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Striving for the BEST

October 1, 2007
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A managed care company helps develop a group therapy program for consumers with bipolar disorder

Behavioral HealthCare, Inc. (BHI) is a Medicaid managed care company that serves consumers in three metropolitan Colorado counties. In 2001, BHI coordinated an interdisciplinary think tank of community mental health (CMH) clinicians, community members, and consumers with bipolar disorder to review evidence supporting the efficacy of treatment for bipolar disorder. The think tank's goals were: (1) to find out what works in the psychosocial treatment of bipolar disorder, and (2) to develop tools for BHI's providers so they could deliver best practices to members. By combining the therapists' clinical expertise, consumers' lived experience of bipolar disorder, and research from the literature, we created a workable evidence-based program.

Program Development

The think tank identified three major psychosocial treatment approaches from the literature: interpersonal and social rhythm therapy, family-focused therapy, and cognitive-behavioral therapy. Additionally, several studies of medication and diagnostic education showed efficacy in reducing relapse. All of these approaches share some common features, but none of the models has achieved enough evidence to be endorsed as the preferred psychosocial intervention by the American Psychological Association. None of the models alone adequately addresses the varying needs of all consumers, and none has been tested in the CMH setting. Research shows that it takes about ten years to translate evidence to everyday practice. The evidence we examined came from highly controlled studies in university-based research settings. For these practices to work in CMH centers, they must be easily implemented by mental health generalists and work for individuals with multiple diagnoses and with substance abuse issues.

The think tank determined that by combining the unique aspects of each of these approaches, more treatment options could be delivered to individuals in a group setting, where consumers could learn at different rates and feel comfortable using one skill/approach over another. After all, physical medicine has subspecialties that treat diabetes, cancer, and heart disease with their own drugs and/or self-management skills. So why then shouldn't CMH centers offer appropriate evidence-based treatment for a consumer's illness on his terms and to treat his specific needs?

The think tank realized that there would be barriers to overcome, such as concerns surrounding consumer recruitment, inclusion and exclusion criteria, clinician/group facilitator training, and data collection and analysis. These issues needed to be addressed so that services could be easily replicated in busy CMH centers that have minimal staff resources.

Some of the strategies used to address these barriers included securing the buy-in of the CMH centers' CEOs, creating a scripted manual to promote program fidelity, minimizing clinician training time, and decreasing the documentation burden by limiting it to consumer feedback forms. To keep costs down, the psychosocial therapy would be delivered in a group format. During the pilot study consumers' copays were waived, and BHI picked up the cost for printing the group therapy materials.

In May 2004, the Bipolar Education and Skills Training (BEST) program was launched. BEST consists of a 9-module, 34-session scripted program (table). Clinician/group facilitator training is relatively easy since BEST is a manualized treatment program, and training takes about six hours. In addition to the weekly group sessions, consumers are given a manual to take home for future reference. Twenty-two consumers originally were enrolled, and currently almost 200 consumers are in various stages of classes or have completed the program.

TABLE. BEST modules

Module Topics Covered
1. Becoming an Expert on Bipolar Disorder Important facts about bipolar disorder
2. Becoming an Expert on Your Medications Tools and guidelines for managing your medications
3. Taking Action with Early Intervention and Relapse Prevention For you, your family, and your friends: Triggers that can cause a return in symptoms—how to catch symptoms early and take constructive action before serious problems occur
4. Stabilizing Your Daily Rhythms How to evaluate your daily rhythms for staying on track for a smoother pattern of sleep and activity
5. Mastering Thinking Skills to Manage Your Mood How to identify, interrupt, and change thoughts that may contribute to mood problems
6. Developing Effective Communication and Problem-Solving Skills For you, your family, and your friends: Communication and effective problem-solving tools and techniques
7. Strengthening Interpersonal Relationships How to identify stressful aspects of your relationships: Skill building and tips
8. Dealing Effectively with Stress and Change For you and your family: How to identify sources of stress and develop skills and strategies for effectively dealing with stressors
9. Developing Peer and Community Support

Your personal meaning of recovery; types of support in a support network that aids the recovery process; how to evaluate your “constellation of support”