Collaborative care for patients with bipolar disorder: randomised controlled trial.

BACKGROUND: A substantial number of people with bipolar disorder show a suboptimal response to treatment. AIMS: To study the effectiveness of a collaborative care programme on symptoms and medication adherence in patients with bipolar disorder, compared with care as usual. METHOD: A two-armed, cluster randomised clinical trial was carried out in 16 out-patient mental health clinics in The Netherlands, in which 138 patients were randomised. Patient outcomes included duration and severity of symptoms and medication adherence, and were measured at baseline, 6 months and 12 months. Collaborative care comprised contracting, psychoeducation, problem-solving treatment, systematic relapse prevention and monitoring of outcomes. Mental health nurses functioned as care managers in this programme. The trial was registered with The Netherlands Trial Registry (NTR2600). RESULTS: Collaborative care had a significant and clinically relevant effect on number of months with depressive symptoms, both at 6 months (z = -2.6, P = 0.01, d = 0.5) and at 12 months (z = -3.1, P = 0.002, d = 0.7), as well as on severity of depressive symptoms at 12 months (z = -2.9, P = 0.004, d = 0.4). There was no effect on symptoms of mania or on treatment adherence. CONCLUSIONS: When compared with treatment as usual, collaborative care substantially reduced the time participants with bipolar disorder experienced depressive symptoms. Also, depressive symptom severity decreased significantly. As persistent depressive symptoms are difficult to treat and contribute to both disability and impaired quality of life in bipolar disorder, collaborative care may be an important form of treatment for people with this disorder.

The Working Alliance Between Patients With Bipolar Disorder and the Nurse: Helpful and Obstructive Elements During a Depressive Episode From the Patients' Perspective.

Despite treatment, many patients with bipolar disorder experience impaired functioning and a decreased quality of life. Optimal collaboration between patient and mental health care providers could enhance treatment outcomes. The goal of this qualitative study, performed in a trial investigating the effect of collaborative care, was to gain more insight in patients' experiences regarding the helpful and obstructive elements of the working alliance between the patient recovering from a depressive episode and their nurse. Three core themes underpinned the nurses' support during recovery: a safe and supportive environment, assistance in clarifying thoughts and feelings, and support in undertaking physical activities.

Treatment of bipolar disorder in the Netherlands and concordance with treatment guidelines: study protocol of an observational, longitudinal study on naturalistic treatment of bipolar disorder in everyday clinical practice.

BACKGROUND: While various guidelines on the treatment of bipolar disorder have been published over the last decades, adherence to guidelines has been reported to be low. In this article we describe the protocol of a nationwide, multicenter, longitudinal, non-intervention study on the treatment of bipolar disorder in the Netherlands. Study aims are to provide information on the nature and content of outpatient treatment of bipolar disorder, to determine to what extent treatment is in concordance with the Dutch guideline for the treatment of bipolar disorder (2008), and to investigate the relationship of guideline concordance with symptomatic and functional outcome. METHODS/DESIGN: Between December 2009 and February 2010, all psychiatrists registered as member of the Dutch Psychiatric Association received a questionnaire with questions about their treatment setting, and whether they would be willing to participate in further research. Psychiatrists treating adult outpatients with bipolar disorder were invited to participate. Consenting psychiatrist subsequently approached all their patients with bipolar disorder. The study is performed with written patient and caregiver surveys at baseline and after 12 months, including data on demographics, illness characteristics, organization of care, treatments received, symptomatic and functional outcome, quality of life, and burden of care for informal caregivers. DISCUSSION: This study will provide information on the naturalistic treatment of bipolar disorder in the Netherlands, as well as degree of concordance of this treatment with the Dutch guideline, and its relationship with symptomatic and functional outcome. Limitations of a survey-based study are discussed.

Collaborative care for patients with bipolar disorder: a randomised controlled trial.

BACKGROUND: Bipolar disorder is a severe mental illness with serious consequences for daily living of patients and their caregivers. Care as usual primarily consists of pharmacotherapy and supportive treatment. However, a substantial number of patients show a suboptimal response to treatment and still suffer from frequent episodes, persistent interepisodic symptoms and poor social functioning. Both psychiatric and somatic comorbid disorders are frequent, especially personality disorders, substance abuse, cardiovascular diseases and diabetes. Multidisciplinary collaboration of professionals is needed to combine all expertise in order to achieve high-quality integrated treatment. 'Collaborative Care' is a treatment method that could meet these needs. Several studies have shown promising effects of these integrated treatment programs for patients with bipolar disorder. In this article we describe a research protocol concerning a study on the effects of Collaborative Care for patients with bipolar disorder in the Netherlands. METHODS/DESIGN: The study concerns a two-armed cluster randomised clinical trial to evaluate the effectiveness of Collaborative Care (CC) in comparison with Care as usual (CAU) in outpatient clinics for bipolar disorder or mood disorders in general. Collaborative Care includes individually tailored interventions, aimed at personal goals set by the patient. The patient, his caregiver, the nurse and the psychiatrist all are part of the Collaborative Care team. Elements of the program are: contracting and shared decision making; psycho education; problem solving treatment; systematic relapse prevention; monitoring of outcomes and pharmacotherapy. Nurses coordinate the program. Nurses and psychiatrists in the intervention group will be trained in the intervention. The effects will be measured at baseline, 6 months and 12 months. Primary outcomes are psychosocial functioning, psychiatric symptoms, and quality of life. Caregiver outcomes are burden and satisfaction with care. DISCUSSION: Several ways to enhance the quality of this study are described, as well as some limitations caused by the complexities of naturalistic treatment settings where not all influencing factors on an intervention and the outcomes can be controlled. TRIAL REGISTRATION: The Netherlands Trial Registry, NTR2600.

