Psychiatric assessment of mood instability: qualitative study of patient experience

What to take up from the patient's talk? The clinician's responses to the patient's self-disclosure of their subjective experience in the psychiatric intake interview

During psychiatric diagnostic interviews, the clinician's question usually targets specific symptom descriptions based on diagnostic categories for ICD-10/DSM-5 (2, 3). While some patients merely answer questions, others go beyond to describe their subjective experiences in a manner that highlights the intensity and urgency of those experiences. By adopting conversation analysis as a method, this study examines diagnostic interviews conducted in an outpatient clinic in South Finland and identifies sequences that divulge patients' subjective experiences. From 10 audio-recorded diagnostic interviews, 40 segments were selected where patients replied to medically or factually oriented questions with their self-disclosures. The research focus was on the clinicians' responses to these disclosures. We present five sequential trajectories that the clinicians offered third-position utterances in response to their patients' self-disclosure of subjective experiences. These trajectories include the following: 1) the clinician transfers the topic to a new agenda question concerning a medical or factual theme; 2) the clinician presents a follow-up question that selects a topic from the patient's self-disclosure of a subjective experience that may orient either towards the medical/factual side or the experiential side of the patient's telling; 3) the clinician provides an expert interpretation of the patient's self-disclosure of his or her subjective experience from the clinician's expert perspective; 4) the clinician gives advice that orients mainly to a treatment recommendation or to another activity; and 5) the clinician presents a formulation that focusses on the core of their patient's self-disclosure of his or her subjective experience from the patient's perspective. In addition, we present what these responsive practices invoke from the patient in the next turn. We argue that an awareness of these strategies facilitates both the diagnosis and an appropriate therapeutic relationship during the psychiatric assessment interview. Finally, we discuss the clinical significance of our results regarding the patient's agency and the clinician's more conscious patient-centred orientation in the psychiatric assessment procedure.

Teaching trainee psychiatrists a Mentalization-Based Treatment approach to personality disorder: effect on attitudes

AIMS AND METHOD

To evaluate whether a brief training using a Mentalization-Based Treatment (MBT) model improves attitudes of trainee psychiatrists working with patients with personality disorder. Trainee psychiatrists (n = 49) completed the Attitudes to Personality Disorder Questionnaire before and after a training consisting of two 3 h lectures on (a) theory of personality disorder and (b) practical skills using an MBT role-play.

RESULTS

There was a significant improvement on composite scores of attitude, with small to moderate effect size (Wilcoxon signed-rank test Z = 3.961, P < 0.001, r = 0.40).

CLINICAL IMPLICATIONS

Brief MBT-informed teaching oriented to the clinical situation appears to have a positive effect on attitudes towards people with personality disorder.

Clinical Targets and Attitudes Toward Implementing Digital Health Tools for Remote Measurement in Treatment for Depression: Focus Groups With Patients and Clinicians

BACKGROUND

Remote measurement technologies, such as smartphones and wearable devices, can improve treatment outcomes for depression through enhanced illness characterization and monitoring. However, little is known about digital outcomes that are clinically meaningful to patients and clinicians. Moreover, if these technologies are to be successfully implemented within treatment, stakeholders' views on the barriers to and facilitators of their implementation in treatment must be considered.

OBJECTIVE

This study aims to identify clinically meaningful targets for digital health research in depression and explore attitudes toward their implementation in psychological services.

METHODS

A grounded theory approach was used on qualitative data from 3 focus groups of patients with a current diagnosis of depression and clinicians with >6 months of experience with delivering psychotherapy (N=22).

RESULTS

Emerging themes on clinical targets fell into the following two main categories: promoters and markers of change. The former are behaviors that participants engage in to promote mental health, and the latter signal a change in mood. These themes were further subdivided into external changes (changes in behavior) or internal changes (changes in thoughts or feelings) and mapped with potential digital sensors. The following six implementation acceptability themes emerged: technology-related factors, information and data management, emotional support, cognitive support, increased self-awareness, and clinical utility.

CONCLUSIONS

The promoters versus markers of change differentiation have implications for a causal model of digital phenotyping in depression, which this paper presents. Internal versus external subdivisions are helpful in determining which factors are more susceptible to being measured by using active versus passive methods. The implications for implementation within psychotherapy are discussed with regard to treatment effectiveness, service provision, and patient and clinician experience.

Service user experiences of mental health assessments: a systematic review and thematic synthesis of qualitative literature

BACKGROUND

Successive governments have placed service users' experiences at the heart of mental health services delivery and development. However, little is known about service users' experiences of assessments and there is some evidence that assessments can cause harm.

AIMS

To synthesise the qualitative literature on service users' experiences of undergoing mental health service assessments.

METHODS

Literature was systematically searched, screened and extracted, following PRISMA guidelines. Several search strategies were employed, including electronic database searches, handsearching, and forward and backward citation tracking, to identify literature which contained data on service users' experiences of mental health assessments. Thematic synthesis was used to derive a set of themes underpinning these experiences.

RESULTS

Of the 10,137 references screened, 47 were identified as relevant to the review. Two main themes were identified: the importance of humanising assessment processes and experiences of service user agency, with each theme containing four sub-themes.

CONCLUSIONS

Findings highlight key factors determining service user experience. We identify key practice implications, contextualised within the literature on trauma-informed approaches and conclude that trauma-informed approaches may aid understanding and improvement of people's assessment experiences. Further research into the experiences of people from Black and minority ethnic communities is indicated.

