The ‘Mood on Track’ (MOT) programme is a Self-Management course specifically designed to help people with a diagnosis of Bipolar Disorder identify early warning signs, monitor mood and improve the management of problem mood changes by enhancing coping skills. Its focus is on relapse management and improving well-being and follows a Cognitive Behavioural approach. In line with guidelines the programme is a combined treatment approach. This means the acknowledgement that the psychological strategies taught on the MOT course work best when combined with medication.
Co-Production
From start: Yes
During process: Yes
In evaluation: Yes
Evaluation
Peer: Yes
Academic: Yes
PP Collaborative: Yes
Find out more
Dr Tony Roach - Clinical Lead Lancashire Care Foundation Trust
In October 2015, Lancashire Care Foundation Trust (LCFT) funded a Psychological Care Network as part of the Community Mental Health redesign to provide an assessment and treatment service dedicated to individuals who have a diagnosis of Psychosis and/or Bipolar Disorder.
Some of the external drivers of the subsequently named Psychosis and Bipolar Psychological Care Network (PBPCN) have been the National Audit of Schizophrenia (NAS, 2014) and the need to be NICE compliant and the Trust’s ambition to attain upper quartile performance with regard to psychological approaches; developments within the SMI IAPT programme and the Schizophrenia Commission Report – The Abandoned Illness (2012). In line with the findings from these reports an internal audit within LCFT identified that just over 1 in 10 people with a diagnosis of bipolar disorder where offered psychological treatment. It is recognised that these groups of people experience high levels of distress resulting in a high impact on their ability to function that consequently results in a high use of inpatient beds.
There exists considerable expertise across the Trust in the assessment and management of Psychosis and Bi-polar Disorder. This service is designed to complement existing levels of expertise and to provide a referral option for psychological input for these individuals within the Adult Mental Health Network.
The overall aim is to provide services which are compliant with NICE guidance and which also recognise the importance of relational aspects of assessment and therapy. In addition, the service aims to contribute to the development of a sense of hope and optimism, for clients and their families, regarding the human potential for positive change following Psychosis and Bi-Polar Disorder.
In line with NICE guidance the service recognises the importance of pharmacological treatments. The available approaches to treatment within the Psychological Care Network are as follows:
a) Cognitive Behaviour Therapy – CBTp
b) Family Therapy – Systemic and/or Behavioural
c) Art Therapy
The initial work of the Network has focused upon people with a diagnosis of Bipolar disorder. The guidance recommends a Structured Psychological Therapy by people with experience working with this group, Mood on Track has been developed for this purpose.
What is Mood on Track?
The ‘Mood on Track’ (MOT) programme is a Self-Management course specifically designed to help people with a diagnosis of Bipolar Disorder identify early warning signs, monitor mood and improve the management of problem mood changes by enhancing coping skills. Its focus is on relapse management and improving well-being and follows a Cognitive Behavioural approach. In line with guidelines the programme is a combined treatment approach. This means the acknowledgement that the psychological strategies taught on the MOT course work best when combined with medication.
The programme can be undertaken by a course hosted by almost all of the local Community Mental Health Teams. The courses are held several times a year in various community team bases. We try to ensure the locations are as convenient as possible for all people to attend.
The course consists of 10 weekly sessions (each lasting two hours with breaks for refreshments). These sessions are dedicated to delivering the following information; information about the condition: what it is and how it diagnosed, ways to manage the lows and the highs, spotting early signs of a problem mood swing (with plans to manage these) the role of medication and problem substances to avoid, plus ways of improving well-being, etc. Included in these sessions are Mind & Body stimulation control techniques, which provide people with an opportunity to try out a range of skills to quieten and calm both the mind and body processes. All of these sessions (1 – 10) take place in a group format of about 8 – 10 people. The group is facilitated by at least 2 members of staff so there is always someone on hand to help if there is something that is not understood or if support is needed.
At the end of the course there are between 4- 6 individual sessions to develop a personalised ‘Early Signs Signature’ and ‘Action Plan’. These will then be incorporated into the ‘On Track’ relapse pack. This pack contains key information and guidelines to help people ‘Stay On Track’ and reduce the risk in the future of the need for home treatment or Inpatient care.
Wider Active Support
Birmingham and Solihull Mental Health NHS Foundation Trust were chosen as the National pilot site for SMI IAPT for Bipolar Disorder. Due to their position we contacted the Trust to learn more about their approach. Subsequently, we developed an excellent relationship with them to the extent that they granted LCFT full permission to use the ‘Mood on Track’ Programme. We have been able to implement and deliver the full benefits of the programme across Lancashire. Birmingham and Solihull Mental Health NHS Foundation Trust have given their full support of this application.
