• A feasibility study of expert patient and community mental health team led bipolar psychoeducation groups: Implementing an evidence based practice

      Morriss, Richard K. (2013)
      Background: Group psychoeducation is a cost effective intervention which reduces relapse and improves functioning in bipolar disorder but is rarely implemented. The aim of this study was to identify the acceptability and feasibility of a group psychoeducation programme delivered by community mental health teams (CMHTs) and peer specialist (PS) facilitators. Organisational learning was used to identify and address systematically barriers and enablers, at organisational, health professional and patient levels, to its implementation into a routine service.Methods: A systematic examination of barriers and enablers to a three day training process informed the delivery of a first treatment group and a similar process informed the delivery of the second treatment group. Triangulation of research methods improved its internal validity: direct observation of training, self-rated surveys of participant experiences, group discussion, and thematically analysed individual participant and facilitator interviews were employed.Results: Barriers and enablers were identified at organisational, educational, treatment content, facilitator and patient levels. All barriers under the control of the research team were addressed with subsequent improvements in patient knowledge about the condition and about local service. In addition, self-management, agency and altruism were enhanced. Barriers that could not be addressed required senior clinical and education leadership outside the research team's control. PS and professional facilitators were successfully trained and worked together to deliver groups which were generally reported as being beneficial.Conclusion: Psychoeducation groups involving CMHT and PS facilitators is acceptable and feasible but their sustainment requires senior leadership within and outside the organisation that control finance and education services. © 2013 Coulthard et al.; licensee BioMed Central Ltd.
    • A novel cognitive behaviour therapy for bipolar disorders (Think Effectively About Mood Swings or TEAMS): Study protocol for a randomized controlled trial

      Tinning, Neil (2014)
      Background: Existing psychological therapies for bipolar disorders have been found to have mixed results, with a consensus that they provide a significant, but modest, effect on clinical outcomes. Typically, these approaches have focused on promoting strategies to prevent future relapse. An alternative treatment approach, termed 'Think Effectively About Mood Swings' (TEAMS) addresses current symptoms, including subclinical hypomania, depression and anxiety, and promotes long-term recovery. Following the publication of a theoretical model, a range of research studies testing the model and a case series have demonstrated positive results. The current study reports the protocol of a feasibility randomized controlled trial to inform a future multi-centre trial. Methods/Design: A target number of 84 patients with a diagnosis of bipolar I or II disorder, or bipolar disorder not-otherwise-specified are screened, allocated to a baseline assessment and randomized to either 16 sessions of TEAMS therapy plus treatment-as-usual (TAU) or TAU. Patients complete self-report inventories of depression, anxiety, recovery status and bipolar cognitions targeted by TEAMS. Assessments of diagnosis, bipolar symptoms, medication, access to services and quality of life are conducted by assessors blind to treatment condition at 3, 6, 12 and 18months post-randomization. The main aim is to evaluate recruitment and retention of participants into both arms of the study, as well as adherence to therapy, to determine feasibility and acceptability. It is predicted that TEAMS plus TAU will reduce self-reported depression in comparison to TAU alone at six months post-randomization. The secondary hypotheses are that TEAMS will reduce the severity of hypomanic symptoms and anxiety, reduce bipolar cognitions, improve social functioning and promote recovery compared to TAU alone at post-treatment and follow-up. The study also incorporates semi-structured interviews about the experiences of previous treatment and the experience of TEAMS therapy that will be subject to qualitative analyses to inform future developments of the approach. Discussion: The design will provide preliminary evidence of efficacy, feasibility, acceptability, uptake, attrition and barriers to treatment to design a definitive trial of this novel intervention compared to treatment as usual. Trial registration: This trial was registered with Current Controlled Trials (ISRCTN83928726) on registered 25 July 2014. Copyright © 2014 Mansell et al.; licensee BioMed Central Ltd.
    • Adult attachment in bipolar 1 disorder