Composition of treatment alliance in bipolar disorder: A cross-sectional study of patients’ perspectives

BACKGROUND

Treatment alliance has an impact on several key patient outcomes in all psychiatric disorders, including bipolar disorder (BD). It has been suggested that the construct of treatment alliance is different among patients from routine psychiatric settings compared to psychotherapeutic settings. However, research on the composition of treatment alliance in psychiatric disorders, such as BD, is relatively limited.

AIM

To determine whether a broader construct of treatment alliance was prevalent among outpatients with BD.

METHODS

This is a cross-sectional study, conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (September 2018 to September 2019). A consecutive sample of 160 remitted adult outpatients with BD on mood stabilizers for at least a year were selected. The principal instrument to assess treatment alliance was the Working Alliance Inventory-client version (WAI-Client). Other potential constituents of the alliance explored were perceived trust in clinicians assessed by the Trust in Physicians (TRIP) scale, perceived support from clinicians assessed by the Psychosocial Care by Physicians (PCP) scale, and perceived treatment satisfaction assessed by the Patient Satisfaction Questionnaire (PSQ). Associations between scores on all scales were determined by correlational and multiple regression analyses. Exploratory factor analysis of combined items of all scales was conducted using a principal components analysis.

RESULTS

Scores on all the three WAI-Client subscales were significantly correlated with each other (r = 0.66-0.81; P < 0.0001). The total TRIP scores were associated with the total WAI-Client scores (r = 0.28; P < 0.01). The total TRIP scores and the total PCP scores were also significantly associated with the WAI-Client scores on the Task subscale (r = 0.28-0.29; P < 0.01). The total TRIP scores were significantly associated with the total PSQ scores (r = 0.45; P < 0.0001). Factor analysis yielded two independent and coherent factors, which explained 69% of the variance in data. Factor-1 (“alliance and support”), which explained about 41% of the variance, was comprised of a combined WAI-Client goal-task-bond component as well as the PCP support items. Factor-2 (“trust and satisfaction”), which explained about 28% of the variance, consisted of all the TRIP trust and the PSQ treatment satisfaction items.

CONCLUSION

A broader construct of treatment alliance in BD was found. Apart from collaborative components, this construct included patients’ perceptions regarding trust in clinicians, support from clinicians, and treatment satisfaction.

Using digital health tools for the Remote Assessment of Treatment Prognosis in Depression (RAPID): a study protocol for a feasibility study

INTRODUCTION

Digital health tools such as smartphones and wearable devices could improve psychological treatment outcomes in depression through more accurate and comprehensive measures of patient behaviour. However, in this emerging field, most studies are small and based on student populations outside of a clinical setting. The current study aims to determine the feasibility and acceptability of using smartphones and wearable devices to collect behavioural and clinical data in people undergoing therapy for depressive disorders and establish the extent to which they can be potentially useful biomarkers of depression and recovery after treatment.

METHODS AND ANALYSIS

This is an observational, prospective cohort study of 65 people attending psychological therapy for depression in multiple London-based sites. It will collect continuous passive data from smartphone sensors and a Fitbit fitness tracker, and deliver questionnaires, speech tasks and cognitive assessments through smartphone-based apps. Objective data on sleep, physical activity, location, Bluetooth contact, smartphone use and heart rate will be gathered for 7 months, and compared with clinical and contextual data. A mixed methods design, including a qualitative interview of patient experiences, will be used to evaluate key feasibility indicators, digital phenotypes of depression and therapy prognosis. Patient and public involvement was sought for participant-facing documents and the study design of the current research proposal.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the London Westminster Research Ethics Committee, and the Health Research Authority, Integrated Research Application System (project ID: 270918). Privacy and confidentiality will be guaranteed and the procedures for handling, processing, storage and destruction of the data will comply with the General Data Protection Regulation. Findings from this study will form part of a doctoral thesis, will be presented at national and international meetings or academic conferences and will generate manuscripts to be submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

https://doi.org/10.17605/OSF.IO/PMYTA.

The Clinical Impacts of Mobile Mood-Monitoring in Young People With Mental Health Problems: The MeMO Study

Background: Limited evidence suggests that mobile mood-monitoring can improve mental health outcomes and therapeutic engagement in young people. The aim of this mixed methods study was to explore the clinical impacts of mobile mood-monitoring in youth with mental health problems, using a publicly accessible app. Methods: Twenty-three patients with mental health problems and 24 young people without mental health problems participated in the quantitative study. Participants monitored their mood using a mood-monitoring app twice a day for 3 weeks, which was preceded by a 3-week baseline period. Outcome measures included momentary and retrospective assessments of affect regulation (all participants) and therapeutic engagement (patients only). Following the quantitative study, patients (n = 7) and their clinicians (n = 6) participated in individual interviews. Interview data was analysed using thematic analysis. Results: Use of the mood-monitoring app significantly reduced momentary negative mood (p < 0.001) and retrospectively assessed impulsivity across all 47 participants (p = 0.001). All other outcomes showed no significant difference. Qualitative feedback similarly indicated the potential of apps to improve problems with impulsivity in patients. Furthermore, apps may aid communication, promote empowerment, and ameliorate memory difficulties in clinical appointments. Conclusions: This mixed methods study demonstrated the potential utility of apps for clinical practice. Apps may potentially be an interventional tool, or at a minimum, an adjunct to existing treatments. Data was collected from a small sample size over a short study duration, limiting the generalisability of findings and inferences regarding long-term effects. Potential sources of bias in the qualitative study (e.g., researcher bias) should also be considered.

