Bipolar disorder (BPD) is associated with negative health outcomes and high relapse rates and group psychoeducation (PE) is recognised as an effective intervention when used in conjunction with pharmacological treatment. Unhealthy beliefs and attitudes have not been measured or related to outcomes in group PE and the mechanism for how PE exerts its effect are unidentified. Aims: (a). An adapted group psychoeducation intervention will change (improve) unhealthy personal beliefs about illness and attitudes towards medication when compared to a treatment as usual group. (b). Changes in unhealthy personal beliefs and attitudes will be maintained overtime (a 12 month follow up period). (c). People who subsequently relapse compared to those who do not relapse, will have less improvement in their unhealthy personal beliefs about illness and attitudes towards medication from PE. (d). An evaluation of the efficacy of psychoeducation in a systematic review for bipolar disorder in preventing relapse and other outcomes will identify factors that relate to clinical outcomes. Methods: A 10 session PE intervention was adapted and 38 participants with bipolar disorder I or II (using DSM-IV criteria) were recruited from a Specialist Affective Disorders Service. A waiting list assessment time was used as a parallel group control and a longitudinal study took place over a 12 month follow up period in all participants once they had received the intervention. A mirror image study reviewed case notes to identify relapse 12 month pre versus post intervention. Assessments measuring, beliefs and attitudes, mood symptoms and satisfaction where carried out, 8 weeks prior to intervention (waiting list), pre intervention, and 6 and 12 months post intervention. Results Summary: The waiting list control comparison showed significant improvement in attitudes measured by the Personal Beliefs about Illness Questionnaire (PBIQ) and Drug attitude Inventory (DAI) and symptoms and functioning. Beliefs on all domains of the PBIQ improved significantly (p<0.001) as did attitudes toward medication (p<0.001) there were also small but significant improvements in mood symptoms. In all participants (n=38) improvements were maintained over the 12 month follow up period. Nine people relapsed in the 12 months after the intervention compared with 22 before (p<0.002) and relapsers improved significantly less than non-relapsers following PE on the PBIQ (p=0.012) and the DAI (p=0.046). Conclusions: A group PE intervention reduced unhealthy personal beliefs and attitudes, both manic and depressive relapse and improved functioning. Improvements are maintained over time except adherence which remained unchanged. The amount of improvement in the PBIQ and DAI is related to relapse with non relapsers improving more than relapsers. The systematic review provides reasonable evidence that psychoeducation is at least modestly effective in preventing relapse in bipolar disorder, with the strongest evidence for reducing overall and manic relapse.

This thesis explores the experience of parenting with severe mental illness, using qualitative methodologies. It is presented in three parts: a literature review, a report of the empirical research, and a critical reflection of the process undertaken. The literature review provides both a systematic review of qualitative studies exploring the experience of parenting with a severe mental illness (SMI), and a meta-synthesis of the findings from the included studies. The findings demonstrated six overarching themes that were central to the parents' experience. The themes were interlinked and often conflictual in nature and a model of the relationship between the themes is provided. The synthesis revealed how the additional and conflicting pressures faced by parents with SMI can interact with their symptoms to affect parenting behaviours and decisions about engagement with services. The model of themes elicited by the synthesis provides a broad conceptual framework in which parenting with SMI can be considered across the age range of children, parental symptoms and parenting roles. The empirical research provides a specific focus on the views and experiences of parents with Bipolar Disorder (BD). Interpretative Phenomenological Analysis was used to explore the lived experience of parenting with BD, to provide insight into the parents' perspective and the influence that this may have on outcomes for parents as well as their children. The analysis resulted in six overarching themes, each of which consisted of a number of sub-themes. There were important interactions between the themes and these are illustrated for the reader. It was found that the parents identified a number of challenges in being a parent with BD and experienced feelings of inadequacy, guilt and worry relating to the impact that their illness had on their children and family. Strategies for managing these feelings and limiting the impact of BD could have an inadvertent negative effect on their own well-being, and that of their child. Learning to accept their diagnosis and developing strategies for managing their symptoms were crucial for positive parenting, although the changing needs of their children often presented new challenges. Contextual factors, including the stigma associated with mental illness, could also either mediate or exacerbate the challenge of parenting with BD. The clinical implications of these findings are discussed. The critical reflection provides a consideration of qualitative methodologies and a personal reflection on the qualitative process in relation to the empirical research. It details the critical debates around qualitative methodology, the application of qualitative methodologies, and the challenges this presented for the researcher. The report was written on completion of the investigation and reflects the process by which, as a novice, the author was able to develop an understanding of qualitative methodology and carry out an insightful piece of research.

