The new millennia has been characterised by developments in the digital world, creating a new space for social work practice globally. The aim of this research is to explore the online medium as an alternative resource for social work with online groups through an observation and interviews in an online group for Bipolar Disorderin Sweden. The results found that lived experience proved central to all forms of participation and support was seen as a resource to be shared. The implications for social work practice were found on multiple levels with broad areas of influence, such as utilising the online medium as an alternative source of insight, thereby allowing needs assessment, both onindividual and [sub]group level. Accessibility by way of the internet was seen as a catalyser to participation as well as a comprehensive method in creating such communities both locally and internationally through the development of digital social work.

Pediatric bipolar disorder (PBD) is a growing public health problem in the United States, especially among adolescent children. Despite awareness of the diagnosis and the effects that it has on the child, little attention has been given to the effects that PBD has on the guardian. The purpose of this qualitative phenomenological study was to explore the factors influencing guardians' experiences related to PBD. Penchansky and Thomas' Theory of Access and Family Systems Theory were used in this study to explore guardians lived experiences of PBD, its effects on the entire family system, and mental health service treatment. This approach was composed through interviewing 6 guardians caring for adolescents diagnosed with PBD. Interviews were conducted, transcribed and coded using NVivo12 software. The findings revealed the emergent themes as follows: disbelief of initial diagnosis, coping mechanisms, advice, barriers, burdens, stressors, and challenges. The themes described the experiences of guardians that led to feelings of denial, frustration, embarrassment, and resentment. Damaged relationships, medical problems, and financial hardships are only some of the challenges that guardians expressed during the interview. The issues that the guardians experienced provide evidence to fill the gap in the literature regarding effects on guardians. Further research into mental health services and guardians' perceptions on PBD is needed. This study promotes social change by informing mental health providers of the feelings and stressors of the guardians of PBD patients, which may lead to improved care for the family unit.

For over a century, there have been suggestions of a link between what is currently called bipolar disorder and cardiovascular mortality. In the contemporary epidemiological literature, this risk has been confirmed and approximates twice that expected based on age and gender. To date, however, this information has come primarily from clinical samples, which carry considerable risk of selection bias. The studies contained in this dissertation sought to assess this relationship using methods less vulnerable to selection bias and to determine the role that course of illness and treatments for illness may play in the development of vascular disease. In a nationally representative sample, we confirmed a link between mood disorders and vascular disease, which was particularly pronounced in women with bipolar disorder. In subsequent studies, a dose-response relationship between the duration of clinically significant hypomanic or manic symptoms and both cardiovascular mortality and endothelial function was seen. While medication exposure did not appear related to mortality or endothelial function, first generation antipsychotics were associated with arterial stiffness, an effect apparently mediated by elevations in blood pressure. In cross-sectional samples, our data suggests that vasculopathy is not present early in the course of bipolar disorder although is much greater than expected later in the course of illness. This dissertation purports that vasculopathy develops over the long-term course of bipolar disorder, is proportional to symptom burden, and is influenced by health behaviors and treatments. These findings may provide opportunities for clinicians and those afflicted to intervene to address this excess risk of vascular morbidity and mortality.

This thesis explores the lived experience of those with Bipolar Disorder type I or type II condition. The aim is to delineate how individuals cope following the diagnosis of this chronic, recurrent mental illness. Twenty participants were interviewed in depth, producing 18 hours of recordings and 480 pages of transcript. Narrative data were thematically analysed to reveal themes common to the process of adaptation. The exploratory framework identified key elements of the lived experience of bipolar disorder, including: the phenomenology of highs and lows, the role of anxiety in triggering episodes, reactions to diagnosis, and issues with prescribed medications. Analyses highlighted how difficult it is for individuals to reconcile themselves to the symptoms and consequences of the illness, and also illustrated the extent of subjective distress and reduced quality of life incurred. The psychosocial burden, particularly the difficulties developing a sense of authenticity and coherent identity, and having to adjust life goals, were examined in detail. Negative coping behaviours, specifically the use of alcohol and drugs, as well as the influence of shame and guilt on peoples??? coping repertoires were also explored. Finally, the importance of psychosocial interventions, collaborative health care strategies and necessity for long-term, follow-up care were emphasised.

