Prophylactic Management of Women With Bipolar Disorder During Pregnancy and the Perinatal Period: Clinical Scenario-Based Practical Recommendations From A Group of Perinatal Psychiatry Authors.

ABSTRACT: Many women with bipolar disorder experience episodes of illness or relapses over the perinatal period, especially in the immediate postpartum period. Risks associated with treated/untreated psychopathologies and fetal exposure to bipolar medications make the management of bipolar disorder during these periods challenging for clinicians and patients. In light of the available effectiveness and reproductive safety data, the current clinical update based on the opinions of a group of international perinatal psychiatry authors recommends general considerations and specific management strategies for each possible clinical scenario, including mixed features, predominant polarity, diagnosis of subtypes of bipolar disorder, severity of previous episodes, and risk of recurrence of mood episodes.

A multicomponent positive psychology intervention for euthymic patients with bipolar disorder to improve mental well-being and personal recovery: A pragmatic randomized controlled trial.

OBJECTIVE: Mental well-being and personal recovery are important treatment targets for patients with bipolar disorder (BD). The goal of this study was to evaluate the effectiveness of an 8-week group multicomponent positive psychology intervention (PPI) for euthymic patients with BD as an adjunct to treatment as usual (TAU) compared to TAU alone. METHODS: Patients with BD were randomized to receive TAU (n = 43) or the PPI in addition to TAU (n = 54). The primary outcome was well being measured with the Mental Health Continuum-Short Form. Personal recovery was measured with the Questionnaire about the Process of Recovery. Data were collected at baseline, mid-treatment, post-treatment and 6- and 12-month follow-up. Life chart interviews were conducted at 12 months to retrospectively assess recurrence of depression and mania. RESULTS: Significant group-by-time interaction effects for well-being and personal recovery were found favouring the PPI. At post-treatment, between-group differences were significant for well-being (d = 0.77) and personal recovery (d = 0.76). Between-group effects for well-being were still significant at 6-month follow-up (d = 0.72). Effects on well-being and personal recovery within the intervention group were sustained until 12-month follow-up. Survival analyses showed no significant differences in time to recurrence. CONCLUSIONS: The multicomponent PPI evaluated in this study is effective in improving mental well-being and personal recovery in euthymic patients with BD and would therefore be a valuable addition to the current treatment of euthymic BD patients. The fact that the study was carried out in a pragmatic RCT demonstrates that this intervention can be applied in a real-world clinical setting.

Why patients diagnosed with bipolar disorder start, continue or discontinue health-related apps supporting their self-management.

WHAT IS KNOWN ABOUT THE SUBJECT?: Self-management is essential in the treatment of those who have bipolar disorder. There are many apps to support self-management, but we know that these apps only sometimes cover the users' needs. WHAT IS ADDED TO EXISTING KNOWLEDGE?: In our research, we made an inventory of apps that people with bipolar disorder use to cover their needs in self-management. We also have searched for the reasons to start, continue, switch or quit the use of those apps. We found that 44% (n = 18) of our respondents use health-related apps for self-management purposes. Apps for physical activity, planning and structure and apps for relaxation were most used. In the use of apps, the "freedom of choice" and user-friendliness are the most important in continuing the use of apps, while malfunctioning and "not fitting in individual needs" the main reasons were for quitting the use of apps. IMPLICATIONS FOR PRACTICE: Various apps can be used for self-management purposes as long as these apps meet the individual user's requirements. Clinicians and patients should have a broad view when looking for suitable apps and not limit the search to just professional apps. In developing new apps, patients, clinicians and developers should collaborate in the development process, requirements and design. ABSTRACT: INTRODUCTION: Self-management is one of the cornerstones in the treatment of bipolar disorder (BD). Complementing interventions by apps are seen as a good opportunity to support self-management. However, there is insufficient knowledge about understanding the use of health-related applications by consumers with BD for self-management purposes. AIM: The study aims to gain insight from patients diagnosed with BD about reasons to use, continue or discontinue health-related apps. METHOD: This study employed a mixed-method design in which 41 participants diagnosed with BD participated in a quantitative survey, and 11 participants also participated in an in-depth interview. RESULTS: The survey showed that 44% (n = 18) of the participants use health-related apps, and 26.8% (n = 11) use those apps consistently. Interviews revealed that adjustability, usability, trustworthiness and the guarantee of privacy were the main reasons determining whether participants used or terminated the use of a health-related app. IMPLICATIONS FOR PRACTICE: Although we found that a substantial number of patients diagnosed with BD use one or more apps to support self-management, their use is often discontinued due to content that needs more robust to address their needs. Besides appropriate content, tailoring and persuasive technologies will likely promote the continued use of an app for self-management purposes. Cooperation between those diagnosed with bipolar disorder and health professionals (like mental health nurses) in developing and designing applications that are aimed to support self-management in BD is necessary for successful implementation and adaptation.