      Morriss, Richard K. (2009)
      OBJECTIVES: To determine how security of adult attachment style is related to the mania, major depression and euthymic mood states in bipolar 1 (BP1) disorder.
    • Aggressive behaviour at first contact with services: Findings from the AESOP First Episode Psychosis Study

      Lloyd, Tuhina (2007)
      Background: Aggressive behaviour is increased among those with schizophrenia but less is known about those with affective psychoses. Similarly, little is known about aggressive behaviour occurring at the onset of illness. Method: The main reasons for presentation to services were examined among those recruited to a UK-based first episode psychosis study. The proportion of individuals presenting with aggressive behaviour was determined and these individuals were compared to those who were not aggressive on a range of variables including sociodemographic, clinical, criminal history, service contact, and symptom characteristics. Among the aggressive group, those who were physically violent were distinguished from those who were not violent but who were still perceived to present a risk of violence to others. Results: Almost 40% (n = 194) of the sample were aggressive at first contact with services; approximately half of these were physically violent (n = 103). Younger age, African-Caribbean ethnicity and a history of previous violent offending were independently associated with aggression. Aggressive behaviour was associated with a diagnosis of mania and individual manic symptoms were also associated with aggression both for the whole sample and for those with schizophrenia. Factors differentiating violent from non-violent aggressive patients included male gender, lower social class and past violent offending. Conclusions: Aggressive behaviour is not an uncommon feature in those presenting with first episode psychosis. Sociodemographic and past offending factors are associated with aggression and further differentiate those presenting with more serious violence. A diagnosis of mania and the presence of manic symptoms are associated with aggression. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • Assessing feasibility and acceptability of web-based enhanced relapse prevention for bipolar disorder (ERPonline): A randomized controlled trial

      Morriss, Richard K. (2017)
      BACKGROUNDInterventions that teach people with bipolar disorder (BD) to recognize and respond to early warning signs (EWS) of relapse are recommended but implementation in clinical practice is poor.OBJECTIVESThe objective of this study was to test the feasibility and acceptability of a randomized controlled trial (RCT) to evaluate a Web-based enhanced relapse prevention intervention (ERPonline) and to report preliminary evidence of effectiveness.METHODSA single-blind, parallel, primarily online RCT (n=96) over 48 weeks comparing ERPonline plus usual treatment with "waitlist (WL) control" plus usual treatment for people with BD recruited through National Health Services (NHSs), voluntary organizations, and media. Randomization was independent, minimized on number of previous episodes (<8, 8-20, 21+). Primary outcomes were recruitment and retention rates, levels of intervention use, adverse events, and participant feedback. Process and clinical outcomes were assessed by telephone and Web and compared using linear models with intention-to-treat analysis.RESULTSA total of 280 people registered interest online, from which 96 met inclusion criteria, consented, and were randomized (49 to WL, 47 to ERPonline) over 17 months, with 80% retention in telephone and online follow-up at all time points, except at week 48 (76%). Acceptability was high for both ERPonline and trial methods. ERPonline cost approximately £19,340 to create, and £2176 per year to host and maintain the site. Qualitative data highlighted the importance of the relationship that the users have with Web-based interventions. Differences between the group means suggested that access to ERPonline was associated with: a more positive model of BD at 24 weeks (10.70, 95% CI 0.90 to 20.5) and 48 weeks (13.1, 95% CI 2.44 to 23.93); increased monitoring of EWS of depression at 48 weeks (-1.39, 95% CI -2.61 to -0.163) and of hypomania at 24 weeks (-1.72, 95% CI -2.98 to -0.47) and 48 weeks (-1.61, 95% CI -2.92 to -0.30), compared with WL. There was no evidence of impact of ERPonline on clinical outcomes or medication adherence, but relapse rates across both arms were low (15%) and the sample remained high functioning throughout. One person died by suicide before randomization and 5 people in ERPonline and 6 in WL reported ideas of suicide or self-harm. None were deemed study related by an independent Trial Steering Committee (TSC).CONCLUSIONSERPonline offers a cheap accessible option for people seeking ongoing support following successful treatment. However, given high functioning and low relapse rates in this study, testing clinical effectiveness for this population would require very large sample sizes. Building in human support to use ERPonline should be considered.TRIAL REGISTRATIONInternational Standard Randomized Controlled Trial Number (ISRCTN): 56908625; http://www.isrctn.com/ISRCTN56908625 (Archived by WebCite at http://www.webcitation.org/6of1ON2S0).
    • Bipolar at-risk criteria: An examination of which clinical features have optimal utility for identifying youth at risk of early transition from depression to bipolar disorders

