Care Summary

Care (support, best practices, health promotion)

Some of this information that I am posting I included in the email to the group in February. I have also included information from the book: Meehle, D; & Meehle, M. (2005). Friends and family bipolar survival guide: Surviving today, thriving tomorrow. Gilbert, AZ: Meehl Foundation Press.

The preliminary discussions (back in Jan) in this area were focused around education of people with bipolar disorder, their families/friends and frontline workers. Education about how a stable environment, including relationships is important. Things such as a regular routine, including sleep patterns and a schedule should be discussed. Also discussed is community based care and other social supports. Research talks about funding and several research articles do talk about the expense of caring for bipolar disorder and how to decrease costs. Employment of people who have bipolar disorder also is within the research in this area.

Out of the approximately 70 articles I reviewed, I found 17 on education, 14 on lifestyle, 36 on relationships, 27 on collaborative care, and 2 on quality of life (although I am not sure this should be a separate discourse so may not have sorted some of the pertinent information into this discourse). Many of the articles have information for multiple discourses within them so need a closer review on the information provided.

In looking at care (support, best practices and health promotion) for bipolar disorder (adult) I searched in a variety of databases as well as online. I looked at ebrary, Academic Search Complete, PsychInfo, CINAHL, Google/Google Scholar, the Education Resource Centre (provincial health region database), UpToDate, and ACPPier. I plan to do some more searches to expand in several areas. I still would like to look at NAMI, National Health Institute, Depression & Bipolar Support Alliance, and Equilibrium The Bipolar Foundation. I also plan to check the references of some of the more important articles along with the above-mentioned online resources. The research that I identified is from a wide variety of backgrounds, including psychiatry, psychology, social work, nursing, medical/clinical, and home care. British, Australian/New Zealand, Scandinavian and American research was found. There was only one article I looked at from Canada. There were many authors whose names reoccurred within the research: Miklowitz, Sajatovic, Wisniewski, Sachs. The articles that I focused on are very current, 2009 to 1995 (one article from this year).

Webpages to review: www.meehlfoundation.org www.dbsalliance.org www.bphope.com www.nimh.nih.gov www.nami.org

Discourse Discussion:

The preliminary discourses that I have found in this area include: Education, Lifestyle, Relationships, Collaborative Care, and Quality of Life.

-	What are the problems that these discourses create? -	What are the implications for people with bipolar disorder, their family/friends and frontline workers?

Collaborative Care

People with bipolar disorder are often not included in practice although inclusion put into policy and procedures often. Collaborative care means the integration of various teams working together with the person who has bipolar disorder and their families. This often means multidisciplinary teams. Collaborative care has been shown to be effective for people with co-occurring conditions and can improve the management of bipolar disorder. Psychosocial interventions often included under the realm of collaborative care; evidence shows that psychosocial interventions should be based on a person’s current presentation. This includes the use of cognitive behaviour therapy, family therapy, etc. Collaborative care improve both mental health and medical outcomes. There were several articles reviews on the “stay well” approach which focuses on the biopsychosocial model which incorporates physical, psychological, social, environmental, economic and cultural factors into a wellness model. The bottom line is that many articles conclude that collaborative care is important for people with bipolar disorder.

The main problem associated with this discourse is how do all of these people work together effectively? Research shows that collaborative care should happen but is is not always realized. There are sometimes just too many “hands in the pot”! The implications of this is that collaborative care is difficult to implement. We know that it is beneficial to the person with bipolar, their support people and frontline workers but a better way to implement collaborative care is the challenge.

Education

Under education, the main point is that it is important for everyone involved to learn about bipolar disorder and to learn specifically about the personal factors associated with an individual’s bipolar. There is evidence that the content of websites on bipolar disorder is good overall. Workers in primary care need education on bipolar disorder as they often encounter a person in a crisis situation. Psychoeducation along with medication is important as well as psychoeducation along with other therapies. As well, evidence shows psychoeducation and lifestyle factors being controlled is beneficial. Active health promotion is discussed as important to prepare a person to manage their illness after a hospital admission or after services are discontinued. Education is also important for support people.

