Implementing Group Psychoeducation for people with Bipolar Disorder across the East Midlands

To improve care, recovery, function, reduce relapse and admission through the implementation of NICE-approved Group Psychoeducation for people with bipolar disorder across the East Midlands.

The EMAHSN project identified four primary objectives:

1. Improve function and recovery for service users that receive group psychoeducation – measured through the completion of the Work and Social Adjustment Scale, Bipolar Recovery Questionnaire and comparing data from the start and end of the group.
2. Reduce avoidable demand on services as a result of improved rates of relapse – measured using an audit of case records in Nottinghamshire and identifying access to services prior to and following the group.
3. Demonstrate positive uptake and service user experience of the intervention – measured using service user questionnaires and qualitative feedback from group participants.
4. Incorporate group psychoeducation within existing service provision and funding streams – measured through the adoption of the programme in the specified NHS sites and the potential development of bipolar care pathways.

The project aimed to improve rates of recovery, function and reduce mania, relapse and avoidable demand on crisis services and other parts of the health service for people with bipolar disorder across the region.

The project team supported the implementation of group psychoeducation through the provision of bespoke training and clinical supervision within participating mental health providers across the East Midlands along with project management, coordination and evaluation support. In addition, services adopting the intervention were provided peer facilitators from the lead Trust to support their first psychoeducation courses.

Patients gained access to a new intervention that improves their ability to self-manage their condition and recognise proactively early signs of relapse into mania and depression. They can express their wishes and feelings with health professionals.

The project aimed to demonstrate that participants use services more proactively and selectively with lower use of crisis services overall. During the programme they developed personalised ‘stay well’ plans which include triggers and early warning signs of relapse.

Patients gained more control over their illness and tailor management to their own personal recovery needs achieved through attending the group psychoeducation programme.

The primary reason for implementation was that (prior to commencing the project) no psychological interventions specific to bipolar disorder were routinely offered by NHS providers in the East Midlands outside of Nottinghamshire Healthcare NHSFT where bipolar group psychoeducation has been delivered routinely since 2014.

This followed the Trust’s participation in a randomised controlled trial of psychoeducation known as PARADES in 2009/10. It was identified that the absence of psychological interventions for bipolar was not in line with the NICE guidelines and represented a significant inequality of access for people with bipolar disorder across the region. Provision of this intervention is also closely aligned with recent strategic policy initiatives in Mental Health such as the NHS Long Term Plan and Five Year Forward View for Mental Health (to increase patients’ resilience and self-care and reduce the occurrence of crises and associated costly inpatient care).

Furthermore, group psychoeducation has been shown to improve outcomes for service users and decrease demand on resources by reducing the likelihood of relapses by 17% and relapses into mania by 34%. In people with fewer previous bipolar episodes, it can reduce the chance of relapse by 72%.

In addition, the evidence base in support of the intervention would suggest a high degree of service user acceptability and retention and a lasting positive impact on clinical outcomes including improved interpersonal function and quality of life.

The bipolar group psychoeducation programme was running successfully in Nottinghamshire and as such the project aimed to spread the intervention across four other mental health NHS Trusts in the East Midlands.

In early 2016 EMAHSN selected the project to implement group psychoeducation for people with bipolar disorder across the East Midlands; the proposal originated from Nottinghamshire Healthcare NHSFT who have been running groups since 2014.

In establishing the project EMAHSN and staff from the Nottinghamshire Healthcare NHSFT identified key decision makers within each ‘adopter’ NHS Trust. The roles of these individuals varied according to the configuration of each Trust’s services; in some cases, initial engagement was with the Research and Innovation Department, in others it was an interface with senior clinicians such as the Lead Nurse for Community Services or Deputy Medical Director.

The project team arranged an awareness raising CPD-accredited event. Clinical teams invited potential peer facilitators or other service user representatives with an interest in bipolar disorder. Trusts with an established recovery college also encouraged their participation. The primary aim of these events was to identify clinicians and peer facilitators to deliver the intervention and to agree the exact team composition at each site which again varied across organisations including community psychiatric nurses, occupational therapists, clinical psychologists and psychiatrists.