      Morriss, Richard K. (2016)
      A clinical and research challenge is to identify which depressed youth are at risk of "early transition to bipolar disorders (ET-BD)." This 2-part study (1) examines the clinical utility of previously reported BD at-risk (BAR) criteria in differentiating ET-BD cases from unipolar depression (UP) controls; and (2) estimates the Number Needed to Screen (NNS) for research and general psychiatry settings. Fifty cases with reliably ascertained, ET-BD I and II cases were matched for gender and birth year with 50 UP controls who did not develop BD over 2 years. We estimated the clinical utility for finding true cases and screening out non-cases for selected risk factors and their NNS. Using a convenience sample (N = 80), we estimated the NNS when adjustments were made to account for data missing from clinical case notes. Sub-threshold mania, cyclothymia, family history of BD, atypical depression symptoms and probable antidepressant-emergent elation, occurred significantly more frequently in ET-BD youth. Each of these "BAR-Depression" criteria demonstrated clinical utility for screening out non-cases. Only cyclothymia demonstrated good utility for case finding in research settings; sub-threshold mania showed moderate utility. In the convenience sample, the NNS for each criterion ranged from ~4 to 7. Cyclothymia showed the optimum profile for case finding, screening and NNS in research settings. However, its presence or absence was only reported in 50% of case notes. Future studies of ET-BD instruments should distinguish which criteria have clinical utility for case finding vs screening. © The Author 2016. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved. For permissions, please email: journals.permissions@oup.com.
    • Characterization of hemodynamic alterations in schizophrenia and bipolar disorder and their effect on resting-state fMRI functional connectivity

      Liddle, Peter F. (2021)
      Common and distinct neural bases of Schizophrenia (SZ) and bipolar disorder (BP) have been explored using resting-state fMRI (rs-fMRI) functional connectivity (FC). However, fMRI is an indirect measure of neural activity, which is a convolution of the hemodynamic response function (HRF) and latent neural activity. The HRF, which models neurovascular coupling, varies across the brain within and across individuals, and is altered in many psychiatric disorders. Given this background, this study had three aims: quantifying HRF aberrations in SZ and BP, measuring the impact of such HRF aberrations on FC group differences, and exploring the genetic basis of HRF aberrations. We estimated voxel-level HRFs by deconvolving rs-fMRI data obtained from SZ (N = 38), BP (N = 19), and matched healthy controls (N = 35). We identified HRF group differences (P < .05, FDR corrected) in many regions previously implicated in SZ/BP, with mediodorsal, habenular, and central lateral nuclei of the thalamus exhibiting HRF differences in all pairwise group comparisons. Thalamus seed-based FC analysis revealed that ignoring HRF variability results in false-positive and false-negative FC group differences, especially in insula, superior frontal, and lingual gyri. HRF was associated with DRD2 gene expression (P < .05, 1.62 < |Z| < 2.0), as well as with medication dose (P < .05, 1.75 < |Z| < 3.25). In this first study to report HRF aberrations in SZ and BP, we report the possible modulatory effect of dopaminergic signalling on HRF, and the impact that HRF variability can have on FC studies in clinical samples. To mitigate the impact of HRF variability on FC group differences, we suggest deconvolution during data preprocessing.
    • Cost-effectiveness of structured group psychoeducation versus unstructured group support for bipolar disorder: Results from a multi-centre pragmatic randomised controlled trial

