization (WHO) trials portal (International Clinical Trials Registry Platform (ICTRP)) and ClinicalTrials.gov. We also checked the reference lists of all papers brought to full-text stage and all relevant systematic reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs), randomised at the level of the individual or cluster, and cross-over designs of interventions for management of obesity, in which at least 80% of study participants had a clinical diagnosis of bipolar disorder and comorbid obesity (body mass index (BMI) ≥ 30 kg/m²), were eligible for inclusion. No exclusions were based on type of bipolar disorder, stage of illness, age, or gender. We included non-pharmacological interventions comprising dietary, exercise, behavioural, and multi-component interventions; pharmacological interventions consisting of weight loss medications and medication switching interventions; and surgical interventions such as gastric bypass, gastric bands, biliopancreatic diversion, and vertical banded gastroplasty. Comparators included the following approaches: dietary intervention versus inactive comparator; exercise intervention versus inactive comparator; behavioural intervention versus inactive comparator; multi-component lifestyle intervention versus inactive comparator; medication switching intervention versus inactive comparator; weight loss medication intervention versus inactive comparator; and surgical intervention versus inactive comparator. Primary outcomes of interest were changes in body mass, patient-reported adverse events, and quality of life.

DATA COLLECTION AND ANALYSIS

Four review authors were involved in the process of selecting studies. Two review authors independently screened the titles and abstracts of studies identified in the search. Studies brought to the full-text stage were then screened by another two review authors working independently. However, none of the full-text studies met the inclusion criteria. Had we included studies, we would have assessed their methodological quality by using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. We intended to combine dichotomous data using risk ratios (RRs), and continuous data using mean differences (MDs). For each outcome, we intended to calculate overall effect size with 95% confidence intervals (CIs).

MAIN RESULTS

None of the studies that were screened met the inclusion criteria.

AUTHORS' CONCLUSIONS

None of the studies that were assessed met the inclusion criteria of this review. Therefore we were unable to determine the effectiveness of interventions for the management of obesity in individuals with bipolar disorder. Given the extent and impact of the problem and the absence of evidence, this review highlights the need for research in this area. We suggest the need for RCTs that will focus only on populations with bipolar disorder and comorbid obesity. We identified several ongoing studies that may be included in the update of this review.

Impact of a prudent lifestyle on the clinical outcomes of older men with bipolar disorder

Objectives: To determine if the excess mortality associated with Bipolar disorder (BD) is independent of lifestyle.Methods: Prospective study of a community-representative sample of 12,203 men aged 65-85 years followed for 17.7 years. We used the 8-item 'prudence score' to assesses lifestyle behaviours, including the use of alcohol and smoking, physical activity, body mass and key aspects of diet. Scores of 5 or more indicate a prudent lifestyle.Results: 69 (0.6%) men had BD - a larger proportion of them than the remainder of the sample had diabetes, ischaemic heart disease, stroke, chronic respiratory diseases and dementia. The odds of a prudent lifestyle were 40% lower among participants with BD. BD was associated with increased risk of future contact with health services due to ischaemic heart disease and cancer, and respiratory, digestive and renal diseases, although such risk became comparable to that of men without BD for men with BD and a prudent lifestyle. The adjusted mortality hazard associated with the diagnosis of BD was 1.66 (95%CI = 1.20, 2.28), while the mortality hazard associated with a prudent lifestyle was 0.81 (95%CI = 0.78, 0.85). The mortality hazard for men with BD who were also prudent was 0.83 (95%CI = 0.52, 1.30). All analyses were adjusted for sociodemographic measures and prevalent morbidities.Conclusion: The excess morbidity and mortality of older men with BD seems to be mediated by non-prudent lifestyle practices. If future studies can demonstrate that this association is causal, then lifestyle interventions will need to become an integral part of the management of older adults with BD.

