Tools to help people with bipolar disorder

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First published in Bipolar Life's June 2020 newsletter

In this article, we’ll look at how tracking symptoms can help, then we’ll consider the range of different tools available including apps for people with bipolar disorder.

Trackers

Many people already track their mood, sleep and energy as part of a treatment and maintenance plan. This is a good example of a way in which we can increase awareness of our moods, including early changes that might herald a mood episode, and monitor effectiveness of medications or other therapies [1]. Examples of printable trackers which you can of course customise can be found here and here. Making notes as you go along can help identify stressors and triggers too.

As a regular circadian rhythm with sufficient sleep is important in bipolar disorder, a decrease or increase in sleep could be a sign of impending mania or depression; or the other way round might be the case, that is, mania may cause decreased need for sleep or depression cause increased need. In either case, early intervention would probably be beneficial than if things were left to spiral out of control.

Perhaps you want to see the effect of walking 15 minutes a day on your mood and energy. Or you wonder if cutting out caffeine will improve your sleep. It may be that you are depressed and you’ve set a basic goal of showering three times a week because anything more feels overwhelming [2]. Recording via a paper or electronic tracker allows you to experiment with positive behavioural changes as you can measure when and how much of an effect a change makes. You can read more on how to use behavioural activation and goal-setting to beat low mood or negative thinking here and here.

It is important to note that some people with bipolar disorder may become over-energised by goal progress and rewards, which may lead to a manic episode [3].  Therefore, it is important to ensure that we avoid setting goals that will require excessive activity that could in turn affect sleep or circadian rhythms [2].

If you’re feeling overactivated, you might use a tracker to add in regular calming activities such as relaxation and meditation, as well as avoiding too much goal seeking [2]. Here’s an online module on using behaviour to prevent mania.

There are also more sophisticated trackers available, such as the Quality of Life (QoL) tool [4] produced by the Collaborative RESearch Team (CREST.BD). The QoL tool is a free online resource where you can intermittently fill in a simple questionnaire, rating satisfaction levels for energy, mood, sleep, work, money, relationships and other life domains. The tool then displays the data as a graph and table, helping you to see progress, which helps to validate your efforts and motivate ongoing efforts [5].

Regular tracking may lead you to a routine that includes a healthy lifestyle (diet, exercise, relaxation, regular sleep pattern, avoiding alcohol and drugs, minimising stress and maintaining consistent sunlight exposure throughout the year) which should help keep your symptoms and mood symptoms to a minimum [6].
 
Tips:

• Don’t forget that trackers are also a helpful way of showing your doctor or psychologist how you’ve been doing since your last visit.
• You could also ask a trusted partner or friend how they think you’re going.

"If you educate your family and friends and involve them in treatment when possible, they can help you spot symptoms, track behaviours and gain perspective."

- International Bipolar Foundation [6]

Apps

Many people with bipolar disorder turn to mobile apps and web programs (mHealth) to find information about the condition, to track symptoms, to record behavioural changes. Apps can appear attractive as they are easy to download, convenient, and are often low-cost or free.

A review by the Australian Communications and Media Authority [7] confirms how prevalent mobile devices are in society. It was found that 89% of Australian adults accessed the internet in the six months to May 2018—74% going online three or more times a day. 90% of Australian adults were using more than one device to go online at May 2018.

Researchers from the Black Dog Institute and Sydney’s School of Psychiatry decided to explore the apps aimed at bipolar disorder in both Google Play and iOS stores in Australia [8]. In particular, they evaluated the apps for features, quality and privacy.

Out of the 571 apps identified, they reviewed 82 apps. Here are some of their conclusions [8]:
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• Apps that provided information only covered one-third of psychoeducation needed and only 15% followed best practice guidelines. No information apps suggested action plans
• None of the 35 monitoring apps had a duty-of-care alert, which was tested by entering three consecutive days of severely depressed mood and suicidal ideation. Seven of 13 monitoring apps failed to remind the user to track mood as directed.
• Some symptom monitoring apps did not monitor medication (57%), sleep (51%) and most self-assessment apps did not use validated (recognised, scientific) screening measures (60%).
• User reviews did not always correlate with an app’s quality or effectiveness.
• Less than a quarter of apps provided a privacy policy.

 
This is not to say that all apps are no good, but from the research above it shows that it is a good idea to be cautious when choosing and using an app. 

Update 27/5/20: The CREST.BD team is working on their Bipolar Bridges project to build an app for people with bipolar disorder. The final product aims to "empower[s] users to combine and learn from different forms of digital self-management and QoL (quality of life) data (for instance, sleep quality, mood management, activity levels, and social connectivity." You can go to their survey here to help them build a picture of how you use apps for your health and wellbeing.

References

1. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.

2. Reiser, R.P., Thompson, L.W., Johnson, S.L., Suppes, T., 2017. Bipolar disorder, 2nd edition. ed, Advances in psychotherapy--evidence-based practice. Hogrefe, Boston, MA.

3. Johnson, S., 2012. The Behavioral Activation System and mania. Annual Review of Clinical Psychology. Annu. Rev. Clin. Psychol. 8, 243–267.

4.. CREST.BD. 2015. Quality of Life Tool. [ONLINE] Available at: https://www.bdqol.com/. [Accessed 15 May 2020].

5. Morton, E, 2019. Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration. Journal of Medical Internet Research, [Online]. 6(12), e16121. Available at: https://mental.jmir.org/2019/12/e16121 [Accessed 15 May 2020].

6. International Bipolar Foundation. n.d. Treatment. [ONLINE] Available at:  https://ibpf.org/learn/education/treatment/. [Accessed 15 May 2020].
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7. Australian Communications and Media Authority Communications Report 2017-2018. 2019. AAA, [Online]. Available at: https://www.acma.gov.au/sites/default/files/2019-08/Communications%20report%202017-18.pdf [Accessed 15 May 2020].

8. Nicholas, J., 2015. Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality. Journal of Medical Internet Research, [Online]. 17(8), e198. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642376/ [Accessed 17 May 2020].

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