      Morriss, Richard K. (2017)
      BACKGROUND: Bipolar disorder (BD) costs the English economy an estimated pound5.2billion/year, largely through incomplete recovery. This analysis estimated the cost-effectiveness of group psychoeducation (PEd), versus group peer support (PS), for treating BD. METHODS: A 96-week pragmatic randomised controlled trial (RCT), conducted in NHS primary care. The primary analysis compared PEd with PS, using multiple imputed datasets for missing values. An economic model was used to compare PEd with treatment as usual (TAU). The perspective was Health and Personal Social Services. RESULTS: Participants receiving PEd (n=153) used more (costly) health-related resources than PS (n=151) (net cost per person pound1098 (95% CI, pound252- pound1943)), with a quality-adjusted life year (QALY) gain of 0.023 (95% CI, 0.001-0.056). The cost per QALY gained was pound47,739. PEd may be cost-effective (versus PS) if decision makers are willing to pay at least pound37,500 per QALY gained. PEd costs pound10,765 more than PS to avoid one relapse. The economic model indicates that PEd may be cost-effective versus TAU if it reduces the probability of relapse (by 15%) or reduces the probability of and increases time to relapse (by 10%). LIMITATIONS: Participants were generally inconsistent in attending treatment sessions and low numbers had complete cost/QALY data. Factors contributing to pervasive uncertainty of the results are discussed. CONCLUSIONS: This is the first economic evaluation of PEd versus PS in a pragmatic trial. PEd is associated with a modest improvement in health status and higher costs than PS. There is a high level of uncertainty in the data and results.
    • Differential effects of depression and mania symptoms on social adjustment: Prospective study in bipolar disorder

      Morriss, Richard K.; Chopra, Arun (2013)
      OBJECTIVES: Previous studies of social adjustment in bipolar disorder have been cross-sectional and small in sample size, have examined a limited number of roles, or were not controlled for baseline mood and other clinical, social, or treatment confounders. We aimed to prospectively explore the strength and stability of correlations between depression and mania-type symptoms and impairment in a broad range of social adjustment roles and domains.
    • Early warning signs checklists for relapse in bipolar depression and mania: Utility, reliability and validity

      Morriss, Richard K. (2011)
      Background: Recognising early warning signs (EWS) of mood changes is a key part of many effective interventions for people with Bipolar Disorder (BD). This study describes the development of valid and reliable checklists required to assess these signs of depression and mania. Methods: Checklists of EWS based on previous research and participant feedback were designed for depression and mania and compared with spontaneous reporting of EWS. Psychometric properties and utility were examined in 96 participants with BD. Results: The majority of participants did not spontaneously monitor EWS regularly prior to use of the checklists. The checklists identified most spontaneously generated EWS and led to a ten fold increase in the identification of EWS for depression and an eight fold increase for mania. The scales were generally reliable over time and responses were not associated with current mood. Frequency of monitoring for EWS correlated positively with social and occupational functioning for depression (beta = 3.80, p = 0.015) and mania (beta = 3.92, p = 0.008). Limitations: The study is limited by a small sample size and the fact that raters were not blind to measures of mood and function. Conclusions: EWS checklists are useful and reliable clinical and research tools helping to generate enough EWS for an effective EWS intervention. © 2011 Elsevier B.V. All rights reserved.
    • The epidemiology of bipolar affective disorder; a review of the literature and introduction to work in progress

      Lloyd, Tuhina (2000)
      The past 20 years have seen much research into affective disorders, reflecting advances in both pharmacological and psychological treatments. However, there has been little basic epidemiological research into bipolar illness. This is particularly apparent regarding its basic occurrence and possible epigenetic causes. This presentation will attempt to bring together and integrate the available evidence regarding the basic epidemiology of bipolar disorder, define areas where further research is needed, and outline a large epidemiological study including bipolar affective disorder that has been supported by the Stanley Foundation.
    • Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology

      Morriss, Richard K. (2016)
      The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change. Copyright © The Author(s) 2016.
    • Explaining why childhood abuse is a risk factor for poorer clinical course in bipolar disorder: a path analysis of 923 people with bipolar I disorder

      Briley, Paul M. (2019)
      BACKGROUNDChildhood abuse is a risk factor for poorer illness course in bipolar disorder, but the reasons why are unclear. Trait-like features such as affective instability and impulsivity could be part of the explanation. We aimed to examine whether childhood abuse was associated with clinical features of bipolar disorder, and whether associations were mediated by affective instability or impulsivity.METHODSWe analysed data from 923 people with bipolar I disorder recruited by the Bipolar Disorder Research Network. Adjusted associations between childhood abuse, affective instability and impulsivity and eight clinical variables were analysed. A path analysis examined the direct and indirect links between childhood abuse and clinical features with affective instability and impulsivity as mediators.RESULTSAffective instability significantly mediated the association between childhood abuse and earlier age of onset [effect estimate (θ)/standard error (SE): 2.49], number of depressive (θ/SE: 2.08) and manic episodes/illness year (θ/SE: 1.32), anxiety disorders (θ/SE: 1.98) and rapid cycling (θ/SE: 2.25). Impulsivity significantly mediated the association between childhood abuse and manic episodes/illness year (θ/SE: 1.79), anxiety disorders (θ/SE: 1.59), rapid cycling (θ/SE: 1.809), suicidal behaviour (θ/SE: 2.12) and substance misuse (θ/SE: 3.09). Measures of path analysis fit indicated an excellent fit to the data.CONCLUSIONSAffective instability and impulsivity are likely part of the mechanism of why childhood abuse increases risk of poorer clinical course in bipolar disorder, with each showing some selectivity in pathways. They are potential novel targets for intervention to improve outcome in bipolar disorder.
    • The extent of user involvement in the design of self-tracking technology for bipolar disorder: Literature review

      Brown, Susan S.; Lang, Alexandra; Moore, Matthew; Morriss, Richard K. (2021)
      BACKGROUNDThe number of self-monitoring apps for bipolar disorder (BD) is increasing. The involvement of users in human-computer interaction (HCI) research has a long history and is becoming a core concern for designers working in this space. The application of models of involvement, such as user-centered design, is becoming standardized to optimize the reach, adoption, and sustained use of this type of technology.OBJECTIVEThis paper aims to examine the current ways in which users are involved in the design and evaluation of self-monitoring apps for BD by investigating 3 specific questions: are users involved in the design and evaluation of technology? If so, how does this happen? And what are the best practice ingredients regarding the design of mental health technology?METHODSWe reviewed the available literature on self-tracking technology for BD and make an overall assessment of the level of user involvement in design. The findings were reviewed by an expert panel, including an individual with lived experience of BD, to form best practice ingredients for the design of mental health technology. This combines the existing practices of patient and public involvement and HCI to evolve from the generic guidelines of user-centered design and to those that are tailored toward mental health technology.RESULTSFor the first question, it was found that out of the 11 novel smartphone apps included in this review, 4 (36%) self-monitoring apps were classified as having no mention of user involvement in design, 1 (9%) self-monitoring app was classified as having low user involvement, 4 (36%) self-monitoring apps were classified as having medium user involvement, and 2 (18%) self-monitoring apps were classified as having high user involvement. For the second question, it was found that despite the presence of extant approaches for the involvement of the user in the process of design and evaluation, there is large variability in whether the user is involved, how they are involved, and to what extent there is a reported emphasis on the voice of the user, which is the ultimate aim of such design approaches. For the third question, it is recommended that users are involved in all stages of design with the ultimate goal of empowering and creating empathy for the user.CONCLUSIONSUsers should be involved early in the design process, and this should not just be limited to the design itself, but also to associated research ensuring end-to-end involvement. Communities in health care-based design and HCI design need to work together to increase awareness of the different methods available and to encourage the use and mixing of the methods as well as establish better mechanisms to reach the target user group. Future research using systematic literature search methods should explore this further.
    • Incidence of bipolar affective disorder in three UK cities: Results from the ÆSOP study