Bipolar disorder is characterised by intense fluctuations in mood, including the experience of severe episodes of depression, mania and hypomania. The experience of bipolar disorder can also be associated with biases in various cognitive processes, including rumination in response to positive and negative mood states and tendencies to make dysfunctional self-appraisals. Preliminary research has also suggested that bipolar disorder may be associated with deficits in the recall of specifically detailed autobiographical memories. The lack of specificity in the recall of autobiographical memories, known as the 'overgeneral' recall bias, refers to tendencies to generate generalised memory representations as the memory recall process is terminated prior to the activation of specifically detailed memories. This overgeneral recall of autobiographical memories can also contribute to ruminative thought patterns, impair the generation of effective solutions to problems, and is associated with poor illness outcomes. The overgeneral bias has been extensively researched within major depressive disorder and suicidality, but has been comparatively under-researched in bipolar disorder and in vulnerable individuals. A series of eight studies were designed to: (i) investigate the cross-sectional associations across measures of positive and negative rumination and self-appraisal with the vulnerability to hypomania, and investigate the associations of these cognitive styles with prospective mood symptoms in an at-risk sample; (ii) investigate the cognitive vulnerability to hypomania in relation to rumination, problem-solving and autobiographical memory specificity; (iii) conduct a preliminary investigation into the associations between goal-related memory processes and extreme goal-pursuit in relation to hypomania vulnerability; (iv) investigate whether the vulnerability to hypomania and future bipolar disorders is associated with similar patterns of overgeneral memory recall on a standardised cue memory task; and (v) investigate the patterns of autobiographical memory specificity within a remitted bipolar sample. The heightened vulnerability to future bipolar disorders was associated with tendencies to engage in both positive and negative forms of ruminative thought processes, and with poorer psychosocial problem-solving, however, this relationship with problem-solving was not independent of current mood symptoms. The results of two studies indicated that the heightened vulnerability to hypomania was associated with an overgeneral memory bias across two different assessments of memory specificity, in direct contrast to previous research. Individuals diagnosed with bipolar disorder also reported more extreme overgenerality during memory recall than a sample of age and gender-matched healthy controls, but were able to recall some specifically detailed negative memories in short response latencies compared to non-bipolar control participants. The research presented within this thesis supports the notion of a continuum of increasing overgenerality in the bipolar disorder spectrum, inclusive of at-risk individuals to people formally diagnosed with bipolar disorder. Although bipolar disorder appears to be associated with a trait-based overgeneral memory bias, bipolar individuals appear to have ready access to some specific negative memories even during remission from symptoms. The clinical implications of this research, methodological considerations in the assessment of memory specificity, and directions for further investigations into the nature of autobiographical memory recall in bipolar spectrum disorders are discussed.

This thesis investigated the experiences of children who have a parent with a mental illness, using qualitative methods. It is divided into three separate sections, the first two written as standalone journal papers. Paper 1 is a systematic review and synthesis of qualitative studies exploring children's experiences of having a parent with a mental illness. The review used specific databases, a search of qualitative journals and a general internet search to identify relevant studies, and the subsequent application of inclusion/exclusion criteria and a quality appraisal assessment. 14 studies meeting inclusion and quality criteria were identified exploring the experiences of 163 children and young people aged between 5 and 22 years, from a range of countries, with a variety of parental mental health diagnoses. The review then involved synthesising the findings of these studies to generate five overarching themes which were found to influence children's experiences. Children who had some knowledge and understanding of their parent's mental illness were more likely to use effective coping strategies, have a more positive relationship with their parent, and experience fewer negative effects on them as a child. Paper 2 is an original research study which explored the experiences of children who have a parent with bipolar disorder, to see how this might impact on the child's emotional wellbeing. This qualitative study used 'In My Shoes', a computer assisted interview tool, to explore the experiences of ten children from England aged between 4 and 10 years. Subsequent comparison with their parent's accounts enabled greater insight into family life. Child and parent interview data was analysed using thematic and content analyses. The four main themes that emerged from the child interviews were: knowledge and awareness of bipolar disorder; perception of parents; managing family life with a 'bipolar' parent; and living in a family with bipolar disorder. The study concluded that further research was needed to understand children's perspectives, which should be taken into account when developing appropriate services and interventions to support children and parents with mental illness, including bipolar disorder. Finally the third section of the thesis was a critical appraisal of the literature review, research study and research process as a whole, including methodological reflections, implications for future research and clinical practice, and the researcher's personal reflections in undertaking the research. The findings were deemed vitally important for the future of families in which a parent has bipolar disorder.

