Perceptions of illness in self and in others among patients with bipolar disorder

Research on clinical aspects of bipolar disorder: A review of Indian studies

Background

Bipolar disorder is one of the severe mental disorders that are associated with significant morbidity of the patients. Despite advancements in our understanding about the disorder, it remains a challenging proposition to treat bipolar disorder, largely since the prophylactic treatment of the disorder requires assessment of complex clinical algorithms. The revisions of the classificatory systems have also changed the conceptualization of the disorder. In this background, we conducted a review of the Indian studies conducted on the clinical aspects of bipolar disorder.

Methods

A narrative review was conducted with focus on the literature published from India. The databases searched included PubMed, Scopus, and Google Scholar, and articles published over the last 15 years by Indian authors were included for this review.

Results

In our review, we could access a substantial volume of research published from India. We could identify studies that catered to most of the relevant themes in bipolar disorder including epidemiology, etiology, comorbidities, stigma, disability, clinical course, cognitive profile, pathways to care, and recovery.

Conclusion

The research trajectory was in line with the research conducted elsewhere in the world. However, certain dissimilarities in terms of focus could also be observed. The possible reason behind this deviation could be the difference in clinical need and unique challenges faced in the management and rehabilitation of patients in bipolar disorder in Indian scenario.

Approaching "highly sensitive person" as a cultural concept of distress: a case-study using the cultural formulation interview in patients with bipolar disorder

Background

Psychiatric patients may refer to concepts neither medically accepted nor easily understood to describe their experiences when seeking medical care. These concepts may lie outside the clinician's cultural references and consequently hinder the diagnostic consultation. In the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the clinical instrument Cultural Formulation Interview (CFI) was included. The CFI aims to facilitate the gathering and synthesis of culturally relevant clinical information. The notion of Cultural Concepts of Distress (CCD) was also introduced in DSM-5. The CCD include the subterms of the cultural syndrome, cultural explanation, and cultural idiom of distress. No previous study has used CFI for conceptualizing a cultural notion as a CCD. This study aimed to approach the cultural notion of being a highly sensitive person (HSP) in patients with bipolar disorder (BD) by applying the CFI. The cultural notion of HSP has garnered great interest globally, although scientific evidence is limited. No direct correlation between BD and HSP was hypothesized before or during the study process.

Methods

In this case study, three patients with BD who reported being HSP were interviewed using the CFI. Furthermore, the applicability of the CCD was examined based on the outcomes of the CFI using an interpretive approach.

Results

All three patients reported that the CFI facilitated the clinical consultation, and in one of the cases, it may also have increased the treatment engagement. Based on the synthesis of the CFI outcomes in these illustrative cases, HSP could be understood as a cultural syndrome, a cultural explanation, and a cultural idiom of distress.

Conclusion

By applying a person-centered perspective, CFI was used for the conceptualization of a cultural notion as a CCD (i.e., HSP in our study). Moreover, the cases highlight the complexity of illness insight in BD as a medical phenomenon when patients' illness perspectives are taken into consideration. Future studies need to further examine the clinical relevance of the CFI in the management of BD.

Insight in patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Background

There are limited number of studies evaluating insight among patients with bipolar disorder (BD).

Aim

This study aimed to examine insight and its correlates in BD using the data from the multicenter BD course and outcome study from India (BiD-CoIN). The additional aim was to evaluate the insight in patients with BD using different scales and understand the correlates of insight.

Materials and Methods

773 BD patients presently in clinical remission were evaluated on the Insight Scale for Affective Disorders (ISAD), insight items of the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS).

Results

The assessment scales influenced the prevalence of poor insight. Poorer insight irrespective of the assessment scale was consistently associated with higher residual depressive and manic symptoms, and a higher level of cognitive impairment and disability. Poor insight as assessed by ISAD was associated with a higher number of episodes in the lifetime, shorter duration of current remission, a higher number of depressive episodes, a higher amount of time spent in depressive episodes, higher depressive affective morbidity, a higher number of manic episodes, and higher residual depressive and manic symptoms.

Conclusion

Poor insight in BD is consistently associated with higher residual depressive and manic symptoms and a higher level of cognitive impairment and disability. However, in terms of course variables, the correlates vary depending on the assessment method.

Reasons for endorsing or rejecting self-binding directives in bipolar disorder: a qualitative study of survey responses from UK service users

BACKGROUND

Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and human rights.

METHODS

This qualitative study used data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision making for patients with bipolar disorder. We included participants who reported that they have been diagnosed with bipolar disorder by a professional (doctor or psychiatrist). In a previous study, quantitative analysis of a closed question about self-binding directives had shown endorsement among a high proportion of participants with bipolar disorder who completed the survey. In this study, we did a thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was done within a multidisciplinary team, including team members with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methods associated with all these areas of expertise were used in the thematic analysis to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues.