Towards a standardized approach of assessing social context of persons receiving home care in Flanders, Belgium: the development and test of a social supplement to the interRAI instruments

BACKGROUND

Apart from a person's physical functioning, the early identification of social context indicators which affect patient outcomes - such as environmental and psychosocial issues - is key for high quality and comprehensive care at home. During a home care assessment, a person's biomedical and functional problems are typically considered. Harder to define concepts, such as psychosocial well-being or living arrangements, are not routinely documented, even though research shows they also affect functioning and health outcomes. The purpose of this study is to develop and test a concise, integrated assessment (BelRAI Social Supplement) that evaluates these social context indicators for persons receiving home care to complement existing interRAI- instruments.

METHODS

The development of the BelRAI Social Supplement is a multi-stage process, based upon the revised MRC-framework, involving both qualitative and quantitative research with stakeholders such as; clients, informal caregivers, care professionals and policy makers. The developmental process encompasses four stages: (I) item generation based on multiple methods and content validation by a panel of stakeholders (II) assessing feasibility and piloting methods, (III) early evaluation, and (IV) final evaluation. Stage II and III are covered in this paper.

RESULTS

During Stages I and II, a testable version of the BelRAI Social Supplement was developed in an iterative process. In Stage III, 100 care professionals assessed 743 individuals receiving home care in Flanders between December 2018 and December 2019. Using inter-item correlation matrixes, frequency distributions and regular feedback from the participants, the BelRAI Social Supplement was improved and prepared for Stage IV. The updated version of the instrument consists of four main sections: (1) environmental assessment; (2) civic engagement; (3) psychosocial well-being; and (4) informal care and support. In total, the BelRAI Social Supplement contains a maximum of 76 items.

CONCLUSIONS

The BelRAI Social Supplement was reviewed and shortened in close collaboration with care professionals and other experts in Flanders. This study resulted in an instrument that documents need-to-know social context determinants of home dwelling adults.

The Systemic Assessment Clinic, a Novel Method for Assessing Patients in General Adult Psychiatry: Presentation and Preliminary Service Evaluation

The traditional model of psychiatric assessment and diagnosis can be criticised as reductive. We developed an innovative model for psychiatric assessment of adult patients referred to our adult mental health team, the Systemic Assessment Clinic, incorporating the principles and techniques of systemic family therapy and dialogical practice into standard psychiatric assessment. We conducted a service evaluation, comparing prospective use of mental health services for patients assessed either in the Systemic Assessment Clinic or in standard assessment. Patients assessed in the Systemic Assessment Clinic had more favourable outcomes than those in standard assessment: they were significantly less likely to need multiple follow-up treatment appointments with a psychiatrist and to be re-referred to mental health services once discharged, indicating reduced healthcare costs. Satisfaction rates for participants attending the systemic assessment clinic were high. Our service evaluation gives preliminary evidence that the Systemic Assessment Clinic could be a potential new model for psychiatric assessment; further evaluation is warranted in a randomised controlled trial.

Differential diagnosis of borderline personality disorder and bipolar disorder: Self-concept, identity and self-esteem

Symptoms of borderline personality disorder (BPD) and bipolar disorder (BD) often overlap. In some cases, it is difficult to conduct a differential diagnosis based only on current diagnostic criteria Therefore, it is important to find clinical factors with high discriminatory specificity that, used together with structured or semi-structured interviews, could help improve diagnostic practice. We propose that a clinical analysis of identity, self-concept and self-esteem may help distinguish the two disorders, when they are not co-morbid. Our review of the studies that analyse these constructs in BD and BPD, separately, points in the direction of qualitative differences between the two disorders. In BPD, there is a well-documented identity diffusion, and the self-concept appears predominantly negative; shifts in self-concept and self-esteem are often tied to interpersonal triggers. In BD, patients struggle with their identity, but narrative identity might be less compromised compared with BPD; the shifts in self-concept and self-esteem appear more linked to internal (i.e. mood and motivational) factors. We end the paper by discussing the implications for clinicians and ideas for future comparative research.

Recommendations for the use of long-term experience sampling in bipolar disorder care: a qualitative study of patient and clinician experiences

Background

Self-monitoring has been shown to improve the self-management and treatment of patients with bipolar disorder. However, current self-monitoring methods are limited to once-daily retrospectively assessed mood, which may not suit the rapid mood fluctuations in bipolar disorder. The experience sampling method (ESM), which assesses mood in real-time several times a day, may overcome these limitations. This study set out to assess the experiences of patients and clinicians with the addition of ESM monitoring, real-time alerts, and personalized feedback to clinical care. Participants were twenty patients with bipolar disorder type I/II and their clinicians. For four months, patients completed five ESM assessments per day on mood, symptoms, and activities. Weekly symptom questionnaires alerted patients and clinicians to potential episodes. After the monitoring, a personalized feedback report based on the patient’s data was discussed between patient and clinician. Three months later, patient and clinician were both interviewed.

Results

Thematic analysis of the transcripts resulted in four themes: perceived effects of the monitoring, alerts, and feedback, and recommendations for implementation of ESM. ESM was perceived as helping patients to cope better with their disorder by increasing awareness, offering new insights, and encouraging life style adjustments. ESM was further believed to facilitate communication between patient and clinician and to lead to new treatment directions. However, high assessment burden and pre-occupation with negative mood and having a disorder were also described. Patients and clinicians advocated for increased personalization and embedding of ESM in care.

Conclusions

This study demonstrates that long-term ESM monitoring, alerts, and personalized feedback are perceived as beneficial to the treatment and self-management of patients with bipolar disorder. Future research should further test the clinical utility of ESM. Clinically relevant feedback and technology need to be developed to enable personalized integration of ESM in clinical care.

