Bipolar disorder (BD) has the highest rate of suicide of all psychiatric disorders, with up to 50% attempting suicide at least once [1]. It is highly recurrent and projected to cost the UK economy £8.2 billion per annum by 2026 [2]. Most treatments (psychosocial and pharmacological) for BD target the important outcomes of depression and relapse rates. However, current NICE guidelines [3] state that the evidence base of psychosocial interventions for BD is mainly of low quality. Trials have produced mixed results and due to the lack of a strong evidence-base, NICE currently suggest a range of options derived from the outcomes of low to moderate quality trials. These include group interventions, psychoeducation, family-focused therapy, cognitive behavioural therapy (CBT), interpersonal and social rhythm therapy and integrated cognitive and interpersonal therapy. There is, therefore, a clear need to develop innovative interventions which directly target the mechanisms underlying mood instability.
Anxiety is highly prevalent in BD, and can persist between acute episodes of mania and depression [4,5,6]. Anxiety within BD is associated with increased levels of suicide, relapse, higher levels of mood fluctuation, and a hampered treatment response to mood stabilisers such as lithium [7,8,9]. Recent studies indicate that people with BD are particularly vulnerable to experiencing frequent, intrusive and emotional mental images [6,10] which fuel anxiety and mood instability. These images are somewhat similar to the intrusive mental ‘flashbacks’ associated with posttraumatic stress disorder (PTSD). However intrusive mental images in BD are typically associated with imagined, emotionally intense, future events or ‘flashforwards’ e.g. an image of attempting suicide (fueling anxiety), or of winning a Nobel prize (fueling elation). Neuroimaging studies indicate that imagining an event provokes a similar response within the visual cortex to experiencing the event ‘for real’. This is likely to explain findings that image-based thought (e.g. imagining jumping off a building) induces a stronger emotional reaction than verbal–based thought (e.g. thinking purely in words about the idea of jumping off a building) [11]. Patients with BD report experiencing these mental images as ‘lifelike’, hard to ignore and difficult to control when compared to people diagnosed with other mental health problems [5,6,10,12]. The intrusive emotional mental images which are highly prevalent in BD therefore represent a specific target for treatment for this disorder with the potential to reduce anxiety and improve mood stability [6,13]. Further, the recent treatment guidelines for BD from the British Association of Psychopharmacology [14] warn of the potential adverse effects of SSRIs in BD and state that “Psychological treatments potentially offer adjunctive approaches for addressing anxiety in bipolar disorder where anxiety-specific medication is counter-indicated and/or in line with a patient’s preference”.
The most widely adopted form of psychological therapy within the NHS is CBT. Whilst effective for a number of disorders [15], at best CBT has produced low to moderate effects in trials targeting depression and relapse prevention in BD [16, 17]. CBT requires patients to engage in a logical verbal discussion about their emotions. Therefore, it may be that the processes adopted within CBT are not best suited to tackling emotional images within BD. Given the proposal that emotional images underlie the anxiety present in BD, it is of note that that the only study of CBT for anxiety in this group did not produce positive results [18]. There is, therefore, a need to develop a psychological intervention for BD which is distinct from traditional CBT and which improves outcomes for those diagnosed with this disabling condition.
Research in the field is also limited due to an overreliance on the assessment of mood at a single time point. This method fails to capture the inherent mood instability in BD. The current trial adopts an innovative, yet simple, measure of mood stability to capture this outcome. The use of single mood ratings collected every day over a 28-day period has been shown to be feasible (over 95% of data captured in our case series [19]).
We have developed a new brief structured psychological intervention for BD called Imagery Based Emotion Regulation (IBER). The treatment translates our experimental work in the area of imagery and emotion into a skills training programme to improve the regulation of intrusive and distressing emotional mental images in BD. IBER also contains a positive imagery module suitable for the small minority of BD patients who may not report anxiety-related mental images [6,10].
An early version of our intervention was adapted after input from service-users, and an improved version was then evaluated within a recently published case series [19]. Results from 14 participants indicated a pre-post effect size for anxiety of 1.89 along with reduced levels of depression, improved mood stability and a high level of engagement with treatment. The specific targeting of one mechanism provides a focused intervention, which requires fewer sessions than other current psychological treatments. The potential to reduce anxiety, mood instability and relapse rates within this group is of clear health benefit to patients and has potential economic benefit to the NHS. A feasibility study is required to determine whether a full trial is indicated.