The effectiveness of the "SMG" model for health-promoting lifestyles among empty nesters: a community intervention trial

Background

With the disintegration of the extended family in recent years, the empty-nest phenomenon is increasingly common in China and the health of empty nesters is attracting more attention. Lifestyles, accounting for 53% in determining death, play a vital role in improving the health of individuals. However, it was rarely studied in promoting the health of empty nesters. In this study, we proposed a “SMG” model in empty nesters, including the self-management, mutual management, and group management, to implement health-promoting lifestyles interventions among empty nesters to provide an effective means to improve their lifestyles and health.

Methods

We conducted a prospective intervention on 350 empty nesters in three communities located in Taiyuan, China. One hundred sixty-seven empty nesters were randomly assigned to the intervention group with SMG-based health-promoting lifestyles interventions used for 7-months, and 183 were randomly assigned to the control group with no measures imposed. The Health-Promoting Lifestyle Profile (HPLP-C) was used to rate the lifestyles of empty nesters. Generalized estimation model was used to analyze the differences between the intervention and control groups over time, adjusted for education and employment.

Results

After 7 months of health-promoting lifestyles intervention, HPLP-C score and each dimension score in the intervention group all increase from baseline. There were significant differences after intervention associated with time and group interaction effects in aspects of HPLP-C (mean score = 8.838, 95%CI:6.369–11.306), self-realization (mean score = 1.443, 95%CI:0.352–2.534), Health responsibility (mean score = 1.492, 95%CI:0.477–2.508), physical activity (mean score = 1.031, 95%CI:0.572–1.491), nutrition (mean = 0.827, 95%CI:0.177–1.476), interpersonal relations (mean = 2.917, 95%CI:2.365–3.469) and stress management (mean score = 0.729, 95%CI:0.131–1.327). And education is contributing to the effect of the health-promoting lifestyle intervention (Estimate:8.833, p < 0.001).

Conclusions

SMG-based health-promoting lifestyles intervention in empty nesters effectively improved the lifestyles of empty nesters, and the outcome was affected by education. Lifestyle change requires ongoing intervention, and community service centres must be involved in implementing the “SMG” model to provide ongoing support and improve the effect of interventions among empty nesters.

Trial registration

Chinese Clinical Trial ChiCTR1800015884. Registration date: 26–04-2018. Retrospectively registered.

Combining baseline characteristics to disentangle response differences to disorder-specific versus supportive psychotherapy in patients with persistent depressive disorder

Does the pre-treatment profile of individuals with persistent depressive disorder (PDD) moderate their benefit from disorder-specific Cognitive Behavioral System of Psychotherapy (CBASP) versus supportive psychotherapy (SP)? We investigated this question by analyzing data from a multi-center randomized clinical trial comparing the effectiveness of 48 weeks of CBASP to SP in n  =  237 patients with early-onset PDD who were not taking antidepressant medication. We statistically developed an optimal composite moderator as a weighted combination of 13 preselected baseline variables and used it for identifying and characterizing subgroups for which CABSP may be preferable to SP or vice versa. We identified two distinct subgroups: 58.65% of the patients had a better treatment outcome with CBASP, while the remaining 41.35% had a better outcome with SP. At baseline, patients responding more favorably to CBASP were more severely depressed and more likely affected by moderate-to-severe childhood trauma including early emotional, physical, or sexual abuse, as well as emotional or physical neglect. In contrast, patients responding more favorably to SP had a higher pre-treatment global and social functioning level, a higher life quality and more often a recurrent illness pattern without complete remission between the episodes. These findings emphasize the relevance of considering pre-treatment characteristics when selecting between disorder-specific CBASP and SP for treating PDD. The practical implementation of this approach would advance personalized medicine for PDD by supporting mental health practitioners in their selection of the most effective psychotherapy for an individual patient.

An appraisal of methodology reporting in lifestyle interventions among people with psychosis: A systematic review

ISSUE ADDRESSED

Lifestyle interventions use nutrition and physical activity behaviour modification techniques to decrease obesity and cardio-metabolic risk in people with psychosis. Evidence on the specific behaviour modification strategies applied to decrease obesity is weakened by inadequate methodology reporting of lifestyle interventions. A systematic review that we conducted earlier highlighted a possible deficiency in reporting; hence we aim to critically appraise lifestyle intervention studies that target weight outcomes for people with psychosis against the methods component of the CONSORT statement for randomised trials of nonpharmacologic treatments.

