Changing practice: assessing attitudes toward a NICE-informed collaborative treatment pathway for bipolar disorder

Abstract

Background: Bipolar disorder is a chronic mental health condition, which can result in functional impairment despite medication. A large evidence base supports use of psychological therapies and structured care in the treatment of mood disorders, but these are rarely implemented. e-Pathways are digital structures that inform and record patient progress through a healthcare system, although these have not yet been used for bipolar disorder.

Aims: To assess the perceived benefits and costs associated with implementing a collaborative NICE-informed e-pathway for bipolar disorder.

Method: Healthcare professionals and people with bipolar disorder attended a workshop to share feedback on e-pathways. Data were collected through questionnaires (n = 26) and transcription of a focus group, analysed qualitatively by a framework analysis.

Results: Patients and healthcare professionals welcomed the development of an e-pathway for bipolar disorder. There were five elements to the framework: quality and delivery of care, patient-clinician collaboration, flexibility and adaptability, impact on staff and impact on healthcare services.

Conclusions: Identification of benefits and costs ensures that future development of e-pathways addresses concerns of healthcare professionals and people with bipolar disorder, which would be essential for successful implementation. Recommendations for this development include making e-pathways less complicated for patients, ensuring sufficient training and ensuring clinicians do not feel their skills become invalidated. Limitations of the study, and directions for future research, are discussed.

Keywords: Bipolar affective disorders; care pathway; change management; e-pathway; qualitative research.

Fig. 1

Psychological pathway for out-of-episode bipolar disorder. Note: Entry onto the pathway is determined by a healthcare practitioner that the patient has bipolar disorder and is currently not in episode. Green and red arrows demarcate ‘yes’ and ‘no’, respectively. A diamond box indicates a decision, and rectangular boxes indicate an action. Behind each of these boxes is the necessary information to make a collaborative decision or action, for example: behind ‘Positive screen for sleep disorder?’ there is a rationale for screening for sleep disorders, and a description and screening tools for sleep apnoea and restless leg syndrome. If patients screen positive, the algorithm takes them to the ‘Resolved?’ decision box, where initial advice is given to address the sleep disorder. If this fails to resolve the situation, the algorithm takes the patient and healthcare practitioner to ‘Refer to sleep clinic’, in which information is provided to inform the decision to refer to local clinic, and if appropriate, a referral form. The algorithm next presents a choice of five options, and the information behind the boxes allows the healthcare practitioner to action the choice, or to flag if the resource is not available, e.g. group psychoeducation. The individual can follow the flow chart, e.g. starting with CBT-I and progressing with some individual psychoeducation delivered by the care coordinator, until the individual has confidence to sign up to group psychoeducation. Once this is complete, the patient and healthcare practitioner may feel that psychoeducation or sleep-work is not appropriate. If ‘Further psychological input needed?’ is answered ‘no’, the patient is discharged from the psychological pathway, and continues on the biological and social pathways. An asterisk indicates that it is outside the scope of the National Institute for Health and Care Excellence guidelines. CBT-I, cognitive–behavioural therapy for insomnia; DBT, dialectical behaviour therapy; IPT, interpersonal therapy.