Toi Même, a Mobile Health Platform for Measuring Bipolar Illness Activity: Protocol for a Feasibility Study

BACKGROUND

The diagnosis and management of bipolar disorder are limited by the absence of available biomarkers. Patients with bipolar disorder frequently present with mood instability even during remission, which is likely associated with the risk of relapse, impaired functioning, and suicidal behavior, indicating that the illness is active.

OBJECTIVE

This research protocol aimed to investigate the correlations between clinically rated mood symptoms and mood/behavioral data automatically collected using the Toi Même app in patients with bipolar disorder presenting with different mood episodes. This study also aimed to assess the feasibility of this app for self-monitoring subjective and objective mood/behavior parameters in those patients.

METHODS

This open-label, nonrandomized trial will enroll 93 (31 depressive, 31 euthymic, and 31 hypomanic) adults diagnosed with bipolar disorder type I/II (Diagnostic and Statistical Manual of Mental Disorders, 5th edition criteria) and owning an iPhone. Clinical evaluations will be performed by psychiatrists at the baseline and after 2 weeks, 1 month, 2 months, and 3 months during the follow-up. Rather than only accessing the daily mood symptoms, the Toi Même app also integrates ecological momentary assessments through 2 gamified tests to assess cognition speed (QUiCKBRAIN) and affective responses (PLAYiMOTIONS) in real-life contexts, continuously measures daily motor activities (eg, number of steps, distance) using the smartphone's motion sensors, and performs a comprehensive weekly assessment.

RESULTS

Recruitment began in April 2018 and the completion of the study is estimated to be in December 2021. As of April 2019, 25 participants were enrolled in the study. The first results are expected to be submitted for publication in 2020. This project has been funded by the Perception and Memory Unit of the Pasteur Institute (Paris) and it has received the final ethical/research approvals in April 2018 (ID-RCB: 2017-A02450-53).

CONCLUSIONS

Our results will add to the evidence of exploring other alternatives toward a more integrated approach in the management of bipolar disorder, including digital phenotyping, to develop an ethical and clinically meaningful framework for investigating, diagnosing, and treating individuals at risk of developing bipolar disorder or currently experiencing bipolar disorder. Further prospective studies on the validity of automatically generated smartphone data are needed for better understanding the longitudinal pattern of mood instability in bipolar disorder as well as to establish the reliability, efficacy, and cost-effectiveness of such an app intervention for patients with bipolar disorder.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03508427; https://clinicaltrials.gov/ct2/show/NCT03508427.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18818.

Collaborative Deprescribing in Borderline Personality Disorder: A Narrative Review

After participating in this activity, learners should be better able to:• Assess medication management in patients with borderline personality disorder (BPD)• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy ABSTRACT: Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients' relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient's medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient's preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient's relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.

Qualitative investigation of relatives' and service users' experience of mental healthcare for suicidal behaviour in bipolar disorder

OBJECTIVE

People with bipolar disorder are known to be at high risk of engaging in suicidal behaviours, and those who die by suicide have often been in recent contact with mental health services. The objective of this study was to explore suicidal behaviour in bipolar disorder and how this is monitored and managed by mental health services.

AIMS

To identify themes within relatives' and service users' accounts of mental healthcare, related to management and prevention of suicidal behaviour in bipolar disorder.

DESIGN

Thematic analysis of 22 semistructured interviews.

PARTICIPANTS

Participants were aged 18 years or over, fluent in written and spoken English, and either had bipolar disorder with a history of suicidal behaviour, or were relatives of people with bipolar disorder who had died by suicide.

SETTING

England, UK.

PRIMARY OUTCOME

Themes identified from participants' accounts of mental healthcare for suicidal behaviours in bipolar disorder.

RESULTS

Two main themes were identified. 'Access to care' was characterised by a series or cycle of potential barriers to care (eg, gate-keepers, lack of an accurate diagnosis) which had the potential to increase risk of suicidal behaviour if failure to access care continued over time. 'Problems with communication' captured the importance of maintaining open routes of communication between all parties involved in care to ensure successful monitoring and management of suicidal behaviours in bipolar disorder.

CONCLUSIONS

Mental health services need to be accessible and respond rapidly to people with suicidal behaviour in bipolar disorder. Open communication and inclusion of relatives in care, where appropriate, could help closer monitoring of changes in symptoms that indicate increased risk.

Exploring Perceptions of Continuity of Care Among People With Long-Term Mental Disorders in Denmark

Continuity of mental health care is central to improve the treatment and rehabilitation of people with mental disorders. While most studies on continuity of care fail to take the perspectives of service users into account, the aim of this study was to explore the perceived meanings of continuity of care among people with long-term mental disorders. Fifteen service users participated in semi-structured in-depth interviews. We used template analysis to guide the analysis. The main transversal themes of continuity were "Navigating the system" and "Connecting to people and everyday life." While the first theme related to the participants' experiences of their interaction with the mental health care system, the latter related to their hopes and perceived opportunities for a good life as desired outcomes of mental health care. We conclude that efforts to improve continuity of mental health care should be tailored to the priorities of service users.

Collaborative diagnosis between clinician and patient: why to do it and what to consider

This article discusses findings from the literature and our own research related to the experience of the diagnostic process in mental healthcare, primarily from the perspective of patients, and it focuses on the benefits of collaboration. A common finding throughout our research is that, if a diagnostic process is undertaken, the majority of patients want to be actively involved and feel valued in it. This helps ensure that they find the process and the resulting diagnosis to be meaningful, informative and useful. We believe that collaboration could also mitigate some of the reported negative unintended consequences of diagnosis, including feeling stigmatised, labelled and disempowered. Our work has led us to conceive of diagnosis as having two overarching elements: the diagnostic process and the resulting diagnostic label. This article focuses specifically on the diagnostic process; we do not consider here the debate surrounding the evidence base for the validity of psychiatric classification.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

Addressing organizational barriers to continuity of care in the Danish mental health system - a comparative analysis of 14 national intervention projects

BACKGROUND

Continuity of mental health care is central to improve the conditions of people with enduring mental disorders. In Denmark, several government-funded projects on the improvement of continuity of mental health care have been initiated since 2009.

