title: Development of a lifestyle intervention for adults with bipolar disorder
Creators: name: Chalmers, Natalie Anne
Publisher: name: University of Glasgow
Year: 2020
Subjects: subject: Bipolar disorder, serious mental illness, lifestyle intervention, weight management, weight loss, weight gain.

description: Background Weight management is a significant issue for people with bipolar disorder. Approximately 68% of people who are receiving treatment for bipolar disorder are overweight or obese. There are few trials testing lifestyle interventions for weight management in this population. Trials including people with bipolar disorder completed to date, have methodological limitations and few aim to impact on longer term maintenance of behaviour change. There are also few qualitative studies exploring weight related issues and challenges for this group in order to inform interventions. Aims To gain an understanding of the evidence base for weight management interventions for people with bipolar disorder. To explore the experiences of people with bipolar disorder and those who support them including family and friends (close social support) and health professionals. To draw together this evidence to inform the design of weight management interventions for people with bipolar disorder. Methods This research consisted of two phases. The first phase was a systematic review of trials of lifestyle interventions for adults diagnosed with a serious mental illness (SMI) (including bipolar disorder and schizophrenia). The behaviour change techniques included in the trials were identified. A systematic review of qualitative studies was also conducted to explore the barriers and facilitators of lifestyle behaviour change for adults with SMI. The qualitative and quantitative data were summarised in tables and the data were combined in a narrative summary. The second phase consisted of 26 semi-structured interviews with: people with bipolar disorder (n=16); their families (n=5); and health professionals (n=5) involved in their care. These interviews explored issues around lifestyle, weight management, diet and physical activity; as well as barriers and facilitators to change. Data were analysed using a thematic approach and just over ten percent were double coded. Social network data were also collected from people diagnosed with bipolar disorder via sociograms. The sociograms explored the nature of social networks in this group and the potential for intervening via social networks. The sociograms were drawn by participants and questions were asked about the people in the diagrams. These were then coded into the social network software, UCINET. Due to the small number of participants included in this study the analyses were exploratory in nature. Results The systematic review did not identify many trials of lifestyle interventions for adults with bipolar disorder and there were few qualitative studies. Through the systematic review 19 articles were identified. A total of ten trials of lifestyle interventions and nine qualitative studies. The identified trials from the review included one physical activity only, and nine combined physical activity and diet. No trials were found for diet only. Of the nine trials included in the systematic review, eight were randomised controlled trials and one was a comparison study. Study quality was generally poor for the trials with small sample sizes and lack of follow-up of interventions. The ten qualitative studies were: four one to one interviews; three focus groups; two ethnographic; and one combination of interviews, observations and focus groups. The overall quality of the qualitative studies was reasonable. There was a lack of detail about the participant demographics and participant recruitment. Trials that included both physical activity and diet were more likely to result in weight loss than trials that included physical activity only. Across the four trials that lost weight, eleven behaviour change techniques were identified in the trials. These were: provide information about behaviour health link; provide information on consequences; prompt intention formation; provide instructions; model or demonstrate the behaviour; prompt specific goal setting; prompt review of behaviour goals; prompt self-monitoring of behaviour; provide feedback on performance; prompt practice; and use follow-up prompts. Two theories, social cognitive theory and control theory were most strongly represented in the BCTs present in the four successful trials. The qualitative studies showed that in order to achieve weight loss for people with bipolar disorder it is important to improve: physical health, mental health, contextual factors (such as access to exercise space and facilities), and social support. These factors are important for supporting behaviour change for weight management interventions. Thematic analysis of participant interview data revealed a number of key themes related to weight management in this group including: the challenges of living with bipolar disorder; lifestyle related issues; and social support and social influences. Living with bipolar disorder was a key theme and it demonstrated how the disorder influences all aspects of the participant’s life. The lifestyle theme covers topics that are linked to managing their bipolar disorder, for example how physical activity, diet, alcohol and coping strategies both influence and are influenced by their bipolar disorder. Social support and social influence were mostly discussed by people who provide support, however people diagnosed with bipolar disorder also identified the importance of social support for weight management. Finally, intervention ideas were discussed with participants. Most participants reported needing and wanting a lifestyle intervention. Using technology was highlighted by participants as being both positive and negative. A number of barriers and facilitators were identified by participants regarding weight management. The barriers and facilitators were grouped into intrapersonal, interpersonal and other. The intrapersonal factors consisted of internal personal factors that contributed to weight management, including motivation to make lifestyle changes and mood impacts on food choices. Interpersonal factors reflected how other people who provide support contribute to the success or otherwise of weight management in patients with bipolar disorder. Other factors that were discussed included medication and hospitalisation and their negative impact on weight. Finally, people identified mood as having a major impact on attempts to manage weight. Although the social network data analysis gave only a preliminary exploration of the structure of the participants’ social networks and social support, there were some interesting findings. Most participants felt that they had the necessary support to make behaviour changes to facilitate weight management. Everyone had a mixture of healthy and unhealthy people providing social support (as identified by bipolar participants). There did not appear to be a difference in the structure or function of social networks between healthy weight participants and participants with overweight/obesity. Due to the small numbers of participants this may have been difficult to assume that this is prevalent across the wider population. Conclusions The systematic review identified that there are gaps in the evidence base related to weight management interventions, including effective behaviour change techniques. Previous studies have a number of methodological problems and few interventions have been shown to be effective. Qualitative studies, including this one, have shown that people with bipolar disorder face similar barriers in relation to weight management as the general population, but they also have additional issues to manage associated with their bipolar disorder. The systematic review and the qualitative evidence indicate that people with bipolar disorder want interventions and that they have the potential to assist with weight management. From the evidence to date, these interventions should consist of both physical activity and dietary components and also include an element of social support, as that has been identified as important. They should also take into consideration the complex nature of bipolar disorder and how this impacts on weight management.