ReviewInternet-based psychological interventions for bipolar disorder: Review of the present and insights into the future
Introduction
Bipolar disorder is a disease affecting approximately 4% of the world population, with severe consequences in the functionality and quality of life of the patients due to frequent relapses, persistent sub-syndromal symptoms, along with cognitive impairment and high morbidity and mortality (Bonnín et al., 2014, Merikangas et al., 2011, Rosa et al., 2014).
With bipolar disorder having clearly a biological etiology, the pharmacological treatment has shown to be effective in mitigating some symptoms of the disorder and decreasing the number of relapses (Vieta et al., 2013). Similarly, adjunctive psychological interventions as an add-on to pharmacological treatment, have shown to further improve long-term outcomes (Reinares et al., 2014). Among them, those with rapidly growing evidence of efficacy and cost-efficiency are individual and group psychoeducation, family-focused interventions and functional remediation. The third generation therapies such as mindfulness-based approaches have been increasingly tested in this population, with inconclusive results so far (Reinares et al., 2014).
However, there are several limitations restricting a broad implementation of these psychological treatments, out of which the most important one is related to a tremendous gap between availability and demand (Mohr et al., 2010, Musiat et al., 2014). There is a consensus in the literature that the shortcomings of the traditional model of episodic care is suboptimal for improving chronic disease outcomes contributing to a high burden of chronic mental diseases (WHO Regional Committee for Europe, 2006, WHO, 2013). Until now, most of the above-mentioned interventions are offered exclusively through face-to-face individual or group meetings at few specialized clinics unevenly geographically distributed and for a limited period. Furthermore, adapting such interventions to individual characteristics in a cost-efficient way represents an imperative challenge to overcome in the oncoming years (Reinares et al., 2014). Therefore, there is an emerging interest to explore new approaches to deliver this kind of treatments tailored to individual needs and in a continuous way (e.g. all year long) from any location while maintaining their efficacy at a low cost (Castle et al., 2009).
The Internet has gradually showed a fast and worldwide global expansion in developed countries reaching almost all social, age, ethnic and educational level groups through user-friendly interfaces and at low costs (Smith et al., 2011, Smith et al., 2011). Additionally, the access to this resource has moved from desktop computers to nearly everywhere through low cost smartphones that most people increasingly use for multiple purposes, carrying with them regularly (International Telecommunication Union, 2014). This rapid adoption of both Internet and smartphones had an impact also on mental health patients, who seek information and help for their disorders using all the increasing available resources (Carras et al., 2014). These individuals, who usually suffer from social stigma, found in the Internet a tempting solution for communicating with their peers and obtaining information about their condition in a convenient and anonymous way (Townsend et al., 2012). Furthermore, modern technologies can unobtrusively sense and analyze human behavior, deliver feedback and provide psychotherapy (Emmelkamp, 2005). Thus, they are emphasized for their potential to shift some intervention tasks from clinical settings to daily life, which could mitigate the pressure that nowadays exists on healthcare systems.
There already exists a huge number of mental health-aimed applications (i.e. apps) developed with multiple aims. These are available for the different operating systems in online stores, and some of them are even free of charge. However, – and very worryingly – only few of them have conducted adequate clinical trials to scientifically validate their usage, effectiveness and safety (Buijink et al., 2013). There should be ways to distinguish evidence-based products from those that have no science behind.
The Internet also has boosted synchronous tele-mental health resources (i.e. videoconferencing, live-text support), which have proven to be not only feasible but also an effective face-to-face approach for a wide array of mental health disorders, and allow the access to mental healthcare services to people with limited mobility or living at remote locations. Yet, the experience with such a modality of delivering psychological interventions for bipolar disorder is limited and it still requires a trained professional for each session, which limits the main aims of new technologies such as reducing costs and associated healthcare resources (Hailey et al., 2008, Hilty et al., 2013, McGinty et al., 2006, Osenbach et al., 2013).
During the last few years, several projects and research studies of psychological interventions for bipolar disorder patients using self-management approaches have been published. However, due to the lack of standardized definitions, frameworks and guidelines to be followed during the development, description and implementation of these conceptual models, there is a significant inconsistency in presenting and reporting the results of the studies related to such interventions. Therefore, it is difficult for clinicians who are not familiar with the technological domains, to fully understand the present and future benefits and challenges of integrating these new technologies into the clinical practice.
Since linking behavioral sciences and current technologies is usually not straightforward for many clinicians, the main aim of this article is to provide a review of the published projects and studies using Internet-based technologies specifically aimed to deliver evidence-based psychological interventions for bipolar disorder patients. Accordingly, we will describe each intervention using a simple yet practical Behavioral Intervention Technologies (BIT) conceptual model proposed by Mohr et al. (2014) as well as the main results of the studies in which they were tested. We will further compare and discuss the advantages and limitations of these BITs as potential adjunctive treatments for bipolar disorder. Finally, taking into consideration this information, we will comment on the insights and future directions of this emerging but promising field.
Section snippets
Search process
We conducted a comprehensive systematic search of the literature employing the Boolean logic algorithm “BIPOLAR AND DISORDER AND (treatment OR intervention) AND (online OR Internet OR web-based OR smartphone OR mobile)” at MEDLINE, SCOPUS, EMBASE, ClinicalTrials.gov, ISI Web of Science and Google Scholar. We restricted our search parameters to the abstracts, protocols or articles published in English between January 1990 and December 2014. Additionally, we also searched for studies in the
Results
More than 250 potential entries matching the search criteria were identified. After a careful manual review conducted by two of the researchers (DH, MR), 29 publications pertaining to 12 different projects and studies Internet-based were selected (Fig. 1). As mentioned, all the selected studies specifically addressed bipolar disorder using a psychological intervention approach through diverse Internet-based methods. Several projects exploited also the advantages of the modern mobile phones in
Current interventions
Despite the potential that modern technologies can provide in terms of delivering strategies to manage disease in a remote manner, only few of such approaches focused on the treatment of mental diseases. Moreover, when it comes to mental disorders, the focus in research and in developing the pioneering intervention application has been mostly placed on the highly prevalent disorders such as depression, anxiety and panic disorder (Ebert et al., 2013, Kok et al., 2015), whereas less prevalent
Conclusions
The mentioned limitations, together with the diversity between studies and outcomes, suggest that there is still not available evidence to draw firm conclusions about the efficacy and effectiveness of interventions using Internet connected technologies in bipolar disorder. Nonetheless, considering the high rates of retention and adherence reported by the studies' authors, they seem a highly feasible and acceptable method of delivering interventions among potential users.
If the ultimate goal is
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