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CAMH Stories Centre for Addiction
and Mental Health

Care pathway helps patients with bipolar depression stay on track with treatment

May 4, 2016 - Bianca first confronted the effects of bipolar depression – with its unpredictable swings between manic and depressive phases – as she balanced raising young children with her career teaching in a community college.

Encouraged by a friend to seek help, she saw a psychiatrist and received medication and counselling that helped stabilize her mood.

But like many people with bipolar depression, as Bianca began to feel better, side effects she experienced caused her to forgo her medication. 

Older woman looking sad People who have bipolar depression must cope with what can be a rollercoaster of mood changes, swinging from highs of a manic episode to lows of depression.

“Each time I went off my medication, it was even more disruptive to my mental health,” Bianca recalls. Her relationship with her husband was increasingly strained. When she was back at home and at work, it was getting tougher and tougher to cope.

Bianca left her job and put her career on hold after a particularly bad bipolar episode. But since then, she has persisted to try to improve her mental health, leverage her professional skills in a part-time role, and pursue activities she loves.

A clear pathway for treatment

Bianca is one of 36 patients now participating in CAMH’s Bipolar Integrated Care Pathway (ICP). Designed by an inter-disciplinary team from Mood and Anxiety Ambulatory Services (MAAS), the pathway just celebrated its first anniversary earlier this year.

The pathway takes a structured approach to helping outpatient clients with bipolar depression – they sign an agreement to be part of this treatment track for up to one year.

“We are addressing a huge problem with treatment retention due to the nature of this illness,” says Psychiatrist Dr. Gaby Abraham. “This care pathway provides structured support, education, medication and therapy, and we are seeing encouraging results. The large majority of patients who take part are staying with the program and making progress.” Dr. Abraham played a key role in developing the program and sees many of the pathway clients regularly. 

Shivali Kapila, Dr. Gaby Abraham and Tanja Kotolenko Developing an integrated care pathway (from left): Shivali Kapila, Dr. Gaby Abraham and Tanja Kotolenko.

Here’s how the pathway works:

  • Assessment: Patients receive a structured assessment for their medication and psychological needs, and see a psychiatrist monthly. Their visits include metabolic monitoring related to medications. Patients can see a clinician as needed in addition to regular visits.
  • Medications -- including mood stabilizers, anti-depressants and anti-psychotics -- are prescribed based on an evidence-based treatment course and may be adjusted for the needs of each patient.
  • Group therapy: Patients are offered two 16-week group therapy options: 1) Cognitive Behavioral Therapy (CBT), focusing on thoughts, feelings and strategies to cope with stress and emotions; and 2) Interpersonal and Social Rhythm Therapy (IPSRT), focusing on relationship building – this is especially important for patients with bipolar depression who may have lost friends or family connections due to their illness.
  • Education and relapse prevention: Patients receive education from a pharmacist and other clinicians about their condition and medications. On completing the pathway, patients leave with a detailed relapse prevention plan developed along the way.

Coordination and follow-up is also provided by a primary care clinician and pharmacist as needed to help patients stay on track.

Building skills to strengthen relationships and manage emotions

Tanja Kotolenko is a Registered Nurse and clinical coordinator for the Bipolar ICP program. She says the two group sessions directly address needs of patients.

“A manic phase of this condition can undermine relationships. The IPSRT group helps our clients build skills to deal with interpersonal issues, evaluate their support system, and strengthen relationships among their family, friends and colleagues. Personal routine is also very important – to have a consistent sleep and meal times, for example.”

The cognitive-behavioural group looks at “how you can be aware of and manage emotions and thoughts,” she says. “Some of our clients look back to a depressive or manic phase and their behavior – such as withdrawal from others or a spending binge -- and they struggle to understand what happened: ‘Was that really me?’  So this group also looks at reinforcing a sense of self for patients: who they are and what is important to them.”

In addition, patients know “they can always come and knock on my door,” says Tanja. “We are here to support them.”

The inter-disciplinary team -- psychiatrists, nurses, social workers, occupational therapists, pharmacists, project staff – get together regularly to discuss issues and opportunities for patients’ treatment. MAAS is part of CAMH’s Ambulatory Care and Structured Treatments (ACST) program.

Bipolar ICP team 
CAMH’s Bipolar ICP team. From left: Dr. Gaby Abraham, Stephanie Carter, Shivali Kapila, Allison Hoffman, Claudia Tindall, Anya Choulsky, Helena Roche, Tanja Kotolenko, Nurit Postelnik, Naomi Mitchell, Dr. Robert Cooke, and Karen Fournier. Not pictured: Dr. Robert Levitan, Dr. Neely Bakshi, Shevanthi Collure, Megan Lewry.

Since the program’s inception in early 2015, “67 per cent of patients are still engaged with the program at the six-month mark,” says Project Manager Shivali Kapila. “That compares to much less than 50 per cent retention for bipolar treatment generally in mental health or community settings. The combination of a structured pathway of care with clinical judgment and nuance is helping patients stay on track,” she says.

Bianca notes that the regular follow-up with her psychiatrist in the CAMH Bipolar ICP gives her a comfort level and flexibility to fine-tune her treatment and keep it moving in a good direction. 

Openness and interaction

Bianca attends the interpersonal group sessions each week. “I enjoy the interaction with other women in the group – they are very open and there is a good interaction about what is going on in our lives.” She is also inspired by the Consumer/Survivor Resource Centre and its communications to share stories, challenges and hopes of people in treatment and recovery.

Bianca continues to leverage her skills as an educator, teaching language and arts courses part-time in a community college. “Some of my classes involve smaller groups of adult learners, where there’s an opportunity for more individual attention, which I find rewarding,” she says, adding that she also needs the income from missing full-time work previously.

Outside of work, she volunteers for an arts organization. Most importantly, she is trying to strengthen relationships with some family and friends. She holds out hope that she can mend the relationship with her children, who struggled with their mom’s diagnosis and their feelings of confusion and sadness.

Bianca also knows deep down that she must always stay on the medications that treat and stabilize her condition.

“For others who have this condition, I would say to always speak with your doctor about your medication – the consequences of stopping medication can be personally disastrous – your doctor can help you manage, taper or adjust your medications.”

Bianca’s story is real. Her name and some details have been changed at her request.

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