Not always on the level: service provision for bipolar disorders

The current supplement of Acta Psychiatrica Scandinavica collates the outcomes of a 1-day standalone symposium (both supplement and symposium were sponsored by Bristol-Myers Squibb, including editorial support) on 3 November, 2011, in London, England, discussing how to set up a bipolar clinic within existing National Health Service (NHS) services in the UK. This supplement includes four papers – two clinical overview articles 1, 2 and two discussion articles 3, 4 – outlining and discussing the nature of bipolar disorder, disease progression and associated comorbidities, as well as potential routes to recovery through psychotherapeutic interventions delivered in bipolar clinics. The objective of the current supplement is to emphasise the need for bipolar clinics with psychoeducation programmes and provide useful hints for their implementation along with a successful real-life example. A workshop carried out during the symposium explored the first steps, challenges and possible barriers for the implementation of bipolar clinics. In addition, the supplement provides an overview of the history of bipolar disorder, physical health considerations associated with pharmacotherapy and the role of psychoeducation as add-on therapy to medication in the treatment of bipolar disorder. Psychiatric care for patients with bipolar disorder usually involves out-patient appointments with a psychiatrist or mental-health team member and long-term medication, with increased support or admission to hospital at times of relapse. However, hospitalisation during acute episodes places a great financial strain on healthcare services 5. Therefore, prevention of acute manic episodes rather than episode management could potentially reduce the financial burden on healthcare systems. Early diagnosis and pharmacotherapy coupled with psychological interventions that educate patients on how to monitor their symptoms and the importance of medication are key factors in the prevention of acute episodes. As a chronic mental illness, bipolar disorder can be managed with pharmacotherapy. However, the risk of developing chronicity through recurring episodes with incomplete remission is high. Young and Grunze 1 discuss studies showing that patients with bipolar disorder are at a high risk of developing medical comorbidities, such as metabolic syndrome, diabetes and cardiovascular disease 6, partly as a consequence of standard pharmacotherapy 7. Regular physical health monitoring is required for the prevention and management of comorbid conditions 8. In addition, many patients self-medicate or abuse substances in response to affective symptoms 9, ultimately leading to low quality of life and an increased physical health burden. Stafford and Colom 2 discuss psychoeducational programmes as a tool for the long-term management of bipolar disorder. As an intervention, psychoeducation aims to provide patients with knowledge about their illness and methods to prevent recurrence of episodes or the development of comorbidities. By increasing the patient's ability to manage their disorder, the goal is to instil a proactive attitude and enhance their competence to decide when to seek help. The goal of psychoeducation is to empower the patient to actively contribute to their care plan by learning how to recognise and handle destabilising factors, such as substance abuse and emotionally straining situations. This chapter highlights the importance of a functional relationship between the patient and clinician in the successful treatment of bipolar disorder, as well as the challenges and ideals of the development of bipolar clinics as a setting for the delivery of psychoeducation, and as an environment for regular interaction between the patient and clinician. Although considered beneficial for the patient, the challenges of setting up a bipolar clinic within existing NHS services are considerable. These are discussed by Young and Hale 3, and highlight the results of workshop discussions among the healthcare professionals attending the 1-day symposium. The considerations necessary to set up a bipolar clinic through the real-life set-up of a bipolar clinic in the UK are shared. Concerns of the workshop attendees revolved around the challenges of placing a bipolar clinic either within existing healthcare services or as a separate entity, as well as funding challenges, recognition as a legitimate clinical unit by fellow clinicians and the staff's additional training needs. The set-up of a UK bipolar clinic demonstrated that it is possible to manage clinician and patient expectations, and successfully implement a bipolar clinic within existing healthcare services. To conclude this supplement, Smith and Young 4 discuss the development of bipolar clinics and psychoeducation programmes, focusing on the differences in applicability and content of group- and web-based psychoeducation programmes used in the Bipolar Education Programme – Cymru 10. Although group-based psychoeducation enables patients to share experiences and engage in group-related therapy, web-based programmes have the advantage of reaching a geographically and demographically diverse patient population. Additional tools such as online exercises and smartphone applications represent a current record of patient mental stability and are beneficial during regular mental-health checks. Psychoeducation, in particular when delivered through a web-based platform, could reduce the cost of traditional treatment. Professor Allan H. Young is employed by Imperial College London. He is an Honorary Consultant Psychiatrist with WLMHT (NHS UK); has given paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders; has no share holdings in pharmaceutical companies; was a Lead Investigator for the Embolden Study (AstraZeneca), BCI Neuroplasticity study and Aripiprazole Mania Study, and for investigator-initiated studies from AstraZeneca, Eli Lilly and Wyeth. He has received grant funding (past and present) from NIMH (USA); CIHR (Canada); NARSAD (USA); Stanley Medical Research Institute (USA); MRC (UK); Wellcome Trust (UK); Royal College of Physicians (Edinburgh); BMA (UK); UBC-VGH Foundation (Canada); WEDC (Canada); CCS Depression Research Fund (Canada); and MSFHR (Canada) and is coholder of one European patent for the use of glucocorticoid antagonists in the treatment for depression.

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