Web-Based Self-Management Programs for Bipolar Disorder: Insights From the Online, Recovery-Oriented Bipolar Individualised Tool Project

Direct medical cost of bipolar disorder: Insights from the FACE-BD longitudinal cohort

BACKGROUND

Bipolar disorder (BD) is a severe chronic psychiatric disorder affecting 0.5 to 1% of the population worldwide. To date, most studies have estimated the cost of BD via information sourced from insurance claims with limited information on clinical characteristics and course of BD. The aims of this study are (i) to estimate the direct healthcare cost associated with BD and to identify contributing factors and (ii) to study the evolution of cost during a two-year follow-up period.

METHOD

We analyzed a sample of 1116 individuals with BD included in the Advanced Centers of Expertise in Bipolar Disorder cohort. We estimated the direct healthcare cost per year and per patient, and we identified the clinical features of patients with BD associated with higher direct healthcare costs. In a subsample of patients followed up for two years centers of expertise for BD, we studied the evolution of direct healthcare cost.

RESULTS

The average cost of bipolar disorder was € 6910 per year and per patient. Clinical features of BD, sociodemographic characteristics, and associated addiction were associated with higher direct healthcare costs. In the subsample of patients followed-up for two years, direct healthcare cost dropped by more than 50%, strongly suggesting the beneficial effect of specialized care organization.

LIMITATION

We did not estimate indirect healthcare and intangible costs.

CONCLUSION

Our study investigates the cost of BD and its evolution in a deeply phenotyped longitudinal sample. Cost-utility and cost-effectiveness analyses are required to inform resource allocation decisions and to promote innovative healthcare organizations.

Pilot Testing in the Wild: Feasibility, Acceptability, Usage Patterns, and Efficacy of an Integrated Web and Smartphone Platform for Bipolar II Disorder

BACKGROUND

Bipolar II disorder (BD-II) is associated with significant burden, disability, and mortality; however, there continues to be a dearth of evidence-based psychological interventions for this condition. Technology-mediated interventions incorporating self-management have untapped potential to help meet this need as an adjunct to usual clinical care.

OBJECTIVE

The objective of this pilot study is to assess the feasibility, acceptability, and clinical utility of a novel intervention for BD-II (Tailored Recovery-oriented Intervention for Bipolar II Experiences; TRIBE), in which mindfulness-based psychological content is delivered via an integrated web and smartphone platform. The focus of the study is evaluation of the dynamic use patterns emerging from ecological momentary assessment and intervention to assist the real-world application of mindfulness skills learned from web-delivered modules.

METHODS

An open trial design using pretest and posttest assessments with nested qualitative evaluation was used. Individuals (aged 18-65 years) with a diagnosis of BD-II were recruited worldwide and invited to use a prototype of the TRIBE intervention over a 3-week period. Data were collected via web-based questionnaires and phone interviews at baseline and 3-week follow-up.

RESULTS

A total of 25 participants completed baseline and follow-up assessments. Adherence rates (daily app use) were 65.6% across the 3-week study, with up to 88% (22/25) of participants using the app synergistically alongside the web-based program. Despite technical challenges with the prototype intervention (from user, hardware, and software standpoints), acceptability was adequate, and most participants rated the intervention positively in terms of concept (companion app with website: 19/25, 76%), content (19/25, 76%), and credibility and utility in supporting their management of bipolar disorder (17/25, 68%). Evaluation using behavioral archetypes identified important use pathways and a provisional model to inform platform refinement. As hypothesized, depression scores significantly decreased after the intervention (Montgomery-Asberg Depression Rating Scale baseline mean 8.60, SD 6.86, vs follow-up mean 6.16, SD 5.11; t24=2.63; P=.01; Cohen d=0.53, 95% CI 0.52-4.36).

CONCLUSIONS

Our findings suggest that TRIBE is feasible and represents an appropriate and acceptable self-management program for patients with BD-II. Preliminary efficacy results are promising and support full development of TRIBE informed by the present behavioral archetype analysis. Modifications suggested by the pilot study include increasing the duration of the intervention and increasing technical support.