Despite an abundance of older and more recent retrospective and considerably fewer prospective-longitudinal studies in bipolar disorders I and II, there are still remarkable deficits with regard to our knowledge about the natural course and burden. The considerable general and diagnosis-specific challenges posed by the nature of bipolar disorders are specified, highlighting in particular problems in diagnostic and symptom assessment, shifts in diagnostic conventions and the broadening of the diagnostic concept by including bipolar spectrum disorders. As a consequence it still remains difficult to agree on several core features of bipolar disorders, such as when they begin, how many remit spontaneously and how many take a chronic course. On the basis of clinical and epidemiological findings this paper summarizes (i) a significant need to extend the study of the natural course of bipolar disorder in clinical samples beyond the snapshot of acute episodes to the study of the mid-term and long-term symptom course, associated comorbidities and the associated burden of the disease. (ii) In terms of epidemiological studies, that are also of key importance for resolving the critical issues of threshold definitions in the context of the bipolar spectrum concept, there is a clear need for identifying the most relevant risk factors for the first onset and those for the further illness progression in early stages. Since there are some indications that these critical processes might start as early as adolescence, such studies might concentrate on young cohorts and clearly before these prospective patients come to clinical attention. (iii) The value of both types of studies might be enhanced, if beyond the use of standardized diagnostic interview, special attempts are made to use prospective life- and episode-charting methods for bipolar illnesses.

På senare år har antalet slutenvårdsplatser i Sverige minskat. Detta har lett till att patienter med psykisk ohälsa själva behöver bli experter på sin sjukdom. I flera delar av landet erbjuds därför psykopedagogiska interventioner som komplement till farmakologisk behandling vid behandling av bipolär sjukdom. Interventionerna har olika struktur och innehåll, men alla syftar till att stärka patienten och ge denne verktyg för att kunna hantera sin sjukdom. Syftet med denna studie var att belysa deltagarnas erfarenheter av att ha deltagit i den psykopedagogiska interventionen som Psykiatri Södra i Stockholm erbjuder, vilka nya kunskaper de har fått och vad de har tyckt varit givande/ mindre givande. Studiens design var kvalitativ och genomfördes med hjälp av personliga intervjuer. Vi tillfrågade 25 personer vilka samtliga har deltagit i psykopedagogiska interventioner. Av dessa tackade sju ja till intervjuerna. Innehållsanalys användes som metod vid bearbetandet av intervjuerna. Resultatet visar att deltagarna hade blivit stärkta i sig själva, att de hade lärt sig att separera sig själva från sjukdomen och att de hade fått större förståelse för vad de kan göra för att förhindra uppkomsten av nya skov. Framför allt visar dock resultatet att deltagarna hade blivit en del av en grupp, det vill säga fått en känsla av sammanhang, vilket de flesta dittills hade saknat i livet. Psykiatrin har en viktig roll i att aktivt bjuda in patienter och anhöriga till psykopedagogiska interventioner. Trots att forskningen påvisar att det bara finns fördelar med psykopedagogiska interventioner, finns det alldeles för få utbildningsplatser för att täcka patienternas behov. En del av specialistsjuksköterskans roll blir att se till att psykopedagogik implementeras i den psykiatriska vården. / During the last years institutional care in Sweden has decreased, which has led to the fact that patients need to become experts on their own disorder. In several parts of the country psycho educational interventions are offered as a complement to pharmacological treatment when treating people with bipolar disorder. The intervention programs have different structures and contents, but they all aim to strengthen the patient and provide him or her with tools to manage the disease. The aim of the study was to illuminate the participants’ experiences of taking part in a psycho educational intervention program offered by Psykiatri Södra in Stockholm, what sort of new knowledge they acquired, what was good/ less good. The design of the study was qualitativeand it was performed through personal interviews. Everyone who participated in the last intervention was asked to participate in the study. The sample was based on the above, and in the end seven people accepted taking part in an interview. A qualitative content analysis was used to process the interviews. The results showed that the participants felt empowered, they had learned to separate themselves from the disease, they had a bigger understanding for what they themselves could do to prevent new relapses, but most of all they had become a part of a group, and they finally felt a sense of coherence which they previously lacked in life.  Psychiatric caregivers have an important part in actively inviting people with bipolar disorder and their relatives to psycho educational intervention programs. Even though research shows that there only are benefits in psycho educational intervention programs, there aren’t enough programs to cover all in need.  A part of the specialist nurse’s roll therefore is to implement psycho educational intervention programs in psychiatric care.