AIM

The aim of this study was to investigate how national intervention projects on continuity of mental health care have addressed major barriers for continuity of care and extract general learning points from the projects on the improvement of continuity of care.

METHOD

The study was designed as a thematic document analysis of external evaluations of 14 major national projects on the improvement of continuity of routine mental health care from 2009 to 2017. The data material was processed through thematic coding and comparative analysis.

RESULTS

The analysis was organized around four main barriers for continuity: Lack of models for collaboration, different professional cultures and methods, lack of channels of communication, and intersectoral differences in management, economy, and legislation. The first three barriers were addressed in a predominant part of the projects through development of collaborative models, common tools and communication systems. The latter structural barrier was not addressed in any of the projects.

CONCLUSION

There is an ongoing need to address barriers for continuity of mental health care. So far, there has been a much larger focus on organizational, cultural and communicational aspects of continuity than on structural aspects. The study calls for an increased focus on how changes in existing managerial, economic and legislative structures can improve continuity of care.

Treatment alliance and adherence in bipolar disorder

The clinician patient relationship lies at the core of psychiatric practice and delivery of mental health care services. The concept of treatment alliance in psychiatry has its origins in psychotherapy, but has also been influenced by several other constructs such as patient-centred care (PCC) and shared decision-making (SDM). Similarly, there has been a shift in conceptualization of treatment-adherence in psychiatric disorders including bipolar disorder (BD) from illness-centred and clinician-centred approaches to patient-centred ones. Moreover, the traditional compliance based models are being replaced by those based on concordance between clinicians and patients. Newer theories of adherence in BD place considerable emphasis on patient related factors and the clinician patient alliance is considered to be one of the principal determinants of treatment-adherence in BD. Likewise, current notions of treatment alliance in BD also stress the importance of equal and collaborative relationships, sensitivity to patients' viewpoints, sharing of knowledge, and mutual responsibility and agreement regarding decisions related to treatment. Accumulated evidence from quantitative research, descriptive accounts, qualitative studies and trials of psychosocial interventions indicates that efficacious treatment alliances have a positive influence on adherence in BD. Then again, research on the alliance-adherence link in BD lags behind the existing literature on the subject in other medical and psychiatric conditions in terms of the size and quality of the evidence, the consistency of its findings and clarity about underlying processes mediating this link. Nevertheless, the elements of an effective alliance which could have a positive impact on adherence in BD are reasonably clear and include PCC, collaborative relationships, SDM, open communication, trust, support, and stability and continuity of the relationship. Therefore, clinicians involved in the care of BD would do well to follow these principles and improve their interpersonal and communication skills in order to build productive alliances with their patients. This could go a long way in confronting the ubiquitous problem of non-adherence in BD. The role of future research in firmly establishing the alliance-adherence connection and uncovering the processes underlying this association will also be vital in devising effective ways to manage non-adherence in BD.

Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings

Receiving a mental health diagnosis can be pivotal for service users, and it has been described in both positive and negative terms. What influences service-user experience of the diagnostic process is unclear; consequently, clinicians report uncertainty regarding best practice. This Review aims to understand and inform diagnostic practice through a comprehensive synthesis of qualitative data on views and experiences from key stakeholders (service users, clinicians, carers, and family). We searched five databases and identified 78 papers for inclusion, originating from 13 countries and including 2228 participants. Eligible papers were assessed for quality, and data were coded and then developed into themes, which generated a model representing factors to consider for clinicians conveying, and individuals receiving, mental health diagnoses. Themes included disclosure, information provision, collaboration, timing, stigma, and functional value of diagnosis for recovery. Variations between different stakeholders and clinical contexts are explored. Findings support an individualised, collaborative, and holistic approach to mental health diagnosis.

How does psychiatric diagnosis affect young people's self-concept and social identity? A systematic review and synthesis of the qualitative literature

Receiving a psychiatric diagnosis in childhood or adolescence can have numerous social, emotional and practical repercussions. Among the most important of these are the implications for a young person's self-concept and social identity. To ensure diagnoses are communicated and managed in a way that optimally benefits mental health trajectories, understanding young people's first-hand experience of living with a diagnosis is paramount. This systematic review collates, evaluates and synthesises the qualitative research that has explored how psychiatric diagnosis interacts with young people's self-concept and social identity. A search of 10 electronic databases identified 3892 citations, 38 of which met inclusion criteria. The 38 studies were generally evaluated as moderate-to-high quality research. Thematic synthesis of their findings highlighted the multifaceted ways diagnosis affects young people's self-concept and social identity. Diagnosis can sometimes threaten and devalue young people's self-concept, but can also facilitate self-understanding, self-legitimation and self-enhancement. A diagnosis can lead to social alienation, invalidation and stigmatisation, yet can also promote social identification and acceptance. Further research is needed to clarify which self and identity outcomes can be expected in a given set of circumstances, and to establish how self and identity effects interact with diagnoses' other clinical, practical, social and emotional consequences.