A randomized pilot study of Rhythms And You (RAY): An internet-based program for bipolar disorder administered with and without clinical helper support in primary care

BACKGROUND

Rhythms And You (RAY) is an online intervention for bipolar disorders (BD) based on Interpersonal and Social Rhythm Therapy. We examined RAY's feasibility and acceptability for individuals with BD recruited from primary care. Because online interventions may be more effective when paired with human support, we evaluated RAY with and without weekly brief (∼5 min) calls from clinical helpers (CH).

METHODS

Participants (n = 47) meeting criteria for BD I, II or other specified BD, presenting for primary care, were randomly assigned to RAY, RAY-CH, or Adjunctive Reading Material (ARM) control. RAY consisted of 12 weekly online modules. ARM consisted of 12 weekly emails. Participants were assessed at baseline, 4, 8, and 12 weeks.

RESULTS

RAY showed high completion rates and Client Satisfaction Questionnaire scores (36/47, 77% and 25.1 ± 5.5, respectively; no group differences). Effect sizes for RAY- CH ranged from small [Internal State Scale-Activation Subscale (ISS-ACT); d = 0.3] to large [SF-12 Mental Health Composite Score (SF-12 MHC); d = 1.3]. ARM also showed moderate effects (ISS-ACT d = 0.7; Quick Inventory of Depressive Symptoms, d = 0.8). SF-12 MHC scores showed a time*group interaction (F = 2.38, df = 6,32, p = 0.05) favoring RAY-CH. Number of logins trended toward significant association with improved social rhythm regularity (F = 4.09, df = 1, 17, p = 0.06).

LIMITATIONS

Sample size is small, limiting conclusions that can be drawn.

CONCLUSIONS

Remote delivery of RAY for individuals with BD is feasible and acceptable. More time spent engaged in RAY was associated with greater improvement in social rhythm regularity. Preliminary evidence suggests adding brief human support to RAY may yield better outcomes.

Towards tailored psychosocial intervention for BD-II: Lived experience perspectives on current and future management options

BACKGROUND

Despite its significant morbidity and mortality, very little is known about how those with lived experience of bipolar II disorder (BD-II) manage their condition. This study sought to understand unmet needs in currently available psychosocial treatments, explore self-management strategies (SMS) that individuals with BD-II currently use, and determine the potential role of digital mental health interventions in this space.

METHODS

Individuals (aged 18-65) confirming they had received a diagnosis of BD-II from a mental health professional were invited to complete an online survey about treatments trialled, coping strategies used to manage their condition and perspectives on the role of digital mental interventions.

RESULTS

Ninety individuals commencing the survey confirmed a diagnosis of BD-II; of these, n = 35 were screened out based on self-reported hospitalisation for mania and/or experiencing a manic episode. A final sample of n = 55 was subsequently analysed. From the perspective of those with BD-II, current psychosocial treatments fall short in terms of meeting their specific needs. Tailored psychosocial interventions delivered by clinicians with BD-II expertise are sought after, however accessibility and cost are ongoing barriers. Participants were open to digital self-management interventions however uptake was limited. In terms of self-management, actively seeking external help was perceived as most helpful for stopping progression in depression, while self-care strategies were prioritised for hypomania.

LIMITATIONS

The study had several limitations: (1) BD-II diagnoses were not formally verified via standardised diagnostic interview, (2) Borderline personality disorder and comorbid substance abuse disorders were not assessed; (3) the influence of current mood state on participant responses was not assessed, (4) females were over-represented, limiting generalisation of  findings to males with BD-II.

CONCLUSIONS

Study findings highlight the need for tailored interventions paying specific attention to nuanced features of BD-II, and the potential role of digital mental health interventions for this underserved group.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Beyond clicks and downloads: a call for a more comprehensive approach to measuring mobile-health app engagement

Downloading a mobile health (m-health) app on your smartphone does not mean you will ever use it. Telling another person about an app does not mean you like it. Using an online intervention does not mean it has had an impact on your well-being. Yet we consistently rely on downloads, clicks, 'likes' and other usage and popularity metrics to measure m-health app engagement. Doing so misses the complexity of how people perceive and use m-health apps in everyday life to manage mental health conditions. This article questions commonly used behavioural metrics of engagement in mental health research and care, and proposes a more comprehensive approach to measuring in-app engagement.