A Web-Based Positive Psychology App for Patients With Bipolar Disorder: Development Study.

BACKGROUND: Patients with bipolar disorder (BD) report lower quality of life and lower levels of well-being than the general population. Despite the growing availability of psychotherapeutic and self-management interventions, important unmet needs remain. These unmet needs are closely linked to positive psychology domains. Although a growing number of studies have evaluated the impact of positive psychology interventions (PPIs) on patients with severe mental illness in general, only few have addressed the application of positive psychology for BD. OBJECTIVE: This study aimed to gain insight into the opinions of patients with BD and health care professionals about (web-based) PPIs for BD and to develop and pilot-test an app containing PPIs specifically designed for patients with BD. METHODS: The study was conducted in accordance with the Center for eHealth and Disease Management road map principles and incorporated cocreation and designing for implementation. Data were collected using focus group discussions, questionnaires, rapid prototyping, and web-based feedback on a prototype from the participants. In total, 3 focus groups were conducted with 62% (8/13) of patients with BD and 38% (5/13) of professionals. The collected data were used to develop a smartphone app containing short PPIs. The content was based on PPIs for which a solid base of evidence is available. Finally, a pilot test was conducted to test the app. RESULTS: Focus groups revealed that PPIs as part of the current BD treatment can potentially meet the following needs: offering hope, increasing self-esteem, expressing feelings, acceptance, and preventing social isolation. Some patients expressed concern that PPIs may provoke a manic or hypomanic episode by increasing positive affect. The pilot of the app showed that the PPIs are moderately to highly valued by the participants. There were no adverse effects such as increase in manic or hypomanic symptoms. CONCLUSIONS: With the systematic use of user involvement (patients and professionals) in all steps of the development process, we were able to create an app that can potentially fulfill some of the current unmet needs in the treatment of BD. We reached consensus among consumers and professionals about the potential benefits of PPIs to address the unmet needs of patients with BD. The use of PPI for BD is intriguing and can be usefully explored in further studies. We emphasize that more evaluation studies (quantitative and qualitative) that are focused on the effect of PPIs in the treatment of BD should be conducted. In addition, to establish the working mechanisms in BD, explorative, qualitative, designed studies are required to reveal whether PPIs can address unmet needs in BD.

[Mental problems, psychosocial problems and substance use during pregnancy: a structured multidisciplinary approach reduces the child's risk]. / Psychische en psychosociale problemen of middelengebruik bij zwangeren.

AIM: To demonstrate the results of routine screening and treatment for psychiatric problems, psychosocial problems and substance use (PPS) among pregnant women in the Netherlands. This approach is advocated by the national program 'The first 1000 days', which focuses on a healthy start for (unborn) children in vulnerable situations. DESIGN: Secondary data analysis of a routine care dataset obtained from midwifery practices and hospitals throughout the Netherlands. All practices and hospitals applied systematic screening with Mind2Care. METHOD: Each Mind2Care screening results in either a negative result (no risk), an alert and/or a treatment advice based on local care pathways. Anonymous data on detected risk factors and subsequent alerts/advices from 22.141 pregnant women were analyzed. RESULTS: Of all women, 24% had at least one PPS risk factor. Accumulation of risks was present in 10% of women. Thirty-one percent of all pregnant women received at least one specific advice (15% alerts, 24% treatment advices, including overlap). CONCLUSION: One in four pregnant women has psychiatric problems, psychosocial problems and/or substance use for which guideline care is available. Implementation of Mind2Care is demanding to the obstetrical system, and requires multidisciplinary care processes of medical and social caregivers. Despite the lack of a scientific evidence on the added value of systematic detection and treatment of PPS-risks in all pregnancies, this programmatic approach is increasingly acknowledged on the national attention level as the way forward to a healthy start for every child, even if born under vulnerable conditions.