Institutionalised otherness: Patients references to psychiatric diagnostic categories

Diagnosis is integral part of the way medicine organises illness: it is important for identifying treatment options, predicting outcomes and providing an explanatory framework for clinicians. Previous research has shown that during a medical visit not only the clinician but also patients provide explanations for the causes of their symptoms and health problems. Patients' lifeworld explanations are often differentiated from the diagnostic explanations provided by clinicians. However, while previous conversation analytic research has elaborated the ways in which diagnostic and lifeworld explanations are interactionally structured in somatic medicine, there is little research on how these explanations are organised in psychiatry. Psychiatric diagnosis is particularly interesting because in mental disorders illness itself is not determined by any objective measurement. Understanding of the patient's problem is constructed in interaction between the patient and clinician. The focus of this research will be patients' references to diagnosis in psychiatry and the functions of these references. The findings are based on conversation analysis of 29 audio-recorded diagnostic interviews in a psychiatric outpatient clinic. Our results demonstrate that patients can utilise diagnostic categories in several ways: disavowing a category to distance their symptoms from it, accounting for their life experiences being rooted in psychiatric illnesses and explaining their illnesses as being caused by certain life experiences. We argue that these explanations are important in patients' face-work - in constructing and maintaining a coherent and meaningful view of the patient's self.

Reactions to Psychiatry Referral in Patients Presenting with Physical Complaints to Medical and Surgical Outpatient Services

BACKGROUND

While it is well known that patients with psychiatric illness feel stigmatized, little is known about the reactions to a psychiatric referral among those who visit general hospital medical and surgical services for their complaints.

MATERIALS AND METHODS

This study assessed the sociodemographic details, psychiatric diagnosis, somatic symptom severity, and interview-based reactions to referral among patients referred to psychiatry services from other departments in a general tertiary hospital in North India. Fifty-nine males and 101 females were assessed over 6 months for this purpose.

RESULTS

A majority of patients were diagnosed with a psychiatric disorder and had significant somatic symptom severity. The themes explored were the decision to accept the referral, possibility of the presence of mental illness as signified by a psychiatric diagnosis and factors that enabled or impeded psychiatric treatment seeking.

CONCLUSIONS

Results indicate that patients did not empower in decision-making, a reluctance to accept the possibility of a psychiatric diagnosis and accept medication and had poor knowledge about psychiatry. Referring clinicians and psychiatrists should be sensitive to patient perceptions so that better care is possible.

Stigma related to bipolar disorder in the perception of psychiatrists from Belo Horizonte, Minas Gerais State, Brazil

This research sought to understand meanings and implications of the stigma related to bipolar disorder in relation to social processes and local cultural value systems. Seven semidirected individual interviews were performed with psychiatrists (from Belo Horizonte city, Minas Gerais State, Brazil) and analyzed with referential from the Medical Anthropology. Some potential stigmatizing views about bipolar disorder patients were endorsed by respondents related to biomedical model of bipolar disorder. They claimed about the extreme trivialization of this diagnosis nowadays and observed that, in spite of the mitigation of stigma related to bipolar disorder over time, it remains an important issue, especially at labor fields and as a cause of refusal of treatment.

Personality disorder: still the patients psychiatrists dislike?

Aims and method In 1988, Lewis and Appleby demonstrated that psychiatrists hold negative attitudes towards patients with personality disorder. We assessed the attitudes of psychiatry trainees towards patients with borderline personality disorder and depression, expecting an improvement. 166 trainees were block randomised to receive one of four case vignettes that varied by diagnosis and ethnic group. We used Lewis and Appleby's original questionnaire and the Attitudes to Personality Disorder Questionnaire (APDQ). Results We received 76 responses. Lewis and Appleby's questionnaire showed more negative attitudes towards personality disorder than depression, with no significant patient ethnic group effects, and the APDQ also showed a (weak) trend towards more negative attitudes to personality disorder. In subgroup analysis, only in the White British patient group were there significantly more negative attitudes to personality disorder. Factor analysis showed significantly less sense of purpose when working with personality disorder. Clinical implications The perceived greater lack of purpose in working with personality disorder should be the target of clinical training and intervention. Targeted interventions that include training in managing personality disorder, supervision and practice in non-specialist, general psychiatry settings are important.

Experiences of remote mood and activity monitoring in bipolar disorder: A qualitative study

BACKGROUND

Mobile technology enables high frequency mood monitoring and automated passive collection of data (e.g. actigraphy) from patients more efficiently and less intrusively than has previously been possible. Such techniques are increasingly being deployed in research and clinical settings however little is known about how such approaches are experienced by patients. Here, we explored the experiences of individuals with bipolar disorder engaging in a study involving mood and activity monitoring with a range of portable and wearable technologies.

METHOD

Patients were recruited from a wider sample of 50 individuals with Bipolar Disorder taking part in the Automated Monitoring of Symptom Severity (AMoSS) study in Oxford. A sub-set of 21 patients participated in a qualitative interview that followed a semi-structured approach.

RESULTS

Monitoring was associated with benefits including increased illness insight, behavioural change. Concerns were raised about the potential preoccupation with, and paranoia about, monitoring. Patients emphasized the need for personalization, flexibility, and the importance of context, when monitoring mood.

CONCLUSIONS

Mobile and electronic health approaches have potential to lend new insights into mental health and transform healthcare. Capitalizing on the perceived utility of these approaches from the patients' perspective, while addressing their concerns, will be essential for the promise of new technologies to be realised.