Some of the problems we can see within this discourse is that there is a lot of information to go through, how does one know what information to trust and what is the most important information to learn. The implications for this are that a lot of time needs to be spent on educating oneself. One needs to find the best and most up to date information which often will require some assistance. Personal factors are important to know and can aid in deciding what learning to focus on.

Lifestyle

Lifestyle is a prominent discourse in any practical research documents. Having a healthy lifestyle and balance in one’s daily life is often listed as having routines and schedules. Work/employment is also discussed under this discourse. Self management of bipolar disorder is discussed as being optimal along with psychoeducation. Avoiding stress, structuring the day, normalizing sleep/wake patterns are some of the areas looked at. It is important to be mindful of personal factors. A wellness plan with strategies in place is important. Physical health is often poor in people with bipolar disorder and therefore physical health needs should be checked regularly. It is important to know that bipolar disorder looks different over time. There is evidence that individual placements and support increases the outcomes in employment. Life skills can help to adapt to community and decrease psychiatric symptoms and hospital admissions. Consistency is important along with stable routines.

The problems in relation to lifestyle are the need to learn triggers/personal factors before one can stabilize their lifestyle or assist in stabilizing another’s lifestyle. It is difficult to structure one’s day and avoid stress if trying to live a “normal” life. Support for employment can increase positive outcomes but can also increase dependency on the support. The implications for these problems is that education must come first and then a person’s lifestyle can be changed for the best. Balance is important so as not to create dependency.

Relationships

Strong social supports is very important and there is an abundance of research in this area. Peer support is also discussed somewhat. Another area of research under this discourse is how the support themselves cope. A supportive environment is important in managing bipolar disorder. Both younger and older people with bipolar disorder have decreased perceptions of social supports. Perceptions include less available and poorer quality of close relationships and is associated with symptom recurrence. Social supports have been shown to be associated with quality of life. Internet groups have been shown to work for those who fear personal relationship situations (online support groups). Psychosocial treatments can enhance relationship functioning. Social support is important to adapt to community and decrease psychiatric symptoms and hospital admissions. Current or former users of mental health services should be included in the evaluation and delivery of services to improve outcomes. Use of more extensive social supports would be used in non-curative models such as a palliative psychiatry. Families’ understanding of mental illness is different than documented histories; it is important to look at what is normal in the family structure. Caregivers have varied levels of stress and coping. Clinicians should help families judge if their involvement is appropriate or not. Effective treatment demands a partnership between clinician and patient. A single helping individual (professional) is important for people to feel safe. Increasing the support for caregivers is recommended. Family based therapy has been shown to be effective.

One of the problems under relationships is that there often poor relationships because of the nature of bipolar disorder and many people may have few supportive relationships. The relationship can be quite taxing on the support people. Often professionals come and go even though we know stability is important. Therefore, it is important to focus on the support people and help them so they, in turn, can help the person with bipolar. It is important for the professionals to ask about supports and help to connect with a support group of some kind if there are few other supports for a person. Further research is needed about support groups.

Quality of Life

How does bipolar disorder impact one’s quality of life? This discourse does not have a lot of information under it and further research is needed here. Research shows that providing care that maximizes hope is important. In general, people with bipolar disorder have a lower quality of life. Quality of life is associated with length of illness, presence of depressive symptoms and social supports. Quality of life is poorer in those with psychosocial impairment so that they could not work or sustain social relationships. Intensive psychosocial treatment enhances life satisfaction.

The problem in the area of quality of life is how to define quality of life. Whose definition of quality of life do you use: the person with bipolar disorder, their support people, professionals? The implications for this I think show how the person with bipolar disorder’s voice needs to be heard.