The course of bipolar disorder in pregnant versus non-pregnant women.

BACKGROUND AND RATIONALE: Although it has been suggested that pregnancy may influence the course of bipolar disorder (BD), studies show contradictory results. Until now, no studies included a finegrained validated method to report mood symptoms on a daily basis, such as the lifechart method (LCM). The aim of the present study is to investigate the course of BD during pregnancy by comparing LCM scores of pregnant and non-pregnant women. METHODS: Study design: Comparison of LCM scores of two prospective observational BD cohort studies, a cohort of pregnant women (n = 34) and a cohort of non-pregnant women of childbearing age (n = 52). Main study parameters are: (1) proportions of symptomatic and non-symptomatic days; (2) symptom severity, frequency, and duration of episodes; (3) state sequences, longitudinal variation of symptom severity scores. RESULTS: No differences in clinical course variables (symptomatic days, average severity scores, frequency, and duration of episodes in BD were found between pregnant and non-pregnant women. With a combination of State Sequence Analysis (SSA) and cluster analysis on the sequences of daily mood scores three comparable clusters were found in both samples: euthymic, moderately ill and severely ill. The distribution differences between pregnant and non-pregnant women were significant, with a majority of the pregnant women (68%) belonging to the moderately ill cluster and a majority of the non-pregnant women (46%) to the euthymic cluster. In pregnant women the average daily variation in mood symptoms as assessed with Shannon's entropy was less than in non-pregnant women (respectively 0.43 versus 0.56). CONCLUSIONS: Although the use of daily mood scores revealed no difference in overall course of BD in pregnant versus non-pregnant women, more pregnant than non-pregnant women belonged to the moderately ill cluster, and during pregnancy the variation in mood state was less than in non-pregnant women. Further research is necessary to clarify these findings.

Psychometric properties and utility of the Responses to Positive Affect questionnaire (RPA) in a sample of people with bipolar disorder.

OBJECTIVES: To evaluate the psychometric properties of the Responses to Positive Affect (RPA) questionnaire in a sample of persons with bipolar disorder (BD). METHOD: Cross-sectional survey study with 107 persons with BD. The original 3-factor model of the RPA was compared with a 2-factor model. Construct validity was determined with measures of well-being, personal recovery, social role participation, and psychopathology and incremental validity was evaluated. RESULTS: The fit of the 3-factor model was acceptable for most fit indices. Subscores of the RPA revealed a significant relationship with aspects of well-being, personal recovery, and psychopathology. Dampening and self-focused positive rumination explained additional variance in personal recovery above and beyond well-being. CONCLUSIONS: The RPA is an internally consistent and valid tool to assess positive emotion regulation processes in persons with BD. Specifically, the processes of dampening and emotion-focused positive rumination seem to play an important role in BD.

Measuring personal recovery in people with bipolar disorder and exploring its relationship with well-being and social role participation.

The relevance of personal recovery receives increasing attention in mental health care and is also important for people with bipolar disorder (BD). There is a need for reliable and valid instruments measuring personal recovery. Therefore, the current study evaluated the psychometric properties of a Dutch translation of the Questionnaire about the Process of Recovery (QPR) in a sample of people with BD and explored the relationship with constructs of well-being, social role participation, and psychopathology. A cross-sectional survey study was conducted in which 102 people diagnosed with BD completed the QPR. Factor structure of the QPR was evaluated by conducting confirmatory factor analyses (CFA), and internal consistency was assessed by calculating reliability coefficients. Convergent validation measures assessed well-being, social role participation, and symptomatology. Incremental validity was determined by evaluating the ability of the QPR to explain variance in symptomatology above and beyond well-being. Findings of the CFA supported a unidimensional factor structure, and internal consistency estimates were excellent. Scores of the QPR showed strong correlations with convergent measures, but were only weakly associated with manic symptomatology. Moreover, personal recovery explained additional variance in symptoms of depression and anxiety above and beyond well-being, indicating incremental validity. The QPR appears to be a reliable and valid tool to assess personal recovery in people with BD. Our findings underline the importance of personal recovery in the context of treatment of BD. Personal recovery demonstrates a substantial overlap with well-being.