Mood Instability Is a Precursor of Relationship and Marital Difficulties: Results from Prospective Data from the British Health and Lifestyle Surveys

The DSM system implies that affective instability is caused by reactivity to interpersonal events. We used the British Health and Lifestyle Survey that surveyed community residents in 1984 and again in 1991 to study competing hypotheses: that mood instability (MI) leads to interpersonal difficulties or vice versa. We analyzed data from 5,352 persons who participated in both waves of the survey. Factor analysis of the Eysenck Personality Inventory neuroticism scale was used to derive a 4-item scale for MI. We used depression measures that were previously derived by factor analyzing the General Health Questionnaire. We tested the competing hypotheses by regressing variables at follow-up against baseline variables. The results showed that MI in 1984 clearly predicted the development of interpersonal problems in 1991. After adjusting for depression, depression becomes the main predictor of spousal difficulties, but MI remains a predictor of interpersonal difficulties with family and friends. Attempts to investigate the reverse hypothesis were ambiguous. The clinical implication is that when MI and interpersonal problems are reported, the MI should be treated first, or at least concurrently.

Patients' perspectives on the use of the Montgomery-Asberg depression rating scale self-assessment version in primary care

OBJECTIVE

The aim of the current study was to better understand how patients with depression perceive the use of MADRS-S in primary care consultations with GPs.

DESIGN

Qualitative study. Focus group discussion and analysis through Systematic Text Condensation.

SETTING

Primary Health Care, Region Västra Götaland, Sweden.

SUBJECTS

Nine patients with mild/moderate depression who participated in a RCT evaluating the effects of regular use of the Montgomery-Åsberg Depression Self-assessment scale (MADRS-S) during the GP consultations.

MAIN OUTCOME MEASURE

Patients' experiences and perceptions of the use of MADRS-S in primary care.

RESULTS

Three categories emerged from the analysis: (I) confirmation; MADRS-S shows that I have depression and how serious it is, (II) centeredness; the most important thing is for the GP to listen to and take me seriously and (III) clarification; MADRS-S helps me understand why I need treatment for depression.

CONCLUSION

Use of MADRS-S was perceived as a confirmation for the patients that they had depression and how serious it was. MADRS-S showed the patients something black on white that describes and confirms the diagnosis. The informants emphasized the importance of patient-centeredness; of being listened to and to be taken seriously during the consultation. Use of self-assessment scales such as MADRS-S could find its place, but needs to adjust to the multifaceted environment that primary care provides. Key Points Patients with depression in primary care perceive that the use of a self-assessment scale in the consultation purposefully can contribute in several ways. The scale contributes to Confirmation: MADRS-S shows that I have depression and how serious it is. Centeredness: The most important thing is for the GP to listen to and take me seriously. Clarification: MADRS-S helps me understand why I need treatment for depression.

What Influences Treatment Satisfaction in Patients with Personality Disorders? A Naturalistic Investigation in a Hospitalization Setting

Treatment satisfaction of different mental disorders is still poorly understood, but of high clinical interest. Inpatients of a general psychiatric care hospital were asked to fill out questionnaires on satisfaction and clinical variables at admission and discharge. On the basis of an exploratory approach, differences in treatment satisfaction among diagnostic groups were examined by means of one-way analysis of variance. Potential associated clinical and socio-demographic variables were studied using multi/univariate tests. Patients with personality disorders (n=18) showed a significantly lower treatment satisfaction (ZUF-8, Zurich Satisfaction Questionnaire) and a slightly lower improvement of symptoms (CGI, Clinical Global Impression) and global functioning (GAF, Global Assessment of Functioning scale) than that of other diagnostic groups (n=95). Satisfaction in patients with personality disorders correlated much stronger with the symptom improvement and slightly with the functioning level than in patients without personality disorders. Interestingly, in patients with personality disorders psychopharmacological treatment in general (present versus not present) was independent from satisfaction. This exploratory investigation suggests that a lower satisfaction of patients with personality disorders in a general psychiatric hospital is mainly based on a reduced improvement of the symptoms and of the global functioning level.

Impact of Diagnosis Disclosure on Adolescents with Borderline Personality Disorder

OBJECTIVE

Establishing a diagnosis of Borderline Personality Disorder (BPD) in adolescents is often met with controversy, in part, due to potential stigmatizing effects. We wished to explore the adolescent patient experience of being diagnosed with BPD.

METHOD

The Impact of Diagnosis Scale (IODS) is a self-report measure we developed with questions targeting patients' subjective experience of receiving a diagnosis of BPD. The IODS was administered to 23 adolescents approximately one month after a diagnosis of BPD had been disclosed to them.

RESULTS

Twenty-one participants had analyzable data. The internal consistency of the measure demonstrated Cronbach's alpha of 0.66. We found wide variability in responses. Patients tended to view the diagnosis as an accurate representation of their symptoms.

CONCLUSION

The IODS represents a novel means by which clinicians might better appreciate how disclosing the diagnosis of BPD may impact a patient's understanding of one's difficulties.

Young patients' views about provided psychiatric care

BACKGROUND

Psychiatric illness is common among young adults, but there are only a few studies examining their views about the care they receive. There is a paradigm shift towards person-centred care and, therefore, a need for patients' perspectives in the development of clinical guidelines.

AIM

The aim of this study was to examine the views about provided psychiatric care in a group of young adult psychiatric patients.

METHOD

This study was part of a larger study. Patients between the ages of 19-29 years old (n = 127) diagnosed with bipolar disorder, borderline personality disorder, and/or attention deficit hyperactivity disorder were interviewed. Participants answered open-ended questions concerning their views about provided psychiatric care in six different areas.

RESULT

The results were categorized into six themes: (1) Wish for better diagnostic assessments, (2) Dissatisfaction with treatment, (3) Inadequate information, (4) Lack of professional attitude, (5) Feeling abandoned, and (6) Satisfaction with care.

