Review articlePsychological interventions for caregivers of people with bipolar disorder: A systematic review and meta-analysis
Introduction
Caregivers of people with bipolar disorder can experience high levels of burden and significant psychological distress (Steele et al., 2010, van der Voort et al., 2007). The majority report at least a moderate level of burden, with around 90% reporting high subjective burden in relation to their relative's symptoms (Perlick et al., 1999, Perlick et al., 2007a). Caregiving is associated with increased risk of mental health problems, with up to 46% experiencing anxiety and depression (Steele et al., 2010). While clinical guidelines emphasise improving the experience of caregivers, there is a lack of clarity about the most effective ways to provide psychological support (NICE, 2014; National Collaborating Centre for Mental Health [NCCMH], 2014a).
Caregiver burden is a multidimensional concept, and there is considerable diversity in definition and operationalisation (Vella and Pai, 2012). Some definitions are based on a concept of global burden, defined as the emotional, social and financial stresses that caregiving imposes on the caregiver (Hoenig and Hamilton, 1967). Others distinguish between objective burden, which comprises the symptoms and behaviour of the patient and their consequences such as disruption of social, financial and occupational functioning; and subjective burden which refers to the psychological consequences of caregiving, such as distress and burnout (Cuijpers and Stam, 2000, Schene, 1990).
Caregiving in bipolar disorder has been conceptualised within a ‘stress-appraisal-coping’ model (Chakrabarti and Gill, 2002, van der Voort et al., 2007). The level of burden and psychological symptoms experienced by caregivers may be linked to the severity of the patient's symptoms and the caregiver's level of social support (Perlick et al., 1999, Perlick et al., 2007a, Perlick et al., 2007b). However, caregiver appraisals may moderate the relationship between patient symptom severity and caregiver burden or psychological symptoms (Perlick et al., 1999, Steele et al., 2010). This may in part be due to how appraisals influence coping style (Chakrabarti and Gill, 2002, Perlick et al., 2007b). Lack of illness awareness (defined as understanding that symptoms are attributable to a mental illness requiring treatment) is associated with more frequent use of maladaptive coping strategies such as avoidance, and less frequent use of adaptive strategies such as positive communication (Chakrabarti and Gill, 2002, Perlick et al., 2008). Appraisals of controllability are also linked to ‘expressed emotion’, defined as the expression of critical attitudes, hostility or emotional over-involvement (Leff and Vaughn, 1984, Wendel et al., 2000). This in turn is associated with negative patient outcomes such as increased relapse and symptom severity (Hooley, 2007, Kim and Miklowitz, 2004). However, research is predominantly cross-sectional, and the direction of causality between caregiver responses and illness severity is unclear (Hooley, 2007).
The ‘stress-appraisal-coping’ model implies the potential for interventions to reduce caregiver burden and psychological symptoms, through modification of appraisals and coping strategies and increasing social support. In accordance with this, NICE guidelines for bipolar disorder recommend psychological interventions to improve the experience of caregiving, including group psychoeducation and support groups (NICE, 2014). Support groups involve caregivers providing mutual support, and may be led by a peer or professional who facilitates interaction between group members. Psychoeducation may predominantly provide information about the nature, treatment and management of bipolar disorder, or can include more complex components such as increasing coping strategies, and teaching problem-solving and communication skills. The NICE guidelines do not explicitly recommend a particular type of psychological intervention, as the evidence that the recommendations are based on is described as being of low to moderate quality (NCCMH, 2014b). It is also important to note that the guidelines are based primarily on studies involving caregivers of people with psychosis and schizophrenia (NCCMH 2014a, NCCMH 2014b).
There is some variation in how psychoeducational interventions are categorised in the literature (Oud et al., 2016; Reinares et al., 2016). However, a broad distinction can be made between interventions involving caregivers alone, such as group psychoeducation, and interventions involving caregivers and patients. Interventions involving caregivers and the index patient can be further sub-divided into those delivered in a group format, such as multi-family group psychoeducation and those delivered to individual families or dyads, such as family-focused therapy (Miklowitz and Goldstein, 1997). This is a modification of the Falloon model of behavioural family therapy for schizophrenia (Falloon et al., 1984, Miklowitz and Goldstein, 1997). The primary aims are the reduction of expressed emotion and modification of associated appraisals, in order to reduce relapse (Miklowitz and Chung, 2016). However, there is a substantial overlap in the content of psychoeducational interventions, with many involving communication skills and problem-solving skills training, as well as basic psychoeducation (Reinares et al., 2016).
