MAPP: Imagery-focused Therapy for Bipolar Disorder
Condition: Bipolar Disorder
MeSH terms: Bipolar Disorder
Study type: Interventional

Summary: 
      Bipolar Disorder (BD) (previously known as "manic depression") is a severe mental health
      illness affecting at least 1% of the population and with annual NHS cost estimated at £342
      million. It is characterised by alternating episodes of acute mood swings: depression and
      "mania" (mood elation). BD also comes with less severe mood swings we call "mood
      instability", and ongoing high levels of anxiety that impair well-being even during periods
      between the acute mood breakdowns. Anxiety and mood instability are associated with worse
      outcome of the disorder.

      All these symptoms can be accompanied by the presence of troublesome mental images (e.g.
      seeing a memory in the mind's eye) such as intrusive "flashbacks" of negative past events.
      Recent studies suggest that individuals with BD experience more vivid, compelling and
      upsetting mental images compared to other patient groups and this could contribute to their
      clinical difficulties.

      Cognitive Behavioural Therapy (CBT) is a well established and successful psychological
      therapy used in the National Health Service (NHS), UK but as yet with limited efficacy in BD.
      Targeting mental imagery has long been part of general CBT. In particular, imagery-based
      treatment techniques have proved successful in anxiety disorders, but have not been brought
      to CBT for Bipolar Disorder yet.

      Our study Mood Action Psychology Programme (MAPP) investigates the delivery of a brief
      imagery-focused cognitive therapy (imCT) intervention to people with BD, studying a series of
      patients in detail one by one a "case series"). We offer a structured and individualised
      psychological treatment in line with the aims of NHS guidelines. The imCT protocol has been
      successfully delivered and audited in our psychological service in Oxford (OxMAPP). The
      proposed MAPP study aims to formally assess for the first time the effectiveness of imCT. In
      particular we hypothesise that imCT via the Mood Action Psychology Programme (MAPP) will
      result in (i) reduced levels of anxiety and (ii) reduced levels of low mood after treatment
      compared to baseline (both measured over 4 weeks) in individuals with BD.

      Overall, this works aims to contribute to improved psychological treatment for BD.
    

Detailed description: 
      Mood Action Psychology Programme (MAPP) is a study that investigates the delivery of an
      imagery-focused cognitive therapy (imCT) intervention to people with Bipolar Disorder (BD)
      via a single case series (N = 15) design. MAPP offers patients a structured and
      individualised psychological treatment (imCT) for BD inline with the aims of the National
      Institute for Clinical Excellence, UK guidelines (NICE, 2006) and as already developed and
      audited in the OxMAPP psychological service that was run within the Professorial Mood
      Disorders clinic at the Warneford Hospital, Oxford. In addition MAPP aims to improve the
      understanding of psychological therapy by formally assessing the effectiveness of imCT in
      reducing anxiety and low mood symptoms. Secondary aims are to test the hypothesis that
      reductions in anxiety and low mood levels are mediated by changes in problematic imagery
      phenomena, and investigating the impact of imCT on interepisodic mood instability, coping
      skills and general functioning of patients with BD. The short term (i.e. at 6 month follow
      up) effect on preventing relapses of (hypo)manic and depressive episodes is also evaluated.
      The rationale for this approach derives from current evidence of (i) the uncertain efficacy
      in BD of traditional CBT relying exclusively on verbal thought modification approaches (Scott
      et al., 2006), (ii) the presence of dysfunctional mental imagery in BD patients (Bonsall et
      al., 2012; Hales et al., 2011; Ivins et al., under review) alongside high rates of anxiety
      comorbidity (Simon et al., 2004) and (iii) the success of imagery-based treatment techniques
      in anxiety disorders such as PTSD and social phobia (Ehlers & Clark, 2008). A case-series
      approach allows flexible and feasible but robust testing of the novel imCT treatment protocol
      with the aim of optimising it for further investigation in future randomised controlled
      clinical trials.

      MAPP provides structured individualised treatment, which includes an extended mapping (i.e.
      assessment) phase for patients with BD based on cognitive behavioural principles. Where
      appropriate, MAPP offers a brief cognitive therapy intervention drawing on mental imagery
      (imCT). It includes a focus on addressing anxiety symptoms that are often present and
      problematic in BD. The patients and clinician jointly identify an agreed treatment target
      (e.g. trauma memories, social anxiety, intrusive imagery) which is hypothesised to have
      impact on the mood stability of patients. The agreed treatment target is one which is judged
      to be tractable and amenable to change in a brief intervention using imagery focused
      techniques.

      Participation in the MAPP study is suitable for outpatients with a diagnosis of BD who would
      like to gain a better understanding of their symptoms, are interested in adding a
      psychological approach to their mood management, and are happy to take part in clinical
      research. The programme involves weekly symptom monitoring, as well as committing to weekly
      therapy sessions (10 sessions), and is suitable for patients who are agreeable to both of
      these. Treatment is offered to patients who comply with the daily mood monitoring active run
      in phase. Referrals of young patients (18-25 years old) are encouraged, given evidence that
      psychological treatment might be more effective at the onset of BD, in particular when
      targeting anxiety and mood instability. Within MAPP, psychological treatment is delivered by
      a team of therapists. The therapists are clinical psychologists and psychiatrists with
      specific imCT training. Typically two co-therapists are present in each session, one of which
      can attend the session also via Skype. MAPP is integrated in psychiatric secondary care
      within two NHS trusts, the Cambridge and Peterborough Foundation NHS Trust and the Oxford
      Health NHS Foundation Trust. In both NHS trusts imCT is given alongside psychiatric
      medication as usual. Patients enrolled in the study maintain their ongoing contact with other
      core clinical services.
    

Intervention name(s): Imagery-focused Cognitive Therapy (ImCT - psychotherapy based on CBT principles)
Intervention type(s): Other
Intervention description(s): ImCT Therapy is carried out by a team of 2 co-therapists and comprises of:
Mapping: Therapists and patient collaboratively map out difficulties and pinpoint a treatment focus, with regards to imagery symptoms and anxiety co-morbidity that impact on bipolar mood instability. This leads to an individualised formulation of the patient's current problem.
Target: Follows the rationale, timing and objectives identified collaboratively in Mapping. It is structured around imagery-based techniques, such as imagery rescripting, which are used to address problematic imagery, to promote management of mood and boost self-care. This results into the acquisition of imagery-based mood- and anxiety-regulating strategies to be integrated into the patient's already existing coping strategies.
Consolidation: Consist of fine tuning the strategies devised during Target based on experience gained after testing them out in real life situations and includes a "video blue print.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Mental imagery, CBT, anxiety, mood instability