CONCLUSION

Young psychiatric patients expressed a need for improvement of services that, if implemented, could make psychiatric care more person-centred.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice

BACKGROUND

Diagnosing mental illness is a central role for psychiatrists. Correct diagnosis informs both treatment and prognosis, and facilitates accurate communication. We sought to explore how psychiatrists distinguished two common psychiatric diagnoses: bipolar disorder (BD) and borderline personality disorder (BPD).

METHODS

We conducted a qualitative study of psychiatrists to explore their practical experience. We then sought to validate these results by conducting a questionnaire study testing the theoretical knowledge and practical experience of a large number of UK psychiatrists. Finally we studied the assessment process in NHS psychiatric teams by analysing GP letters, assessments by psychiatrists, and assessment letters.

RESULTS

There was broad agreement in both the qualitative and questionnaire studies that the two diagnoses can be difficult to distinguish. The majority of psychiatrists demonstrated in survey responses a comprehensive understanding DSM-IV-TR criteria although many felt that these criteria did not necessarily assist diagnostic differentiation. This scepticism about diagnostic criteria appeared to strongly influence clinical practice in the sample of clinicians we observed. In only a minority of assessments were symptoms of mania or BPD sufficiently assessed to establish the presence or absence of each diagnosis.

CONCLUSION

Clinical diagnostic practice was not adequate to differentiate reliably BD and BPD. The absence of reliable diagnostic practice has widespread implications for patient care, service provision and the reliability of clinical case registries.

Mood instability: significance, definition and measurement

Mood instability is common, and an important feature of several psychiatric disorders. We discuss the definition and measurement of mood instability, and review its prevalence, characteristics, neurobiological correlates and clinical implications. We suggest that mood instability has underappreciated transdiagnostic potential as an investigational and therapeutic target.

Mood instability as a precursor to depressive illness: A prospective and mediational analysis

OBJECTIVE

Mood instability levels are high in depression, but temporal precedence and potential mechanisms are unknown. Hypotheses tested were as follows: (1) mood instability is associated with depression cross-sectionally, (2) mood instability predicts new onset and maintenance of depression prospectively and (3) the mood instability and depression link are mediated by sleep problems, alcohol abuse and life events.

METHOD

Data from the National Psychiatric Morbidity Survey 2000 at baseline (N = 8580) and 18-month follow-up (N = 2413) were used. Regression modeling controlling for socio-demographic factors, anxiety and hypomanic mood was conducted. Multiple mediational analyses were used to test our conceptual path model.

RESULTS

Mood instability was associated with depression cross-sectionally (odds ratio: 5.28; 95% confidence interval: [3.67, 7.59]; p < 0.001) and predicted depression inception (odds ratio: 2.43; 95% confidence interval: [1.03-5.76]; p = 0.042) after controlling for important confounders. Mood instability did not predict maintenance of depression. Sleep difficulties and severe problems with close friends and family significantly mediated the link between mood instability and new onset depression (23.05% and 6.19% of the link, respectively). Alcohol abuse and divorce were not important mediators in the model.

CONCLUSION

Mood instability is a precursor of a depressive episode, predicting its onset. Difficulties in sleep are a significant part of the pathway. Interventions targeting mood instability and sleep problems have the potential to reduce the risk of depression.

The Relationship between Mood Instability and Suicidal Thoughts

The objective of this study was to determine whether affective instability predicts suicidal thoughts. Data from a Dutch panel study (N = 1686) was used. Affective instability was assessed with 7 items representing suddenly shifting moods. Suicidal thoughts were assessed by the occurrence of suicidal thoughts in the past week. Negative affect was indexed by anxious, depressed and angry moods extracted by factor analysis. Odds ratios using logistic regression modeling were calculated, adjusting for clinical and demographic variables. The study found that both males (OR: 1.14; 95% CI: 1.02-1.28) and females (OR: 1.11; 95% CI: 1.00-1.23) were more likely to experience suicidal thinking with higher affective instability. Affective instability and negative affect independently predict suicidal thoughts. Affective instability requires more attention in the assessment of suicide risk.

What is it like to be diagnosed with bipolar illness, borderline personality disorder or another diagnosis with mood instability?

Patients with mood instability represent a significant proportion of patients with mental illness. Important lessons need to be learnt about how current assessment processes do not meet their expectations. Changes at various levels, including medical and nursing education, service provision and research priorities, appear necessary if we are to help our patients better.

Collaborative care psychiatrists' views on treating bipolar disorder in primary care: a qualitative study

OBJECTIVE

To understand collaborative care psychiatric consultants' views and practices on making the diagnosis of and recommending treatment for bipolar disorder in primary care using collaborative care.

METHOD

We conducted a focus group at the University of Washington in December 2013 with nine psychiatric consultants working in primary-care-based collaborative care in Washington State. A grounded theory approach with open coding and the constant comparative method revealed categories where emergent themes were saturated and validated through member checking, and a conceptual model was developed.

RESULTS

Three major themes emerged from the data including the importance of working as a collaborative care team, the strengths of collaborative care for treating bipolar disorder and the need for psychiatric consultants to adapt specialty psychiatric clinical skills to the primary care setting. Other discussion topics included gathering clinical data from multiple sources over time, balancing risks and benefits of treating patients indirectly, tracking patient care outcomes with a registry and effective care.

CONCLUSION

Experienced psychiatric consultants working in collaborative care teams provided their perceptions regarding treating patients with bipolar illness including identifying ways to adapt specialty psychiatric skills, developing techniques for providing team-based care and perceiving the care delivered through collaborative care as high quality.