Despite the fact that psychological interventions often aim to improve caregiver outcomes through promoting coping strategies (Reinares et al., 2016), these are often not reported in reviews of the literature (e.g. Oud et al., 2016). To date there have been no reviews exclusively evaluating the impact of psychological interventions aiming to improve the experience of caregiving in bipolar disorder. In a wider review of family interventions for bipolar disorder, Reinares et al., (2016) reported that five trials of psychoeducation showed positive effects on caregiver knowledge, burden, and psychological symptoms, but did not meta-analyse study effects. A systematic review and meta-analysis of interventions for caregivers of those with severe mental illness found some evidence to support the efficacy of psychoeducation and support groups in improving the experience of caregiving (primarily operationalised within individual studies as burden) and reducing psychological symptoms (Yesufu-Udechuku et al., 2015). However, the review only evaluated interventions provided to caregivers alone, and was based predominantly on interventions for caregivers of people with psychosis. There were insufficient numbers of studies to meta-analyse findings for bipolar disorder.
The aim of the current review and meta-analysis is to critically evaluate and synthesise the impact of psychological interventions aiming to improve the experience of caregiving in bipolar disorder. The experience of caregiving is defined broadly as encompassing any carer-focused outcome, including burden, psychological symptoms or knowledge of bipolar disorder. This is the first review to focus exclusively on outcomes for caregivers of patients with bipolar disorder, and to use meta-analytic methods to synthesise study findings. Although there have been recent reviews in this area, new trials have been published since this time, which enable the use of meta-analytic methods. In contrast to the most recent meta-analysis of caregiving (Yesufu-Udechuku et al., 2015), interventions involving caregivers alone and caregivers with the index patient will be included in the meta-analysis, thus increasing completeness and transparency of findings. In line with the literature on caregiving in bipolar disorder, the primary outcome variable will be caregiver burden. However, other relevant carer-focused outcomes, including psychological symptoms and knowledge of bipolar disorder, will also be synthesised. No reviews to date have evaluated the impact of psychological interventions on caregiver knowledge. Given that improving knowledge of bipolar disorder is a primary aim of psychoeducational interventions, and there has been found to be a relationship between illness awareness and coping style (Chakrabarti and Gill, 2002), this seems a significant gap in the literature. A further aim of the review is to assess the quality of the studies included in order to highlight possible areas for further research.
In summary, the review will address whether psychological interventions for caregivers are effective in:
- 1.
reducing burden.
- 2.
Improving other caregiver-focused outcomes, including psychological symptoms and knowledge of bipolar disorder.
Section snippets
Inclusion criteria
Studies were selected based on the PICOS framework (Petticrew and Roberts, 2006):
- (1)
Population. Informal caregivers of adults with a diagnosis of bipolar disorder. Caregivers included relatives, spouses, partners, friends or neighbours. Caregivers could be living with the person with bipolar or not. Where the study included caregivers or index patients under the age of 18, over 75% of caregivers and patients had to be over the age of 18. Studies where the population had significant comorbidities,
Study selection
Fig. 1 shows the number of studies identified, examined and excluded at each stage. The combined electronic searches yielded 985 references; 318 duplicates were removed. A total of 667 references were screened and 653 excluded based on title and abstract. The most common reasons for exclusion were that bipolar disorder was not the main focus of the study, the study did not evaluate an intervention, or the study evaluated a drug treatment. Many studies were excluded based on multiple reasons.
Author's contributions
The first author (Ella Baruch) designed and wrote the review protocol, carried out the systematic search, screened the studies, evaluated them for risk of bias, analysed the data, and wrote the manuscript. The second author (Chris Barker) screened a sample of the studies for inclusion and co-rated studies for risk of bias. The second and third authors (Chris Barker and Nancy Pistrang) both contributed substantially to the design of the study, supervised the data collection and analysis, and
Funding
Funding: The research was conducted as part of Ella Baruch's doctorate in clinical psychology, completed at University College London. Financial support was provided by the university.
Conflicts of interest
None.
Acknowledgement
We thank Amanda Williams who provided consultation on carrying out the meta-analysis.
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