Risk of recurrence of mood disorders during pregnancy and the impact of medication: A systematic review.

BACKGROUND: Mood disorders can be difficult to treat during pregnancy. There is still lack of evidence whether pregnancy influences their natural course and whether continuation of pharmacotherapy, despite potential risks for the unborn child, is beneficial in preventing recurrence of mood episodes during pregnancy. METHODS: Systematic review conducted according to the PRISMA guidelines, searching Pubmed, PsycINFO, Embase and Cochrane databases up till January 9th, 2018. Recurrence rates and various measures of risk were calculated. RESULTS: Out of 1387 articles from an initial search 22 studies met the inclusion criteria. Included studies reported a wide variation in the recurrence rate of bipolar disorder and major depressive disorder during pregnancy (BD: mean = 19%, range = 4%-73%; MDD: mean = 8%, range = 1%-75%). Observational data showed a relative risk reduction of maintenance therapy during pregnancy of 66% in women with BD and 54% for women with MDD, a significant difference (95% CI 9.4-14.6; p < 0.001). LIMITATIONS: heterogeneous samples, study designs, and reported outcomes in included studies. CONCLUSIONS: Despite the importance of the topic there is a paucity of evidence on recurrence rates of mood episodes during pregnancy among women with MDD or BD. Unlike the impact of the postpartum period, it is still uncertain whether the course of mood disorders is influenced by pregnancy. Non-randomized studies show that maintenance pharmacotherapy during pregnancy in women with mood disorders significantly (p < 0.01) reduces the risk of recurrence.

The characteristics of psychotic features in bipolar disorder.

BACKGROUND: In a large and comprehensively assessed sample of patients with bipolar disorder type I (BDI), we investigated the prevalence of psychotic features and their relationship with life course, demographic, clinical, and cognitive characteristics. We hypothesized that groups of psychotic symptoms (Schneiderian, mood incongruent, thought disorder, delusions, and hallucinations) have distinct relations to risk factors. METHODS: In a cross-sectional study of 1342 BDI patients, comprehensive demographical and clinical characteristics were assessed using the Structured Clinical Interview for DSM-IV (SCID-I) interview. In addition, levels of childhood maltreatment and intelligence quotient (IQ) were assessed. The relationships between these characteristics and psychotic symptoms were analyzed using multiple general linear models. RESULTS: A lifetime history of psychotic symptoms was present in 73.8% of BDI patients and included delusions in 68.9% of patients and hallucinations in 42.6%. Patients with psychotic symptoms showed a significant younger age of disease onset (ß = -0.09, t = -3.38, p = 0.001) and a higher number of hospitalizations for manic episodes (F11 338 = 56.53, p < 0.001). Total IQ was comparable between groups. Patients with hallucinations had significant higher levels of childhood maltreatment (ß = 0.09, t = 3.04, p = 0.002). CONCLUSIONS: In this large cohort of BDI patients, the vast majority of patients had experienced psychotic symptoms. Psychotic symptoms in BDI were associated with an earlier disease onset and more frequent hospitalizations particularly for manic episodes. The study emphasizes the strength of the relation between childhood maltreatment and hallucinations but did not identify distinct subgroups based on psychotic features and instead reported of a large heterogeneity of psychotic symptoms in BD.

B-positive: a randomized controlled trial of a multicomponent positive psychology intervention for euthymic patients with bipolar disorder - study protocol and intervention development.