METHODS COMPONENT

We considered randomised controlled studies which delivered lifestyle interventions to community-dwelling adults with psychotic disorders, and included those with the following outcomes of interest: weight, body mass index, waist circumference and waist-to-hip ratio. The Cochrane Library, MEDLINE/PREMEDLINE, EMBASE, CINAHL, Scopus and PsycINFO were searched for English publications between 1985 and 2018. Methodology and reporting of studies were evaluated using the CONSORT statement for randomised trials of nonpharmacologic treatments.

RESULTS

Thirty-two studies met the inclusion criteria. Critical appraisals revealed that reporting of lifestyle intervention studies was generally incomplete. Fewer than 50% provided the recommended information on trial design, participant characteristics, detail of interventions, outcomes, sample size, randomisation, blinding and statistical methods.

CONCLUSIONS

Application of guidelines, like the CONSORT statement, in future publications of lifestyle interventions for people with psychosis will improve accuracy of reporting. SO WHAT?: Enhanced reporting in lifestyle intervention studies for people with psychosis will promote guideline creation and translation of research, which is likely to positively impact physical health outcomes.

Weight Gain During Treatment of Bipolar Disorder (BD)-Facts and Therapeutic Options

Bipolar disorder (BPD) is a mood disorder, which is characterized by alternating affective states, namely (hypo)mania, depression, and euthymia. Evidence is growing that BPD has indeed a biologic substrate characterized by chronic inflammation, oxidative stress, and disturbed energy metabolism. Apart from this, there is obviously a hereditary component of this disease with multi-genetic factors. Most probably a susceptibility threshold favors the outbreak of clinical disease after a cascade of stress events that remain to be elucidated in more detail. Evidence is also growing that weak points in brain energy metabolism contribute to outbreak and severity of BPD. Conventional psychopharmacologic therapy must be reassessed under the aspects of weight cycling and development of central obesity as a deterioration factor for a worse clinical course leading to early cardiovascular events in BPD subgroups.

Improving Functioning, Quality of Life, and Well-being in Patients With Bipolar Disorder

People with bipolar disorder frequently experience persistent residual symptoms, problems in psychosocial functioning, cognitive impairment, and poor quality of life. In the last decade, the treatment target in clinical and research settings has focused not only on clinical remission, but also on functional recovery and, more lately, in personal recovery, taking into account patients' well-being and quality of life. Hence, the trend in psychiatry and psychology is to treat bipolar disorder in an integrative and holistic manner. This literature review offers an overview regarding psychosocial functioning in bipolar disorder. First, a brief summary is provided regarding the definition of psychosocial functioning and the tools to measure it. Then, the most reported variables influencing the functional outcome in patients with bipolar disorder are listed. Thereafter, we include a section discussing therapies with proven efficacy at enhancing functional outcomes. Other possible therapies that could be useful to prevent functional decline and improve functioning are presented in another section. Finally, in the last part of this review, different interventions directed to improve patients' well-being, quality of life, and personal recovery are briefly described.

Bipolar Disorder and Obesity: Contributing Factors, Impact on Clinical Course, and the Role of Bariatric Surgery

PURPOSE OF REVIEW

Bipolar disorder (BD) is a severe, common, and chronic affective disorder. This review highlights the BD and obesity connection and the role of treatments for obesity in this population.

RECENT FINDINGS

Patients with BD are at a significantly increased risk for obesity, as compared to those without BD, with obesity serving as a proxy for severity and predictor of poorer outcome. BD is characterized by substantial medical burden, with obesity-related conditions contributing to premature mortality. Pharmacotherapy for BD can cause weight gain and may be moderated by binge eating behavior. Bariatric surgery may be the most robust intervention for weight loss in patients with stable BD, but access may be limited. There is a greater need for interventions to prevent weight gain in BD, the development weight-neutral medications for BD, and more research into the role of bariatric surgery for patients with BD.