Friends and Family Bipolar Survival Guide:

•	Introduction o	Book written by a couple trying to deal with bipolar disorder, written specifically for the loved ones trying to deal with the illness o	A practical book for families o	Questions trying to help with: o	What did I need to have in my hand to file for disability for Mark? o	How did I need to go about digging us out of debt? o	What is the standard treatment protocol? o	How do I find the right therapist? o	The right medication doctor? o	The right communication skills? o	“we believe that recovery, plus the ability to have and enjoy a “normal” life and loving relationships, lies in mindfulness, emotional stability and personal spirituality, combined with medication and therapy to reduce and overcome the effects of this illness” (p. vi) o	Mindfulness – become aware of changes in behaviour, mood and perception; allows people to recognize emotional changes and be alert to triggers o	Emotional well being is indispensable in keeping relationships and families together o	Spirituality in any form when combined with above can help keep a person centered and balanced o	For families of people with bipolar disorder there are some things that you can do for yourself that will undeniably make a difference in the bipolar’s life, and, in your life: 	Take care of yourself 	Learn new communication and coping skills to help you and your partner, and, 	Find a support group.

•	Chapter 1 – Taking Back your Life o	Join a support group – learn that I cannot control this, 	I did not cause this, and I cannot cure this o	Boundaries – 1. where do you need boundaries? Are you in financial crisis due to someone else’s actions? Is your credit a problem? 2. do you shift the responsibility for your life to someone else by blaming that person for your current situation? 3. do you justify some particularly negative or damaging behaviour that you would not usually do? 4. by not setting boundaries do you tend to justify your nagging, harping or unreasonableness? **set boundaries** o	Take care of yourself, develop a support system

•	Chapter 2 – Practical Financial Matters (American resource so American info) o	Protect your credit o	File for disability o	Buy term insurance, set up trust funds o	Find the right job

•	Chapter 3 – Our Core Beliefs o	Think positively

•	Chapter 4- Doing what Works o	Be willing to change o	Learn as much as possible o	Plan on several therapists; some questions you might ask: what experience with bipolar disorder do you have? Are you open to trying a variety of medications and closely monitoring their effectiveness? What have they learned in the last few months about bipolar disorder? What is your success rate in treating the other personality symptoms that accompany bipolar disorder? Will you meet separately with me (the non-bipolar) to evaluate my bipolar’s progress? Are you available 24 hrs a day in case of emergency? If not, what re the backup procedures? Do you know, understand and use dialectal behavior therapy in your therapy practice? o	Communication - support, empathy, truth o	Learn the triggers o	A few things to try as ways to reduce the emotional response to triggers: regular sleep times; regular, calming meals; at the sign of irritation, no caffeine or spicy food; back rubs, hand or foot rubs, neck rubs; hot bath or Jacuzzi, with lavender oil; moderate exercise; tea: chamomile or some other decaffeinated tea; eliminate overtime at work; yoga; deep breathing; get a massage, a pedicure or a manicure; light a candle at church; take a nap

•	Chapter 5 – Nurturing your Relationship o	Measure the progress o	Journal your feelings – asking and answering questions in your journal is helpful (I have always wanted to -, the 10 things I am most grateful for today are - , a nurturing place near my home is - , things I enjoy that don’t cost money are - , my favorite things to do in bad weather is - , the things I like about myself are - , my best talents are - , my spouse is great because - ); collect photos of anything that nourishes you in the journal o	Laugh o	Intimacy

•	Chapter 6 – Other practical matters o	Should have a power of attorney o	Have a letter of diagnosis o	Know the admissions policy (Mental Health Act here): what is the admissions policy? Where can someone be admitted? For how long can you have someone committed for evaluation? What is the treatment protocol? What paperwork do you need to have in hand at the time of commitment? Will the authorities contact your primary therapist or doctor? o	Have a fallback person; ask the following questions ahead of time: which family member of friend do you want to help you first? How long do they need to stay? Do you need help in picking an assistant? Will you need to live with a family member or friend for awhile? And finally, do you want your partner, in a time of crisis, to have to decide to cremate you or bury your remains?

•	Chapter 7 – Final thoughts o	Consider alternatives o	Exercise and eat right

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