Transcript Anxiety and alcohol use in bipolar disorder

ANXIETY AND ALCOHOL USE IN
BIPOLAR DISORDER
STEVEN JONES
Treatment development and feasibility studies
Some of the slides in this talk present independent research commissioned by the National
Institute for Health Research (NIHR) under its Programme Grants for Applied Research funding
scheme (RP-PG-0407-10389 & RP-PG-0606-1086). Further support was received from primary
care trusts, mental health trusts, the Mental Health Research Network and Comprehensive
Local Research Networks in North West England.
The views expressed in this publication are those of the authors and not necessarily those of
the NHS, the NIHR or the Department of Health.
ANXIETY
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93% of people with a bipolar diagnosis have lifetime experience of
anxiety.
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32% of people have current anxiety difficulties
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Co-morbid anxiety and bipolar are associated with
poor treatment response
increased suicidality
earlier age of onset
 greater risk of relapse
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Effective interventions exist for anxiety and bipolar separately.
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No definitive research into psychological treatment of bipolar and anxiety
together.
McIntyre, et al., 2006
Otto et al., 2006
Feske, et al., 2000
Frank, et al., 2002
Henry, et al., 2003
Ouimet et al, 2009
ALCOHOL USE IN BIPOLAR DISORDER
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Most commonly used substance
• 30-35% prevalence alcohol use
Linked to
• More severe mood disturbance
• Higher subsyndromal symptoms
• Great risk of suicide and violence
DiFlorio et al 2014
Goldstein et al 2006
Bellivier et al 2011
Elbogen & Johnson 2008
CAN WE TARGET COMORBID ISSUES IN
BD?
Anxiety
Alcoho
l
Both common, worsen clinical outcome, cause
distress
SOME INTERESTING DEVELOPMENTS
Lack of RCT
trials
specifically
designed for
anxiety or
alcohol in BD
WAYS FORWARD
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PARADES programme
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2 streams devoted to development of integrated
approaches to
Anxiety
 Alcohol
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Both based on qualitative interviews and focus
groups with people with bipolar disorder to develop
Focus, structure
 Support materials
 Timing
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FEASIBILITY STUDIES
PRACTICALITIES - ANXIETY
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Based on current evidence-based CBT for anxiety & Bipolar
disorder
Therapy
• Up to 4 months
• Up to 10 therapy sessions
• Cognitive behavioural therapists (2 nurses, 1 CP)
RCT
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Recruitment = 72 participants (37 intervention/35 control).
Bipolar disorder & anxiety (HADS 8+)
18+
English speaking
No episode in the past 4 weeks
No current suicidal intent
Not taking part in any other intervention study
CLINICAL OUTCOMES
Primary clinical outcomes
 Anxiety symptoms - HAM-AD and STAI
 Time to relapses of mood episodes as measured
by SCID-LIFE
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FEASIBILITY OUTCOMES
122 potential participants screened
 N = 72 randomised
 76% retention to final 20 month follow-up
 Mean session attendance 7.7 (6.6-8.8)
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CLINICAL OUTCOMES
STAI-S
60
HAM-A
14
50
12
10
40
AIBD
30
TAU
20
8
AIBD
6
TAU
4
2
10
0
0
0
0
16
48
80
16
32
48
64
80
0.20
0.40
0.60
0.80
1.00
TIME TO ANY MOOD RELAPSE
0
20
40
Time (Weeks)
60
80
Number at risk
MI-CBT 37
TAU 35
24
26
20
21
17
19
13
17
AIBD
TAU
QUALITATIVE INTERVIEWS
17 participants
 Attended mean 8.65 session (SD = 2.91)
 Range of attendance 1-10
 9 female, 8 male
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I have healed better and
with coping strategies
that have allowed me to
do things, a lot quicker
than before
A
N
X
I
E
T
Y
I do have my bad
periods, I am not going
to lie, I have had a bad
period recently but when
those bad periods
happen I know what to
do to quickly turn them
into a good period...00
MI-CBT
Individual therapy
 Up to 20 sessions over 6 months
 Based on case series
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Primary focus on alcohol and links to bipolar mood
experiences
 Where not ready to change address other client led
issues
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Link back to alcohol using MI
RCT
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Recruitment = 44 participants (24 intervention/20 control).
Bipolar disorder 1 or 2
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Alcohol use
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>21 units for mem/ >14 for women or
• At least one alcohol binge per fortnight over past 3 months
• Score >8 on AUDIT
•
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18+
English speaking
No episode in the past 4 weeks
No current suicidal intent
Not taking part in any other intervention study
CLINICAL OUTCOMES
Primary clinical outcomes
 Frequency and severity of alcohol use (Time Line
Follow Back)
 Time to relapses of mood episodes as measured
by SCID-LIFE
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FEASIBILITY OUTCOMES
76 referred by trusts or self
• 74 consented to screening
• N = 44 randomised
 75% retention to final 12 month follow-up
 Mean session attendance 17.6 (range 1-20)
 Recruitment was challenging – partly clinicians
unaware of client alcohol use – improved when
self referral option was offered
•
ALCOHOL UNITS PER DAY
10
9
8
7
6
MI-CBT
5
TAU
4
3
2
1
0
0
3
6
9
12
PERCENTAGE DAYS ABSTINENT
80
70
60
50
MI-CBT
40
TAU
30
20
10
0
0
3
6
9
12
PERCENTAGE BINGE DAYS
60
50
40
MI-CBT
30
TAU
20
10
0
0
3
6
9
12
0.20
0.40
0.60
0.80
1.00
TIME TO ANY BIPOLAR RELAPSE
0
10
20
30
Time (Weeks)
MI-CBT
40
TAU
50
POST THERAPY QUALITATIVE
INTERVIEWS
15 participants
 Attended from 15 – 20 sessions
 10 men, 5 women
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I feel it’s much more
manageable it is not my
go-to place, so it is not
the first thing that I go
right I need a
drink…because always
there is a reason to
drink…
A
L
C
O
H
O
L
it was good, it was clear…I
knew what exactly what
coming up, and also I felt I
was in control of it as well I
wasn’t just kind of spieling
off answers to questions that
I didn’t really want to know
myself
CONCLUSIONS
Feasibility and acceptability demonstrated
 People want help
 They will attend integrated therapy
 Some people report very +ve outcomes
 Overall quantitative outcomes NS
 Review
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Therapy content and thresholds for intervention
 Consider different models of delivery
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