Impact of lifestyle modification on some components of metabolic syndrome in persons with severe mental disorders: A meta-analysis

BACKGROUND

Metabolic syndrome (MS) is reportedly associated with high mortality from mostly cardiovascular causes in patients with severe mental disorders (SMD). Lifestyle interventions augment effective management of MS in patients with SMD. The present meta-analysis aims at updating the recent evidence on the effectiveness of lifestyle intervention for MS in patients with SMD.

METHOD

A literature search for English Language publications of randomized controlled trials (RCTs) from 2001 to 2016 comparing lifestyle modification (LM) with treatment as usual (TAU) in the management of MS were identified. Using PRISMA guidelines, 19 RCTs reporting data on 1688 SMD and MS patients and providing data on change in Body Weight, Body Mass Index (BMI) and waist circumference (WC) were included. Using random effects model, standardized mean difference between LM and TAU for the mean baseline-to-endpoint change in body weight, BMI and WC was calculated with a 95% confidence limit, on RevMan 5.3. The study was registered with PROSPERO (CRD42016046847).

RESULTS

LM had significantly superior efficacy in the reducing weight (-0.64, 95% CI -0.89, -0.39, Z = 5.03, overall effect p < 0.00001), BMI (-0.68, 95% CI -1.01, -0.35, Z = 4.05, overall effect p < 0.0001), and WC (-0.60, 95% CI -1.17, -0.03, Z = 2.06; overall effect p = 0.04), compared to TAU. LM was significantly more effective than TAU even in short duration (p = 0.0001) and irrespective of the treatment setting.

CONCLUSION

Interventions targeting LM in persons with SMD and MS are effective in reducing body weight, BMI and WC. It must be routinely recommended to all patients with SMD, ideally during commencement stage of second generation antipsychotic treatment.

Metabolic syndrome and actigraphy measures of sleep and circadian rhythms in bipolar disorders during remission

OBJECTIVE

This study explored the correlations between sleep and circadian rhythm measures and the metabolic syndrome (MetS) components in remitted patients with bipolar disorder (BD).

METHOD

Euthymic patients with BD (n = 67) were recorded by 3 weeks with actigraphy. We used nonparametric correlations to study the links between the MetS parameters, atherogenic index of plasma (AIP), sleep efficacy, sleep latency, fragmentation index, and phase and amplitude of rhythms. We performed multivariable analyses to take into account potential confounding factors such as sleep apnea risk, antipsychotics use, and smoker status.

RESULTS

We found correlations between lower sleep efficiency and higher triglyceride levels (P = 0.002), lower M10 onset (beginning of the 10 most active hours during the 24-h cycle) and higher systolic blood pressure (P = 0.03), higher fragmentation index and higher systolic blood pressure (P = 0.009), lower sleep efficiency, higher fragmentation index, and higher AIP (respectively P = 0.02 and P = 0.04). These correlations mostly remained significant when adjusting for confounders, with the exception of M10 onset and systolic blood pressure.

CONCLUSION

Sleep efficiency and fragmentation index might contribute to the cardiovascular risk of patients with BD independently of major confounding factors. Although these associations did not imply causality, proposing interventions on sleep quality and circadian rhythm regularity might contribute to reduce cardiovascular risk in patients with BD.

Using optimal combined moderators to define heterogeneity in neural responses to randomized conditions: Application to the effect of sleep loss on fear learning