FINDINGS

Between Oct 23, 2017, and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 individuals (154 men, 400 women, 11 transgender or other), predominantly white British, providing free-text answers to the open question. 463 (82%) of the 565 participants endorsed self-binding directives, of whom 411 (89%) describing a determinate shift to distorted thinking and decision making when unwell as their key justification. Responses indicating ambivalence (37 [7%) of the 565 responses) were dominated by logistical concerns about the drafting and implementation of self-binding directives, whereas those who rejected self-binding directives (65 [12%] of the 565 responses) cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights.

INTERPRETATION

This study is, to our knowledge, the first large study assessing the reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health services as well as advance decision-making practice and policy, and might help address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations.

FUNDING

The Wellcome Trust.

The Visible and Less Visible in the Suffering of a Conversion Disorder in Children and Adolescents. A Qualitative Study of Illness Explanatory Models Presented to Caregivers of Children and Adolescents with Conversion Disorder

BACKGROUND

Conversion disorder is a challenge for clinicians due to the conceptual gaps as regards its pathogenesis, the way in which it converges with other psychiatric disorders, and the lack of approaches to the experiences of both patients and family members with the disease.

OBJECTIVE

To describe Explanatory Models (EM) offered to caregivers of paediatric patients with conversion disorder who attended the Hospital de la Misericordia.

METHODS

A qualitative study was conducted with a convenience sample of 10 patients who attended the Hospital de La Misericordia, ¿Bogota? between May 2014 and April 2015. The tool used was an in-depth interview applied to parents and/or caregivers.

RESULTS

Caregivers have different beliefs about the origin of the symptoms, especially considering sickness, magical-mystical factors, and psychosocial factors. The symptoms are explained in each case in various ways and there is no direct relationship between these beliefs, the pattern of symptoms, and help-seeking behaviours. Symptomatic presentation is polymorphous and mainly interferes in the patient's school activities. The medical care is perceived as relevant, and psychiatric care as insufficient. Among the therapeutic routes, consultations with various agents are described, including medical care, alternative medicine, and magical-religious approaches.

CONCLUSIONS

EMs in conversion disorder are varied, but often include magical-religious elements and psychosocial factors. The underlying beliefs are not directly related to help-seeking behaviours or other variables.

Treatment-adherence in bipolar disorder: A patient-centred approach

About half of the patients diagnosed with bipolar disorder (BD) become non-adherent during long-term treatment, a rate largely similar to other chronic illnesses and one that has remained unchanged over the years. Non-adherence in BD is a complex phenomenon determined by a multitude of influences. However, there is considerable uncertainty about the key determinants of non-adherence in BD. Initial research on non-adherence in BD mostly limited itself to examining demographic, clinical and medication-related factors impacting adherence. However, because of inconsistent results and failure of these studies to address the complexities of adherence behaviour, demographic and illness-related factors were alone unable to explain or predict non-adherence in BD. This prompted a shift to a more patient-centred approach of viewing non-adherence. The central element of this approach includes an emphasis on patients’ decisions regarding their own treatment based on their personal beliefs, life circumstances and their perceptions of benefits and disadvantages of treatment. Patients’ decision-making processes are influenced by the nature of their relationship with clinicians and the health-care system and by people in their immediate environment. The primacy of the patient’s perspective on non-adherence is in keeping with the current theoretical models and concordance-based approaches to adherence behaviour in BD. Research over the past two decades has further endorsed the critical role of patients’ attitudes and beliefs regarding medications, the importance of a collaborative treatment-alliance, the influence of the family, and the significance of other patient-related factors such as knowledge, stigma, patient satisfaction and access to treatment in determining non-adherence in BD. Though simply moving from an illness-centred to a patient-centred approach is unlikely to solve the problem of non-adherence in BD, such an approach is more likely to lead to a better understanding of non-adherence and more likely to yield effective solutions to tackle this common and distressing problem afflicting patients with BD.