Co-designing a Self-Management App Prototype to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Mixed Methods Study

BACKGROUND

Spinal cord injury is a complex chronic health condition that requires individuals to actively self-manage. Therefore, an evidence-based, self-management app would be of value to support individuals with spinal cord injury in the prevention of pressure injuries.

OBJECTIVE

The main objectives of this study were to (1) establish a co-design approach for developing a high-fidelity prototype app for the self-management of individuals with spinal cord injury, (2) design the prototype that resulted from this process, and (3) conduct the first usability assessment of the prototype app.

METHODS

We adopted a co-design approach to develop an evidence-based app prototype. Starting from a preliminary content model (based on clinical guidelines for the prevention of pressure injuries) and three research-based user personas, we conducted an ideation workshop involving individuals with spinal cord injury and health care professionals. The ideation workshop formed the basis for two consecutive design sprints. The result of this co-design phase was an interactive app prototype. The prototype was evaluated in two rounds of usability testing (N=4 and N=15, respectively) using a combination of qualitative and quantitative methods.

RESULTS

The co-design process resulted in a high-fidelity prototype with two key components: a self-management component and a communication component. The final prototype included a combination of features to support individuals with spinal cord injury in the prevention of pressure injuries, namely a smart camera, pressure injury diary, expert consultation, reminders, and knowledge repository. Findings of the usability testing showed that most participants navigated the app fluently with little back and forth navigation and were able to successfully complete a set of assigned tasks. These positive results are supported by the average system usability score achieved (78.5/100; range 47.5-95.0) and our qualitative analysis of the semistructured interviews. Despite an overall positive evaluation of the app prototype, we identified areas for improvement (eg, inclusion of a search function).

CONCLUSIONS

Individuals with spinal cord injury often need to navigate competing interests and priorities, paired with uncertainty about the accuracy and relevance of clinical recommendations. Understanding what matters to individuals with spinal cord injury can help guide the design of behavioral interventions that are useful and acceptable to these individuals in their daily lives. This study shows that involving individuals with spinal cord injury and health care professionals in co-designing a self-management app can foster knowledge cocreation at the intersection of lived experience, medical expertise, and technical solutions.

The Impact of Subsyndromal Bipolar Symptoms on Patient's Functionality and Quality of Life

Subsyndromal symptoms have rarely been in the focus of bipolar research. This may be, in part, due to the fact that there is neither a uniform definition nor do they constitute an indication of regulatory and commercial interest. Nevertheless, they do have a decisive impact on the long-term course of bipolar disorder (BD), and the degree of functionality and quality of life (QoL) is more likely determined by their presence or absence than by acute episodes. Summarizing the literature an estimated 20-50% of patients suffer inter-episodically or chronically from subsyndromal BD. The most prominent symptoms that interfere with functionality are subsyndromal depression, disturbances of sleep, and perceived cognitive impairment, whereas anxiety negatively impacts on QoL. In the absence of evidence-based pharmacological treatments for subsyndromal BD, clinical practice adopts guidelines designed for treatment-resistant full-blown episodes of BD, supplemented by cognitive-behavioral, family focused or social-rhythm-based psychotherapies.

Young People's Satisfaction With the Online Mental Health Service eheadspace: Development and Implementation of a Service Satisfaction Measure

BACKGROUND

Online youth mental health services are an expanding approach to meeting service need and can be used as the first step in a stepped-care approach. However, limited evidence exists regarding satisfaction with online services, and there is no standardized service satisfaction measure.

OBJECTIVE

This study implemented an online youth mental health service satisfaction questionnaire within eheadspace, an online youth mental health service. The aims were to test the questionnaire's psychometric properties and identify current levels of satisfaction among service users, as well as to identify client and service contact characteristics that affect satisfaction.

METHODS

Data were collected from 2280 eheadspace clients via an online questionnaire advertised and accessed through the eheadspace service platform between September 2016 and February 2018. Client and service contact characteristics, potential outcomes, and session and service feedback data were collected.