Co-Production
From the outset service users have been involved in the writing the Standard Operating Procedures for the Network that includes the Mood on Track Programme. They have offered invaluable feedback and even suggested that our Network’s SOP’s be used as a template for other SOP’s within our organisation.
Following completion of the MOT programme each locality offers a support group where service users are encouraged to have increasingly more ownership on both how these courses are run and the content of the meetings.
We are also in the process of offering some graduates from the programmes honorary voluntary contracts to join us in reviewing, promoting, recruiting and running the sessions.
Additionally, we have developed good relationships with local charitable organisations that include ‘Rethink’ where we have promoted the programme at one of their meetings. We are also in discussions with the local ‘Bi-Polar UK’ group who have requested we attend their meeting to promote the work we are doing.
Looking Back/Challenges Faced
The greatest initial challenge facing the Network has been promoting the service across different localities to ensure that the necessary volume of appropriate referrals where received. Some of the challenges relating to this included: raising awareness of the programme with CMHT, beliefs around capacity for psychological treatment and staff confidence in running the MOT programme. To ensure that sufficient numbers of people were recruited we decided to open up the programme to Primary Care teams (PCT’s).
However, we are delighted that the programme has been a great success but consequently demand is far greater than supply. In the section below on ‘Sharing’ we will detail our ideas of how we aim to address this increasing demand both in the CMHT’s and PCT’s.
Sustainability
The service is currently in a fledgling state there is a National Shortage of trained CBT and Family therapists. As a service we have committed to fully supporting our staff to undertake such training. The structure of the Network constitutes Band 7’s, B8a and 8b members of staff which allows for succession planning.
In addition, to this to create a critical mass of skills in what is a developing area we are working closely with our Early Intervention Service colleagues.
Evaluation (Peer or Academic)
When the programme was first rolled out we conducted a small pilot study some of the findings from which are described below. Further to this Lancaster University are undertaking a Service Evaluation Research Project, this will be conducted by the Department of Clinical Psychology overseen by Professor Bill Sellwood, which may well lead to formal publication in academic journal(s).
Outcomes
Measures
The measures used include:
IAPT Measures
Generalized Anxiety Disorder- 7
(GAD 7)
Patient Health Questionnaire -9 (PHQ 9)
Work and Social Adjustment Scale (WSAS) Quality of Life Measures
Bipolar Recovery Questionnaire
Quality of Life – Bipolar Disorder (QoL-BD see below). Patient Experience
Patient Experience Questionnaire (see Table 1 below)
The Bipolar Recovery Questionnaire – BRQ (Jones, S., Mulligan, L. D., Higginson, S., Dunn, G., Morrison, A.; 2013)
The BRQ has been developed in order to understand more about recovery in bipolar disorder; what recovery is and what can help or hinder recovery. The questionnaire has been developed by interviewing individuals with a diagnosis of bipolar disorder about their experiences and personal accounts of recovery.
The BRQ not only produces a total score (by summing all 36 items), but consists of 4 themes, each of which produce a subscale total. The subscales include:
Mood experiences as understandable and manageable
Developing resources to self-manage health
Access to personally meaningful activity
Recovery as a life-long process.
The Quality of Life scale for Bipolar disorder – QoL-BD (Murraya, G. and Michalak, EE.; 2009)
The QoL.BD assess 12 domains: Physical, Leisure, Household, Sleep, Social, Self-esteem, Mood, Spirituality, Independence, Cognition, Finance, Identity
Simply calculate the total score for all items on the brief version by adding the scores (range 12-60).
When used as a repeated measures tool to measure change across time, either in clinical practice or in research raw scores are again the most meaningful data to inspect (see Appendix 1).
In clinical settings, it is suggested that response to treatment should be evaluated by examining change in the individual’s scores from their baseline assessment, or to use the scale to explore wellbeing at a domain level with an eye to treatment goal setting.
Results.
The following graphs and table represent the patient reported outcome measures and the patient reported experience measure.
Graph 1 Pre Post Score for GAD 7, PHQ 9 and WSAS
*Incomplete data sets have been excluded from total score (2 people did not complete WSAS post measure, I person did not complete GAD 7, PHQ 9 and WSAS measure, 5 people did not compete any measures).
Graph 2 Pre Post Score for the Brief Quality of Life Scale (QoL-BD)
*Incomplete data sets have been excluded from total score (5 people did not complete post measures for BRQ, 5 people did not compete any measures).