BACKGROUND: Bipolar disorder (BD) is characterized by recurrent (hypo)manic and depressive episodes, alternating with euthymic states in which patients are relatively symptom free. Besides clinical recovery, it is important to also strive for improvement of mental well-being and personal recovery. One prominent field focussing on the improvement of well-being is positive psychology. However, studies assessing the effects of positive psychology or personal recovery interventions for people with BD are scarce and have used weak methodological designs. The study described in this protocol article aims to assess the effectiveness of a multicomponent positive psychology intervention ("Living well with bipolar disorder") adjusted for people with BD in the euthymic phase to improve well-being and personal recovery. METHOD: The study concerns a pragmatic randomized multicenter trial. The principle objective of the study is to assess whether the positive psychology intervention offered to BD patients in remission in addition to usual care (CAU) is more effective than CAU. The study will include 112 participants randomized to either the experimental condition receiving the intervention in addition to CAU or the control condition receiving CAU. The study population are patients with BD I or II in the euthymic phase. The inclusion criteria are 1) diagnosis of BD I or BD II, 2) between the ages of 18-65, 3) four or more supportive sessions in the last year, and 4) only residual depressive or manic symptoms. Patients are excluded if they are in a depressive or manic episode, have current addiction problems or have optimal levels of well-being. Measurements take place at baseline, post-intervention and follow-up 6 and 12 months from baseline. Outcomes of measures include positive well-being, personal recovery, psychopathology, self-compassion, positive relationships, dampening of positive affect and relapse. DISCUSSION: The outlined study will be the first RCT examining the effects of a multicomponent positive psychology intervention for patients with bipolar disorder. Several limitations, including generalizability of the results and possible attrition issues, are discussed in advance. TRIAL REGISTRATION: This study has been registered in the Netherlands Trial Register ( NTR6729 ) on 12 October 2017.

Thoughts and Considerations of Women With Bipolar Disorder About Family Planning and Pregnancy: A Qualitative Study.

BACKGROUND: Women with bipolar disorder have an increased risk of relapse during pregnancy and the postpartum period, and they often express broad concerns about family planning. OBJECTIVE: To explore the thoughts and considerations of women of childbearing age with bipolar disorder, about family planning and pregnancy. DESIGN: A qualitative study was conducted: 15 women with bipolar I disorder were individually interviewed. Content analysis was applied. RESULTS: Women worried about heritability of bipolar disorder, medication issues, and risk of relapse during pregnancy. They mentioned their fear to be incompetent as a mother during future mood episodes. Support of partner, family/friends, and professionals was mentioned as essential. CONCLUSIONS: Family planning is an essential topic in the treatment of every woman with bipolar disorder of childbearing age. These women expect early consultation with professionals for support, and specific information about heritability of the illness and use of medication during and after pregnancy.

Postpartum mania in a man with bipolar disorder: case report and a review of the role of sleep loss.

BACKGROUND: In contrast to postpartum mood episodes in women with bipolar disorder, little is known about the risk of recurrence in men with bipolar disorder who have just become fathers. CASE REPORT: We present the case of a man with bipolar disorder who had a manic episode immediately after becoming a father. His spouse had a normal pregnancy, and delivery started during daytime and lasted until the early morning hours. The patient subsequently developed a manic episode, which had a major impact on the family. CONCLUSIONS: There is a well-known relationship between sleep loss and the occurrence of a manic episode. The study of psychopathology in the postpartum period in relation to sleep disturbance refers mainly to women. Disturbance of sleep patterns in the perinatal and postpartum period may also negatively impact the course of bipolar disorder in the father. In cases of pregnancy of a male bipolar disorder patient's spouse, preventive strategies for the postpartum period should be planned in advance.

The prevalence and management of side effects of lithium and anticonvulsants as mood stabilizers in bipolar disorder from a clinical perspective: a review.

Side effects are among the most frequent reasons preventing patients from taking their medication. Although the management of side effects is an important issue in clinical practice, particularly in patients with physical comorbidities, research on clinical management of side effects is rather scattered. The aim of this article was to provide an overview on the prevalence and management of various side effects of mood-stabilizing drugs. In December 2012, we carried out a PubMed search for publications reporting side effects in patients with bipolar disorder. Naturalistic studies describing the prevalence of side effects in treatment with mood stabilizers are sparse. We describe the prevalence of neurological, gastrointestinal, metabolic, thyroid, dermatological, nephrogenic, cognitive, sexual, hematological, hepatogenic, and teratogenic side effects of lithium, valproate, carbamazepine, and lamotrigine and discuss their clinical management. There are specific strategies that aim at reducing side effects, but, to date, studies on the efficacy of these interventions are lacking. With age, the renal elimination and hepatic metabolism of drugs reduce and comedication and somatic comorbidity increase, making elderly patients particularly susceptible to side effects. Most side effects can be managed by striving for the lowest possible dose without losing efficacy by lowering the dose below the therapeutic window. Specific measurements to limit certain side effects are available and may ameliorate treatment adherence.