Training was provided based on the Colom and Vieta (2006) psychoeducation manual adapted for the NHS and utilised the delivery model from Nottinghamshire. Initial training on the referral process and eligibility criteria was complemented by guidance on facilitation and group dynamics provided in partnership with Nottingham Recovery College.

A ‘community of practice’ for clinicians and peer facilitators was established to share learning and experiences. Clinical mentoring and supervision were provided by the Nottinghamshire team and experienced peer facilitators from the Nottinghamshire service supported other Trusts to deliver their initial courses.

The project launched in September 2017 with the initiation of psychoeducation groups in Leicestershire and Northamptonshire and was subsequently spread successfully to Derbyshire in 2018. Initially Lincolnshire were engaged in the project but unfortunately withdrew in 2018, after running one psychoeducation course, due to resource constraints. The EMAHSN project concluded in December 2019 and three of the four Trusts have plans to continue and a majority plan to further embed and expand their group psychoeducation programme.

Improve function and recovery: This was measured through use of the Work and Social Adjustment Scale (WSAS) and Bipolar Recovery Questionnaire (BRQ). Improvement on both outcomes were realised with the majority of patients reporting a clinically significant improvement on at least one scale at the end of the programme. The effect size was small and moderate for the WSAS and BRQ respectively.

Reduce relapse rates and avoidable demand on services: Relapse rates for psychoeducation participants (n=43) versus treatment as usual (n=46, TAU) based on admissions and crisis team contacts were evaluated through a small Nottinghamshire non-randomised service audit. The results showed that the proportion of patients receiving psychoeducation who had any relapse was 40% compared to 63% in the TAU group. Of these relapses 27% were major in the psychoeducation groups compared to 58% in TAU supporting the likelihood of significant potential savings from reducing costly inpatient spells. The total crisis team involvement was also lower for the psychoeducation group compared to TAU at 98 vs 167 days respectively. These findings should be treated with caution due to the small sample and non-randomised nature of the audit.

Demonstrate positive uptake and service user experience of the intervention: In order to demonstrate the positive uptake of the project service user evaluation forms were used and retention of service users on psychoeducation courses was measured (attending ≥75% of sessions). Unfortunately, very few service user evaluation forms were completed (n=8), however this feedback was very positive with a net promoter score of 100%.

Anecdotal feedback from service users was equally positive. Due to low numbers of respondents this cannot be considered conclusive. Retention of service users from enrolment to course completion was good, at 67%.

Incorporate group psychoeducation within existing service provision and funding streams: Despite significant challenges in accessing service-level data to inform business case development, three of the four NHS Trusts that adopted psychoeducation are continuing to deliver it without continuing external funding.

To date, 19 bipolar psychoeducation courses have been initiated across the region since project launch and 236 people with bipolar disorder enrolled. The NHS Trusts that adopted group psychoeducation during the project plan to continue to offer it routinely alongside the lead Trust in Nottinghamshire.

• Patient feedback was positive with most respondents valuing the course highly and likely to recommend it to others.

• There was some variation in delivery between sites. Significant deviations from the original manual and model of delivery e.g. shortening the course, changing composition of delivery teams and manual content were not supported by the evidence but smaller deviations to meet individual service needs could enhance delivery.

• The variation in delivery models provided useful perspectives on how to make a service work in different settings given available resources and organisational contexts.

• The evaluation of the project demonstrated that delivery of this evidence-based intervention can be achieved in a variety of different organisations, service models and geographies.

• The role of a community of practice was important in sharing learning, experience and reinforcing the importance and effectiveness of the intervention for clinical staff with heavy caseloads and competing priorities.

• The experiences of participants submitting feedback were positive. Many mentioned an increased sense of control over their illness and the opportunity to discuss experiences with people who “understand” in a “safe space”. The group format is also valued as participants learn from each other’s experiences in addition to benefit from the course itself.

• There are plans to include group psychoeducation within redesigned clinical pathways for bipolar disorder in two Trusts. This will help ensure it is offered to all patients who could benefit.