Graph 3 Pre Post Score for The Bipolar Recovery Questionnaire
*Incomplete data sets have been excluded from total score (5 people did not complete post measures for QoL-BD, 5 people did not compete any measures).
Table 1 Post Treatment Patient Exerience Questionnaire
At all times Most of the time Sometimes Rarely Never
Did your therapist listen to you and treat your concerns seriously?
95%
(21 out of 22)
5%
(1 out of 22) – – –
Do you feel that the therapy has helped you to better understand and address your difficulties?
82%
(18 out of 22)
18%
(4 out of 22) – – –
Did you feel involved in making choices about your treatment and care?
90%
(20 out of 22)
10%
(2 out of 22) – – –
Were you satisfied with the time you waited for your first and subsequent appointments?
95%
(21 out of 22)
5%
(1 out of 22) – – –
On reflection, did you get the help that mattered to you?
82%
(18 out of 22)
18%
(4 out of 22) – – –
Did you have confidence in your therapist and his/her skills and techniques?
95%
(18 out of 22)
5%
(1 out of 22) – – –
Discussion
The results of study show that all of the outcome measures are in the desired direction. Graph 1 shows that the average pre post scores on the Gad 7, PHQ9 and WSAS have all reduced by more than 45% (10.1 – 5.1, 13.2 – 7.1 and 20.2 – 11.9 respectively) .
With the exception of one service user’s score on the GAD 7 that remained the same, all other service users post treatment scores on both the GAD 7 and PHQ 9 decreased. The post treatment scores on the WSAS shows a similar picture, although three people did show an increase in scores following treatment.
Scores according to the Gad 7 therefore indicate that the average scores before treatment fell into the range of moderately severe anxiety however this fell into the mild/moderate range post treatment.
The PHQ 9 scores show that the average scores fell into the moderate depression range before treatment falling into the mild depression range following treatment.
The WSAS scores between 10 and 20 are associated with significant functional impairment but less severe clinical symptomatology. Scores below 10 appear to be associated with subclinical populations. As can be seen from above the average scores for participants have reduced from 20.2 before treatment to 11.9 after treatment.
As noted above the Bipolar Recovery Questionnaire (BRQ) and the Brief Quality of Life Scale (QOL-BD) overall results on both measures are also in the desired direction. Participants have therefore indicated that treatment has been effective in aiding their recovery process at the same time as improving aspects of their quality of life. Closer examination of the data shows that this finding was not universal with four people on the BRQ and six people on the QoL-BD scoring slight decreases on the measures following treatment (see Appendix 1).
Feedback from the Patient Experience Questionnaire (PEQ) has been particularly pleasing. The overwhelming feedback from people is that most people all of the time: have felt listened to and treated seriously; have gained a better understanding of their difficulties and how to address them; have felt involved in choices in their care, have got the help they needed in a timely manner and have had confidence in the skills of the therapists. In addition to the responses from the PEQ there is further compelling testimonial evidence and compliments describing how people have been helped by the Mood on Track programme (see Appendix 2).
Overall, the Patient Reported Outcome Measures and Patient Reported Experience Measure provide some strong evidence to support the efficacy of the Mood on Track programme. This was a small pilot study with a limited sample size the findings should therefore be regarded with some caution. However, since the original pilot study a further six therapists have been trained and MOT groups are now currently being run in a further four CMHT’s totalling nine all together. Within six months it is fully expected that all CMHT’s will have access to these groups. Further evaluation of this programme will be conducted by Lancaster University, Department of Clinical Psychology. Following this it is our intention to share our experiences with the Birmingham group and hopefully arrange a meeting to review our learning and the programme.
Sharing
One of the aims of our service was to increase knowledge on how to manage these conditions and we have set out how to we can train front line CMHT and improve their knowledge. Initially, the groups are run by Band 7, 8a and Bb therapists with each group always having two facilitators. Given that the Team consists of 14 therapists there is a limit to how many groups with our ‘buddy’ system that can be run. However we plan to recruit members of staff from CMHT’s to co-facilitate a group with a therapist. The aim is to increase skills and knowledge and capacity too. We predict that we will be able to offer these opportunities twice per year in each of the CMHT bases. Similarly, we have also been approached and are actively considering the applicability of the programme to our Early Intervention Service, Forensic Service and Older Adult population.
We also share by promoting our work at venues such as: the LCFT Psychological Conference 2016, Quality Improvement Conference 12th May (2017) and through the Mental Health Awards (2107)
Is there any other information you would like to add?
Hi – the graphs did not paste in so I have included some discussion in the outcomes data. I hope I haven’t bombarded you 🙂