Background: Research into the benefits of exercise for individuals with Bipolar Disorder (BD) is limited and no current guidelines exist around recommending exercise during a hypomanic/manic state. The Behavioural Activation System (BAS) dysregulation theory is a popular model that attempts to explain the link between approach motivation (AM) and the difficulties that individuals with BD experience. It may offer an explanation for the ‘upward spiral’ reported by individuals with a diagnosis of BD in response to certain types and intensities of exercise. This study looked to investigate the impact of different intensities of exercise on the maintenance of AM levels. The presence of hypomanic traits and how these interacted between AM and exercise was also of interest. Method: Participants filled out an online pre-screening questionnaire identifying hypomanic traits. 61 then completed a computer task designed to induce higher levels of AM before taking part in one of three 15 minute activities (sedentary, moderate exercise or vigorous exercise). Various measures linked to hypomanic symptoms were taken during testing. Results The main findings indicated that vigorous exercise significantly increased individuals AM levels in comparison to moderate or no exercise. This relationship was not however found to be moderated by the presence of hypomanic traits. Conclusions: Vigorous exercise seems to have a greater impact on AM levels regardless of an individual’s levels of hypomanic traits. This has implications in terms of the type of exercise should engage in when experiencing hypomania. Any recommendations however within this study should be taken in light of the limitations identified. Further research replicating these results with a larger sample or using a BD population are recommended.

The objective of this dissertation is to evaluate whether two different types of policy interventions in the United States are associated with health service utilization and economic outcomes. Paper 1: The number of government lawsuits accusing pharmaceutical companies of off-label marketing has risen in recent years. We use Medicare and Medicaid claims data to evaluate how an off-label marketing lawsuit and its accompanying media coverage affected utilization and spending on gabapentin as well as other anticonvulsant medications. In this interrupted time series analysis of dual eligible patients with bipolar disorder, we found that the lawsuit and accompanying media coverage corresponded with a decrease in market share of gabapentin, a substitution of newer and expensive anticonvulsants, and a substantial increase in overall spending on anticonvulsants. Paper 2: Medicare Part D was a major expansion of Medicare benefits to cover pharmaceuticals. There were initial concerns about how the dually eligible population who previously had drug coverage through Medicaid would fare after transitioning to Part D plans. Using a nationally representative longitudinal panel survey of Medicare Beneficiaries that are dually eligible for Medicaid, we investigated whether differences in generosity of Medicaid drug benefits were associated with differential changes in drug utilization and out-of-pocket spending for duals after they transitioned to Part D. Our finding suggest that those who previously encountered a monthly drug cap prior to Part D implementation experienced a differentially higher increase in annual prescription drug fills compared with those who did not face a cap.

This thesis explores the subject positions available to users of genetic tests for bipolar disorder in the United States. In advanced liberal societies, tests for genetic susceptibility to complex disorders may be promoted and used as means of performing responsible citizenship through the consumption of health care services. In the context of mental illness, however, key assumptions about the characteristics of consumers may not be met. The research found that because the category of “potential test user” substantially overlaps with the category of “mental health care user,” both the rationality and autonomy of these individuals is subject to question. Test users are framed in relational terms: as family members, as patients, and as consumers – but the last of these relational frames is considered problematic. Therefore, while the tests are framed as tools for proactive health management, responsibilities surrounding their use are largely allocated to family members and doctors.

This study was aimed at evaluating effects of psycho education on medication compliance and symptom management for clients with bipolar affective disorder attending community psychiatric clinics in the Ethekwini Health District of KwaZulu-Natal Province. A quantitative study was done using a quasi-experimental design. A one group pre-test and post-test design was used to assess the effects of psycho education. The population of the study were all clients with bipolar affective disorder attending Escoval House community psychiatric clinic and its satellite clinic (Austerville). Systematic sampling was used to select clients to participate in the study and a total of forty clients were selected. Two self-administered questionnaires were used to collect data. Clients were assessed in areas of their knowledge, medication compliance and symptom management (Pre-test). The group was then exposed to six sessions of psycho education, and they were assessed again a week after the psycho education (post-test) using the same instruments. The data was analyzed using the Statistical Package for Social Sciences (SPSS). Descriptive statistics were used to analyse participants' characteristics and some selected variables. Cross tabulations, chi-squares and paired t-tests were used on dependent variables and on social variables of interest to compare the changes in scores and means respectively and lastly to determine the relationship of social variables and the dependent variables. The findings of this study revealed that psycho education improved respondents' knowledge about their illness and symptom management techniques (with P-values ranging from 0.0001- 0.03), psycho education also improved medication compliance with P-value =0.000, but it did not affect the respondents' ability to use new techniques in managing their symptoms (with P-values ranging from 0.125- 0.75). / Thesis (M.A.)-University of KwaZulu-Natal, 2005.