Comparing the neural outcomes of two randomized experimental groups is a primary aim of many functional neuroimaging studies. However, between-group effects can be obscured by heterogeneity in neural responses. Optimal Combined Moderator (OCM) approaches have previously been used to clarify heterogeneity in clinical outcomes following treatment randomization. We show that OCMs can also be used to clarify heterogeneity in the effect of a randomized experimental condition on neural responses. In 78 healthy adults aged 18-30 from the Effects of Dose-Dependent Sleep Disruption on Fear and Reward (SFeRe) study, we used demographic, clinical, genetic, and polysomnographic characteristics to develop OCMs for the effect of a randomized sleep restriction (SR) versus normal sleep (NS) condition on blood-oxygen-level dependent responses in the right amygdala (RAmyg) and subgenual anterior cingulate cortex (sgACC) during fear conditioning (FC) and extinction (FE) paradigms. The OCM for the RAmyg during FE was strongest [r (95% CI) = 0.52 (0.42, 0.68)], withstood cross-validation, and divided the sample into two subgroups with opposing experimental effects. Among N = 48 participants ("SR < NS"), those with SR exhibited less RAmyg activation during FE than those with NS [d (95%CI) = -1.10 (-1.86, -0.77)]. Among the remaining N = 30 participants ("SR > NS"), those with SR exhibited greater RAmyg activation during FE following SR than those with NS [d (95%CI) = 0.87 (0.37,1.78)]. SR > NS participants were more likely to be female, white, l/l genotype carriers, and have a psychiatric history. They had less sleep (overall and in REM), lower REM density, and lower spindle activity (12-16 Hz). Applying OCMs to randomized studies with neural outcomes can clarify neural heterogeneity and jumpstart mechanistic research; with further validation they also offer promise for personalized brain-based treatments and interventions.

Moving Towards Wellness: Physical activity practices, perspectives, and preferences of users of outpatient mental health service

OBJECTIVE

This study assessed the beliefs, barriers and preferences for physical activity (PA) among users of outpatient mental health (MH) services. Outpatient discussions with MH providers were also evaluated.

METHOD

Between September-December 2014, patient advisors approached adult and family members in an academic MH clinic's waiting room on high volume patient visit days during peak clinic hours; 83% participated in the survey. Analyses were restricted to MH services users (n=295).

RESULTS

Fully 84% of respondents reported a link between PA and their mood or anxiety level and 85% wanted to be more active. Less than half currently met US PA guidelines (≥150min/week). Most (52%) reported their mood limited their involvement in PA. Only 37% reported their MH providers regularly discussed PA with them. Beliefs about the benefits of physical activity (p<0.0001), mood limiting their ability to be physically active (p=0.03), and wanting to be more physically active (p=0.02) were significant predictors of PA (min/week) in the multivariate linear regression model.

CONCLUSIONS

Most MH outpatients may need and want assistance in increasing PA. Patient-centered research could inform the development of PA programs in MH settings.

Mental health and behavioral weight loss: 24-month outcomes in Veterans

BACKGROUND

Individuals with mental health (MH) disorders have an increased risk of being overweight/obese; however research on behavioral weight loss interventions has been limited. A priori hypothesis was that Veterans with serious mental illness (SMI) and/or affective disorders (AD) would lose significantly less weight and have a different pattern of weight loss than Veterans without these diagnoses.

METHODS

Secondary data analysis of ASPIRE-VA study, three-arm randomized, effectiveness weight loss trial among Veterans (n=409) categorized by MH diagnoses: 1) SMI, 2) AD without SMI, or 3) No SMI/No AD. Linear mixed-effects model analyzed weight changes from baseline thru 24 months.

RESULTS

SMI and AD were diagnosed in 10% (n=41) and 31% (n=125). Participants attended approximately 15 sessions from baseline to 24 months. On average, participants lost a modest amount of weight over 24 months regardless of MH diagnosis. Longitudinally, no statistically significant differences were found in weight loss patterns by MH diagnosis. Unadjusted average weight loss (kg) was 1.6±4.0 at 3 months (n=373), 1.9±6.5 at 12 months (n=361), 1.5±7.8 at 18 months (n=289), and 1.4±8.0 at 24 months (n=279).

LIMITATIONS

ASPIRE-VA study was not designed or powered to detect weight loss differences among MH diagnostic groups.