      Lloyd, Tuhina (2005)
      Background: There has been a relative dearth of epidemiological research into bipolar affective disorder. Furthermore, incidence studies of bipolar disorder have been predominantly retrospective and most only included hospital admission cases. Aims: To determine the incidence of operationally defined bipolar disorder in three areas of the UK and to investigate any differences in gender and ethnicity. Method: All patients who contacted mental health services with first-episode psychosis or non-psychotic mania between September 1997 and August 1999 were identified and diagnosed according to ICD-10 criteria. Incidence rates of bipolar affective disorder were standardised for age and stratified by gender and ethnic group across the three areas. Results: The incidence rate per 100 000 per year in south-east London was over twice that in Nottingham and Bristol. There was no significant difference in the rates of disorder in men and women. Incidence rates of bipolar disorder in the combined Black and minority ethnic groups in all three areas were significantly higher than those of the comparison White groups. Conclusions: The incidence of bipolar disorder was higher in south-east London than in the other two areas, and was higher among Black and minority ethnic groups than in the White population. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)
    • Is early exposure to cannabis associated with bipolar disorder? Results from a Finnish birth-cohort study

      Sami, Musa (2022)
      BACKGROUND AND AIMSThere are few longitudinal studies assessing the association of cannabis use and subsequent onset of bipolar disorder. We aimed to measure the association between early cannabis exposure and subsequent bipolar disorder.DESIGN, SETTING, AND PARTICIPANTSObservational study linking a sample from the Northern Finland Birth Cohort 1986 (n=6,325) to nationwide register data to examine the association of life-time cannabis exposure at age 15/16 years and subsequent bipolar disorder until age 33 (until the end of 2018). 6,325 individuals (48.8% males) were included in the analysis.MEASUREMENTSCannabis exposure was measured via self-report. Bipolar disorder was measured via bipolar disorder-related diagnostic codes (ICD-10: F30.xx, F31.xx) collected from the Care Register for Health Care 2001-2018, the Register of Primary Health Care Visits 2011 - 2018, the medication reimbursement register of the Social Insurance Institution of Finland 2001 - 2005 and the disability pensions of the Finnish Center for Pensions 2001 - 2016. Potential confounders included demographic characteristics, parental psychiatric disorders, emotional and behavioral problems and other substance use.FINDINGS352 adolescents (5.6 %) reported any cannabis use until the age of 15-16 years. Of the whole sample, 66 (1.0 %) were diagnosed with bipolar disorder. Adolescent cannabis use was associated with bipolar disorder (hazard ratio [HR] =3.46; 95% confidence interval [CI] 1.81-6.61). This association remained statistically significant after adjusting for sex, family structure, and parental psychiatric disorders (HR =3.00; 95% CI 1.47-6.13) and after further adjusting for adolescent emotional and behavioral problems (HR =2.34; 95% CI 1.11-4.94). Further adjustments for frequent alcohol intoxications, daily smoking and lifetime illicit drug use attenuated the associations to statistically non-significant.CONCLUSIONSIn Finland, the positive association between early cannabis exposure and subsequent development of bipolar disorder appears to be confounded by other substance use.
    • Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): A randomised open-label trial