RESULTS

The service satisfaction questionnaire demonstrated high internal consistency for the overall satisfaction scale (alpha=.95) and its three subscales: session satisfaction, potential outcomes, and service satisfaction. A three-factor model was the best fit to the data, although including a higher order unidimensional construct of overall satisfaction was also a reasonable fit. Overall, young people were very satisfied with eheadspace (mean 3.60, SD 0.83). Service characteristics, but not client characteristics, were significantly associated with satisfaction. Young people were more satisfied with eheadspace when they had greater engagement as evident through receiving esupport rather than briefer service provision, having a longer session and greater interaction with the clinician, and not previously attending a face-to-face headspace center.

CONCLUSIONS

The online youth mental health service satisfaction questionnaire developed for and implemented in eheadspace showed good psychometric properties. The measure is brief, has good internal consistency, and has a clear factor structure. The measure could be adapted for use in other online youth mental health services. The young people using eheadspace and completing the feedback survey were highly satisfied. Greater engagement with the online service was shown to be associated with greater satisfaction. No specific client demographic groups were shown to be more or less satisfied.

Supporting Self-Management in Bipolar Disorder: Mixed-Methods Knowledge Translation Study

BACKGROUND

Self-management is increasingly recognized as an important method through which individuals with bipolar disorder (BD) may cope with symptoms and improve quality of life. Digital health technologies have strong potential as a method to support the application of evidence-informed self-management strategies in BD. Little is known, however, about how to most effectively maximize user engagement with digital platforms.

OBJECTIVE

The aims of this study were (1) to create an innovative Web-based Bipolar Wellness Centre, (2) to conduct a mixed-methods (ie, quantitative and qualitative) evaluation to assess the impact of different sorts of engagement (ie, knowledge translation [KT]), and (3) to support engagement with the self-management information in the Bipolar Wellness Centre.

METHODS

The project was implemented in 2 phases. In phase 1, community-based participatory research and user-centered design methods were used to develop a website (Bipolar Wellness Centre) housing evidence-informed tools and strategies for self-management of BD. In phase 2, a mixed-methods evaluation was conducted to explore the potential impact of 4 KT strategies (Web-based webinars, Web-based videos, Web-based one-to-one Living Library peer support, and in-person workshops). Quantitative assessments occurred at 2 time points-preintervention and 3 weeks postintervention. Purposive sampling was used to recruit a subsample of participants for the qualitative interviews, ensuring each KT modality was represented, and interviews occurred approximately 3 weeks postintervention.

RESULTS

A total of 94 participants were included in the quantitative analysis. Responses to evaluative questions about engagement were broadly positive. When averaged across the 4 KT strategies, significant improvements were observed on the Bipolar Recovery Questionnaire (F_1,77=5.887; P=.02) and Quality of Life in Bipolar Disorder (F_1,77=8.212; P=.005). Nonsignificant improvements in positive affect and negative affect were also observed. The sole difference that emerged between KT strategies related to the Chronic Disease Self-Efficacy measure, which decreased after participation in the webinar and video arms but increased after the Living Library and workshop arms. A subsample of 43 participants was included in the qualitative analyses, with the majority of participants describing positive experiences with the 4 KT strategies; peer contact was emphasized as a benefit across all strategies. Infrequent negative experiences were reported in relation to the webinar and video strategies, and included technical difficulties, the academic tone of webinars, and feeling unable to relate to the actor in the videos.

CONCLUSIONS

This study adds incremental evidence to a growing literature that suggests digital health technologies can provide effective support for self-management for people with BD. The finding that KT strategies could differentially impact chronic disease self-efficacy (hypothesized as being a product of differences in degree of peer contact) warrants further exploration. Implications of the findings for the development of evidence-informed apps for BD are discussed in this paper.

What Would Digital Early Intervention for Bipolar Disorder Look Like? Theoretical and Translational Considerations for Future Therapies

There are growing calls for the development of early intervention/preventive interventions for young people identified to be at risk of bipolar disorder (BD), and digital delivery appears to be a strong candidate delivery method. To date, no such interventions exist, and the aim of this perspective paper is to advance the literature by reviewing theoretical issues related to early intervention in BD and introducing a framework for design of feasible, acceptable, and effective online psychosocial interventions for this population. It is concluded that, by adopting an appropriate transdiagnostic and humanistic framework, and recognizing emerging tenets of digital psychotherapy development, testable online interventions for young people at risk of BD are within reach.