Collaborative care for patients with bipolar disorder: Effects on functioning and quality of life.

BACKGROUND: Functioning and quality of life are impaired in bipolar patients. METHODS: Collaborative Care (CC) is a multi-component intervention, provided by a multidisciplinary team, in which a nurse-care manager plays a central role. Effects on functioning and quality of life were tested in a clinical trial. We also investigated the mediating role of depression severity on these outcome variables. RESULTS: Patients randomized to CC showed more improvement in overall functioning compared to patients in the control group who obtained care as usual (CAU), with a small effect size (ES=0.3, z=-2.5, p=0.01). In the domains of autonomy and leisure time, a medium effect was found in favor of CC (autonomy: ES=0.5, z=-2.9, p=0.004; leisure-time: ES=0.4, z=-2.4, p=0.02). No differences between conditions were found in the other domains of functioning. Concerning quality of life, patients in CC improved more in the domain physical health (ES=0.4, z=2.5, p=0.01), if compared to CAU. No differences were found in overall quality of life. Half of the effects on functioning are mediated through the effects of CC on depression severity. LIMITATIONS: At baseline, differences on the main outcomes existed between conditions. Two teams stopped participation in the experimental condition after randomization. Sample size was limited. CONCLUSION: Besides effects on depressive symptoms, CC seems to have direct beneficial effects on both level of functioning and aspects of quality of life.

Functional versus syndromal recovery in patients with major depressive disorder and bipolar disorder.

OBJECTIVE: Many patients with major depressive disorder (MDD) or bipolar disorder (BD) experience impairments in daily life. We investigated whether patients with single-episode MDD (MDD-s), recurrent MDD (MDD-r), and BD differ in functional impairments, whether time since last episode (syndromal state, in 4 categories) contributes to impairment, whether this association is moderated by diagnosis, and the role of depressive symptoms. METHOD: Data were derived from 1,664 participants in the Netherlands Study of Depression and Anxiety (MDD-s, n = 483; MDD-r, n = 1,063; BD, n = 118), from 2006 into 2009. In additional analyses, 530 healthy controls were included. DSM-IV-TR diagnosis and information about syndromal state were based on the Composite International Diagnostic Interview. Psychosocial impairment was assessed with the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Adjusted associations between diagnosis, syndromal state, impairment, and depression severity were investigated. RESULTS: Syndromal state not being taken into account, patients with BD experienced more functional impairment than patients with MDD-s or with MDD-r, and in all diagnostic groups, impairments decreased with increasing time since last episode. However, impact of syndromal state on functioning showed a different course between diagnostic groups (mean [SD] WHODAS score: current: MDD-s 30.8 [2.8], MDD-r 32.7 [0.9], BD 37.7 [2.1], P = .07; recently remitted: MDD-s 21.7 [3.5], MDD-r 24.0 [1.2], BD 22.1[3.2], P = .7; remitted: MDD-s 10.6 [3.7], MDD-r 21.6 [1.4], BD 19.2 [4.4], P = .02; remitted > 1 year: MDD-s 13.3 [0.6], MDD-r 14.7 [0.5], BD 17.1 [2.2], P = .8). Depression severity accounted for these differences. Moreover, functioning in all remitted patients remained impaired when compared to that in healthy controls. CONCLUSION: Functional recovery may take up to 1 year after syndromal remission in recurrent depressive and bipolar disorder, mainly due to residual depressive symptoms, emphasizing the need for prolonged continuation treatment.

Alone together: A grounded theory study of experienced burden, coping, and support needs of spouses of persons with a bipolar disorder.

Bipolar disorder is a chronic and severe mental disorder. Little is known about the experiences of the spouses of such patients. A grounded theory study was undertaken to examine the burden for spouses living with a partner with a bipolar disorder and to explore how they cope and what support they need. Fifteen spouses and ex-spouses were interviewed; they experienced heavy burden and found themselves to be 'alone together.' Their coping process is found to involve appraisal of the situation and attempts to achieve a balance between self-effacement and self-fulfilment. While support can clearly reduce experienced burden, the spouses surprisingly receive virtually no professional support. A theory is developed that constitutes a starting point for the development of adequate support for spouses.