      Barrett, Sara; Lidder, Jasvinder S.; McCartney, Mark; Middleton, Hugh; Ononve, Frank; Solanki, Ramesh D. (2010)
      Background Lithium carbonate and valproate semisodium are both recommended as monotherapy for prevention of relapse in bipolar disorder, but are not individually fully effective in many patients. If combination therapy with both agents is better than monotherapy, many relapses and consequent disability could be avoided. We aimed to establish whether lithium plus valproate was better than monotherapy with either drug alone for relapse prevention in bipolar I disorder. Methods 330 patients aged 16 years and older with bipolar I disorder from 41 sites in the UK, France, USA, and Italy were randomly allocated to open-label lithium monotherapy (plasma concentration 0.4-1.0 mmol/L, n=110), valproate monotherapy (750-1250 mg, n=110), or both agents in combination (n=110), after an active run-in of 4-8 weeks on the combination. Randomisation was by computer program, and investigators and participants were informed of treatment allocation. All outcome events were considered by the trial management team, who were masked to treatment assignment. Participants were followed up for up to 24 months. The primary outcome was initiation of new intervention for an emergent mood episode, which was compared between groups by Cox regression. Analysis was by intention to treat. This study is registered, number ISRCTN 55261332. Findings 59 (54%) of 110 people in the combination therapy group, 65 (59%) of 110 in the lithium group, and 76 (69%) of 110 in the valproate group had a primary outcome event during follow-up. Hazard ratios for the primary outcome were 0.59 (95% CI 0.42-0.83, p=0.0023) for combination therapy versus valproate, 0.82 (0.58-1.17, p=0.27) for combination therapy versus lithium, and 0.71 (0.51-1.00, p=0.0472) for lithium versus valproate. 16 participants had serious adverse events after randomisation: seven receiving valproate monotherapy (three deaths); five lithium monotherapy (two deaths); and four combination therapy (one death). Interpretation For people with bipolar I disorder, for whom long-term therapy is clinically indicated, both combination therapy with lithium plus valproate and lithium monotherapy are more likely to prevent relapse than is valproate monotherapy. This benefit seems to be irrespective of baseline severity of illness and is maintained for up to 2 years. BALANCE could neither reliably confirm nor refute a benefit of combination therapy compared with lithium monotherapy.
    • Melatonin response to bright light in recovered, drug-free, bipolar patients

      Perini, Tony (1991)
      Melatonin suppression by bright light was investigated in 15 drug-free euthymic bipolar patients and control subjects matched for age and sex with the patients. There were no differences between groups on the extent of melatonin suppression by 500 lux bright light administered between 0200h and 0400h. These results do not support the hypothesis that melatonin suppression by bright light is a reliable trait marker in recovered bipolar patients. © 1991.
    • National survey and analysis of barriers to the utilisation of the 2005 mental capacity act by people with bipolar disorder in England and Wales

      Morriss, Richard K.; Mudigonda, Mohan; Bartlett, Peter (2017)
      BACKGROUND: The Mental Capacity Act (2005) (MCA) provides a legal framework for advance planning for both health and welfare in England and Wales for people if they lose mental capacity, for example, through mania or severe depression. AIMS: To determine the proportion of people with bipolar disorder (BD) who utilise advance planning, their experience of using it and barriers to its implementation. METHODS: National survey of people with clinical diagnosis of BD of their knowledge, use and experience of the MCA. Thematically analysed qualitative interviews with maximum variance sample of people with BD. RESULTS: A total of 544 respondents with BD participated in the survey; 18 in the qualitative study. 403 (74.1%) believed making plans about their personal welfare if they lost capacity to be very important. A total of 199 (36.6%) participants knew about the MCA. A total 54 (10%), 62 (11%) and 21 (4%) participants made advanced decisions to refuse treatment, advance statements and lasting power of attorney, respectively. Barriers included not understanding its different forms, unrealistic expectations and advance plans ignored by services. CONCLUSION: In BD, the demand for advance plans about welfare with loss of capacity was high, but utilisation of the MCA was low with barriers at service user, clinician and organisation levels.