The potential consequences of informal interpreting practices for assessment of patients in a South African psychiatric hospital

In South Africa health care practitioners are commonly professionals who speak only one, or at most two, of the languages spoken by their patients. This provides for language provision challenges, since many patients are not proficient in English or Afrikaans and ad hoc and haphazard arrangements are made for interpreting by untrained personnel. As part of a larger study (conducted in 2010) in a public psychiatric hospital, we report here on the potential consequences for diagnostic assessments of 13 psychiatric evaluations mediated by ad hoc interpreters who were employed as health care workers and household aides. The psychiatric evaluations were recorded and transcribed verbatim. The first author checked for accuracy of transcription and translations, and the two members of the author team who are both senior African language academics rechecked transcription and translation. We used the typology developed by Vasquez and Javier (1991) to study interpreter errors (i.e. omissions, additions and substitutions). All errors were independently rated by a senior psychiatrist and a senior clinical psychologist to determine whether the errors were likely to have a bearing on clinical decisions concerning the patient and to rate whether errors deemed clinically significant contributed to making the patient appear more ill psychiatrically, or less ill. Of the 57 errors recorded, 46% were rated as likely to have an impact on the goal of the clinical session. Raters concurred that the clinically significant errors contributed towards potentially making the patient look more psychiatrically ill. Detailed analyses of evaluations demonstrate the complexity of informal interpreter positioning regarding issues of diagnosis and cultural factors in illness. Evaluations conducted where clinicians and interpreters are not trained in language and interpreting issues may create a distorted picture of the patients' mental health conditions.

Diagnostic and statistical manual-5: Position paper of the Indian Psychiatric Society

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

Insight in bipolar disorder: associations with cognitive and emotional processing and illness characteristics

OBJECTIVE

To investigate the multifactorial relationship between illness insight, cognitive and emotional processes, and illness characteristics in bipolar disorder patients.

METHODS

Data from 85 euthymic or mildly to moderately depressed bipolar disorder patients were evaluated. Insight was measured using the Mood Disorder Insight Scale (total score and subscale scores: awareness of illness, symptom attribution, and need for treatment). Cognitive and emotional functioning was measured in four domains (processing speed, memory, executive functioning, and emotional learning) in addition to premorbid IQ. Illness characteristics were assessed using the Mini-International Neuropsychiatric Interview, the Questionnaire for Bipolar Disorder, and the Inventory of Depressive Symptomatology-self rating scale. Regression analyses were performed for the whole sample. Post-hoc, interactions with lifetime psychotic features (LPF) were statistically tested and if significant, analyses were repeated for patients with (n = 36) and without (n = 49) LPF separately.

RESULTS

In the whole group, better insight was associated with lower processing speed, better memory performance, increased emotional learning, higher level of depressive symptoms, and longer duration of illness. Patients with LPF had worse awareness of illness, but better symptom attribution than patients without LPF. No group differences for need for treatment and overall insight were found. Finally, processing speed significantly predicted subscores for symptom attribution in patients with LPF only.

CONCLUSIONS

Cognitive functioning as well as impairments in emotional learning and psychotic features independently contributes to impaired insight in bipolar disorder. Processing speed seems to be a key variable in the prediction of insight in patients with LPF and not in patients without LPF.

The assessment of insight across cultures

The assessment of insight is a part of the routine clinical examination for people with mental illness. Such assessment, by psychiatrists, is based on the current definitions of insight, which rely on western notions of health and illness. This paper discusses the recent findings of illness perspectives of people with a variety of physical diseases and mental disorders from India. Studies on insight in schizophrenia and bipolar disorders also examined explanatory models of illness among patients, relatives, and the general population. The findings argue for the fact that the assessment of insight should be against the local cultural standards rather than universal yardsticks. The assessment of insight should evaluate awareness, attribution, and action. People with psychosis who are able to re-label their psychotic experience, offer non-delusional explanations for changes in themselves, which correspond to beliefs about illness held by the subculture, admit to the need for restitution, and seek locally available help, can be said to possess insight. The results recommend the use of universal conventions to assess insight in people with psychosis rather than the use of uniform criteria.

Early intervention in psychotic disorders: Challenges and relevance in the Indian context

Over the last two decades, there has been an increasing interest in the concept of early intervention (EI) in psychotic disorders, notably schizophrenia. Several lines of research underlie this emerging paradigm shift: (a) an increasingly well-established association between the duration of prolonged untreated illness and poor outcome; (b) evidence of progressive neurobiological changes in the early course of schizophrenia both in the pre-psychotic and psychotic phases, as evidenced by brain imaging studies in schizophrenia; and (c) emerging data, albeit preliminary, suggesting the efficacy and effectiveness of EI programs in improving the outcome in these patients. Mental health service systems across the globe, including Asian countries, have been incorporating specialized early intervention programs. However, literature on EI in the Indian setting is relatively sparse. In this article, we will review the rationale and approaches to EI and the application of these approaches to the Indian context, in light of the available literature. We also examine the constraints in the implementation of EI. Controlled data are needed to evaluate EI and the roadblocks to them, in order to implement EI in the resource-strapped mental health service settings in India.