CONCLUSIONS

Veterans achieved and maintained modest weight loss, through 24 months, with the three behavioral weight loss interventions. Contrary to our hypotheses, the amount and pattern of weight loss did not differ by MH diagnosis. Greater inclusion of individuals with MH diagnoses may be warranted in behavioral weight loss interventions not specifically tailored for them.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

The role of day-to-day emotions, sleep, and social interactions in pediatric anxiety treatment

Do day-to-day emotions, social interactions, and sleep play a role in determining which anxious youth respond to supportive child-centered therapy (CCT) versus cognitive behavioral therapy (CBT)? We explored whether measures of day-to-day functioning (captured through ecological momentary assessment, sleep diary, and actigraphy), along with clinical and demographic measures, were predictors or moderators of treatment outcome in 114 anxious youth randomized to CCT or CBT. We statistically combined individual moderators into a single, optimal composite moderator to characterize subgroups for which CCT or CBT may be preferable. The strongest predictors of better outcome included: (a) experiencing higher positive affect when with one's mother and (b) fewer self-reported problems with sleep duration. The composite moderator indicated that youth for whom CBT was indicated had: (a) more day-to-day sleep problems related to sleep quality, efficiency, and waking, (b) day-to-day negative events related to interpersonal concerns, (c) more DSM-IV anxiety diagnoses, and (d) college-educated parents. These findings illustrate the value of both day-to-day functioning characteristics and more traditional sociodemographic and clinical characteristics in identifying optimal anxiety treatment assignment. Future studies will need to enhance the practicality of real-time measures for use in clinical decision making and evaluate additional anxiety treatments.

Medical burden, body mass index and the outcome of psychosocial interventions for bipolar depression

OBJECTIVE

Individuals with bipolar disorder experience a disproportionately high incidence of medical co-morbidity and obesity. These health-related problems are a barrier to recovery from mood episodes and have been linked with unfavorable responses to pharmacological treatment. However, little is known about whether and how these characteristics affect responses to adjunctive psychotherapy.

METHOD

Embedded in the Systematic Treatment Enhancement Program for Bipolar Disorder was a randomized controlled trial of psychotherapy for bipolar depression comparing the efficacy of intensive psychotherapy plus pharmacotherapy with collaborative care (a three-session psycho-educational intervention) plus pharmacotherapy. We conducted a post-hoc analysis to evaluate whether medical burden and body mass index predicted and/or moderated the likelihood of recovery and time until recovery from a depressive episode among patients in the two treatments.

RESULTS

Participants who had medical co-morbidity and body mass index data constituted 199 of the 293 patients in the original Systematic Treatment Enhancement Program for Bipolar Disorder trial. Higher medical burden predicted a lower likelihood of recovery from depression in both treatment conditions (odds ratio = 0.89), but did not moderate responses to intensive psychotherapy vs collaborative care. Intensive psychotherapy yielded superior recovery rates for individuals of normal body mass index (odds ratio= 2.39) compared with collaborative care, but not among individuals who were overweight or obese.

CONCLUSION

Medical co-morbidity and body weight impacts symptom improvement and attention to this co-morbidity may inform the development of more personalized treatments for bipolar disorder.

The association between meal timing and frequency with cardiometabolic profile in patients with bipolar disorder

OBJECTIVE

The goal of this study was to explore the association of timing of and frequency of meals with markers of cardiometabolic risk in patients with bipolar disorder in out-patient maintenance treatment.

METHODS

We used Pittsburgh Sleep Diary and actigraphy measures for individuals with bipolar I disorder. Linear and logistic regression analyses were used to determine whether dinnertime, instability of dinnertime, and/or interval between meals were associated with metabolic syndrome and its components.

RESULTS

Later dinnertime was associated with greater waist circumference (β = 0.25, P = 0.02) after adjusting for age, sex, dinner-to-bed interval, and sleep duration. Longer breakfast-to-lunch intervals were also associated with greater waist circumferences (β =-.35, P = .002) after adjusting for age, sex, and sleep duration. Neither instability of dinnertime nor number of meals per day was associated with the metabolic syndrome or its components.

CONCLUSION

Weight gain is often perceived as inevitable side-effect of medications. While patients often need to be on medication to function, a more careful lifestyle assessment with attention to social rhythms and timing of activities may be critical not only for mood stability, but also to reduce cardiovascular risk.

Development, acceptability and efficacy of a standardized healthy lifestyle intervention in recurrent depression

BACKGROUND

Research evidence on the effects of integrated multifaceted lifestyle interventions for depression is scanty. The aim of the present study is to report on the development, acceptability and efficacy of a standardized healthy lifestyle intervention, including exercise, eating habits, sleep hygiene and smoking cessation in preventing relapses.