The purpose of the current study was to examine neuropsychological functioning in patients with bipolar disorder (BD) with psychotic features. Data from a large, epidemiological study of patients with first-episode psychosis was used to examine verbal learning and working memory 10 years after onset of psychosis in patients with BD relative to patients with schizophrenia (SZ) and patients with psychotic major depressive disorder (MDD). Cross-sectional comparisons of verbal learning and working memory at the 10-year follow-up mirrored findings of relative performance at the 2-year follow-up (Mojtabai, 2000), as patients with SZ performed significantly worse than patients with psychotic affective disorders. When FEP patients' cognitive performance was examined longitudinally, all groups showed non-significant decline over time, with no significant diagnostic group differences after accounting for current symptoms. More frequent hospitalizations and longer treatment with antipsychotics were associated with poorer performance on cognitive testing 10 years after illness onset, but these associations disappeared when controlling baseline cognitive performance. Within the BD sample, current positive and negative psychotic symptoms were associated with poorer performance on cognitive testing. After controlling for baseline cognitive performance, markers of clinical course were unrelated to cognitive performance, consistent with existing literature on longitudinal cognitive functioning in patients with BD. The current findings support a neurodevelopmental model of verbal learning and working memory deficits in patients with bipolar disorder.

There is generally a lack of studies examining prevalence and phenomenology of bipolar disorder in Africa. In literature, a unipolar manic course of illness in particular is reported to be rare. The purpose of this study was to investigate and describe the course of illness and clinical features in a cross-section of patients diagnosed with bipolar disorder attending public hospitals in Limpopo Province, South Africa and to determine the rate of a unipolar manic course in this sample of patients. This was a descriptive, cross-sectional study of patients presenting with a history of mania between October 2009 and April 2010, to three hospitals in Limpopo Province. A purposeful sample of 103 patients was recruited and interviewed using the Affective Disorders Evaluation. This study confirms that a unipolar manic course is indeed much more common than rates suggested in present day literature with57% of the study sample only ever experiencing manic episodes. The study also confirms the debilitating nature of bipolar disorder with more than two-thirds being unemployed in spite of a quarter of the study subjects having a tertiary education. The high rates of attempted suicide, history of violence and history of drug abuse all furthermore points to the devastating effects bipolar disorder has on individuals and their families. Treatment choice appeared to be a combination of a mood-stabilising agent in combination with an anti-psychotic. It was found that two-thirds of study subjects had consulted with faith- or traditional healers. Significant gender differences appeared in that females were more likely to suffer from comorbid anxiety disorders, have a history of sexual trauma, and be HIV positive whilst men were more likely to have a forensic- and substance-abuse history, experience hallucinations and receive clozapine. Patients presenting with a unipolar manic course of illness, as described in this thesis, may contribute to the search for an etiologically homogeneous sub-group which presents unique phenotype for genetic research and the search for genetic markers in mental illness. A unipolar manic course therefore needs to be considered as a specifier in diagnostic systems in order to heighten the awareness of such a course of illness in bipolar disorder, with a view to future research. / Thesis (MD)--University of Pretoria, 2012. / Psychiatry / unrestricted

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TOPIC. Advances in the psychopharmacologic treatment of bipolar affective disorders (BPAD). PURPOSE. To increase advanced practice nurses' ability to match prescribing practices with known etiological factors and the neurobiology of this complex set of disorders. SOURCES. Published literature. CONCLUSIONS. A wide array of pharmacological agents exist that can be useful to manage BPAD symptoms. APRNs play a critical role in helping patients and their families to use these drugs effectively.

Altered intracellular calcium homeostasis and oxidative stress are involved in the pathophysiology of bipolar disorder (BD)-I. To explore the genes contributing to these abnormalities, we examined the association with BD of the iPLA2β (PLA2G6), a signaling enzyme that mobilizes the arachidonic acid signaling cascade and activates oxidative stress, and assessed whether it interacts genetically with type 2 transient receptor potential channel gene (TRPM2), an oxidative stress-responsive calcium channel implicated both functionally and genetically in BD-I. Two tag single nucleotide polymorphisms rs4375 and rs3788533 in iPLA2β were genotyped in 446 White case-control individuals and 296 BD families using a 5′-nuclease TaqMan assay. The results were analyzed using χ-test and transmission disequilibrium tests, and Haploview. In a secondary analysis, we tested gene-gene interactions between TRPM2 and iPLA2β on BD vulnerability by logistic regression using a case-only design in PLINK. iPLA2β-rs3788533 showed a borderline association with BD-I in patients with a history of psychosis in both case-control and family designs. Association with BD as a whole was observed in the family study (significant over transmissions of rs3788533-allele C, P=0.015, PBonferroni=0.03, TDTPHASE). A borderline interaction was found between rs749909 within TRPM2 and rs4375 within iPLA2β (Puncorrected=0.009), on the basis of the case-only design analyzed with PLINK. A significant association of iPLA2β variants with BD-I and a trend gene-gene interaction between iPLA2β and TRPM2 provides additional support for the notion that genetic variation in these two functionally implicated candidates contributes toward the risk and pathophysiology of this illness.