METHODS

One hundred-sixty outpatients with recurrent unipolar depression or bipolar disorder were recruited after achieving full remission or recovery from the most recent depressive episode. Patients were randomized to 3-months of usual care or to an intervention aimed at promoting a healthy lifestyle (HLI), as an augmentation of pharmacological maintenance treatment. Usual care consisted of clinical management visits. At the end of the intervention, follow-up visits were scheduled at 3,6,9 and 12 months.

RESULTS

During the intervention phase, 1 relapse occurred in the HLI group and 4 in the control group. Over the 12 months of follow-up, relapses were 5 in the HLI group and 16 in control group. Using an intent-to-treat approach, the overall percentage of relapses was 6/81 (7.4%) in the HLI group vs. 20/79 (25.3%) in the control group.. In a Kaplan-Meier survival analysis the risk of relapse was significantly lower in patients receiving the HLI intervention (log-rank test, p=0.003) over the 60 weeks of observation. The majority of patients assigned to HLI adhered to the program, and were highly motivated throughout the intervention.

LIMITATIONS

The retention rate was low because patients were recruited during the maintenance phase and the 1-year follow-up was relatively short to detect a long-term effect of HLI.

CONCLUSIONS

The HLI program proved to be efficacious in preventing relapses. Given the absence of contraindications and its cost-effectiveness in routine practice, the use of HLI should be encouraged to promote the well-being of patients with recurrent depression.

Lifestyle interventions targeting dietary habits and exercise in bipolar disorder: A systematic review

BACKGROUND

Bipolar disorder (BD) is a serious mental illness associated with a high risk of medical comorbidities, long-term disability and premature death. This systematic review examined the current literature on therapeutic interventions targeting nutrition, physical activity and wellness in BD and collecting health-related measures such as mood and course of illness.

METHODS

Scopus (all databases), Pubmed and Ovid Medline were systematically searched with no language or year restrictions, up to June 2015, for studies focusing on lifestyle interventions in BD. Search terms were related to bipolar disorder, nutrition, physical activity, wellbeing, psychosocial interventions and course of illness. We hand searched content pages of Bipolar Disorders and Journal of Affective Disorders and checked references of relevant reviews and dissertations to identify additional papers.

RESULTS

After applying inclusion and exclusion criteria to identified hits, this literature search retrieved six papers. Overall findings point towards a beneficial role of lifestyle interventions on mood, weight, blood pressure, lipid profile, physical activity and overall wellbeing. Methodological limitations include small sample size, gender ratio imbalance, inconsistencies in terms of laboratory measures, and lack of randomized controlled trials and absence of follow-up and longitudinal studies to determine the benefits of these factors on clinical and functional outcomes over time

CONCLUSIONS

Lifestyle interventions in BD targeting nutrition, exercise, wellbeing alongside beliefs, coping strategies and attitudes towards health show promise in reducing the risk of comorbid ailments in BD. There is still a strong need for studies a) developing interventions which are informed by the patient's input and b) examining the effectiveness of such interventions targeting general wellness using well-controlled trials.

Self-management and bipolar disorder--a clinician's guide to the literature 2011-2014

This review provides clinicians and individuals with bipolar disorder (BD) with an overview of evidence-based skills shown to be effective in BD and amenable to self-management including psychoeducation; monitoring moods, medications, and social function; sleep hygiene; setting goals and relapse plans; and healthy lifestyles (physical activity, healthy eating, weight loss and management, medical comorbidities). Currently available self-management resources for BD are summarized by mode of delivery (workbooks, mobile technologies, internet, and peer-led interventions). Regardless of the self-management intervention/topic, the research suggests that personally tailored interventions of longer duration and greater frequency may be necessary to achieve the maximal benefit among individuals with BD. Means to support these self-management interventions as self-sustaining identities are critically needed. Hopefully, the recent investment in patient-centered research and care will result in best practices for the self-management of BD by mode of delivery. Since self-management of BD should complement rather than replace medical care, clinicians need to partner with their patients to incorporate and support advances in self-management for individuals with BD.