Setting up and running an evidence based clinical e-practice: BipolarLab.com
Setting up and running an evidence based clinical e-practice in the field of mental health is an exhilarating challenge!
In other fields of medicine, this may not be the case, but in the mental health world, evidence based practice is a relatively new development.
"Evidence-based practice" means we conduct our clinical practice based on evidence that we've acquired from clinical research. Similar to drug research, your doctor will usually prescribe medications that've been tested thoroughly through many trials, and have been proven to benefit your health condition. Once upon a time, your therapy could've been based on Dr. Ego’s clinical expertise, big name or great insights, but thankfully these days such practices are slowly becoming a nightmare of the past (although, drug companies still invest on armies of Dr. Egos “aka opinion leaders” to influence your local doctor’s prescription practices).
However, evidence-based practice is a fairly recent development in the field of mental health, and especially in the field of psychotherapy. The rise of behavioral therapy in the 60s, partly as a reaction to the psychoanalytic status quo, and later its marriage with cognitive therapy, have given us a remarkable new tradition of true evidence-based psychotherapeutic practice.
The development of diagnostic manuals such as the DSM-IV, even though they are heavily criticised by many, have enabled us to quantify severe behavioral and emotional problems. We can now have large enough homogeneous groups of patients that allow us to try out different treatments, and be confident that the improvements we see are not due to chance, individual differences or simply a matter of time. Even when we focus on single patient cases, our diagnostic and measurement methods take this kind of work to a different level.
Clinical trial designs have become sophisticated enough to address almost all biases and errors that a single clinician is prone to make, with one patient or even a small group of patients, over his lifetime.
We now have the tools to quantify almost all clinical states. We can safely measure how depressed, manic, anxious a patient is, and so forth. Of course our tools are far from perfect, but they are improved study after study.
This quantification of human pain and distress, distasteful as it may sound to some, has enabled us to be able to evaluate properly all kinds of therapeutic interventions. Let's even assume that some genius comes up with the wonderful idea that clapping your hands three times a day and jumping up and down your bed twice a day will cure your bipolar disorder. We can now evaluate and test whether this is true or not.
Nevertheless, despite this tremendous progress in mental health, we find that true evidence-based practice is only delivered through a few specialist university clinics, and only through their research trials. The lucky few patients who can enroll in these studies usually experience significant clinical benefits.
I grew up professionally in such a place, at the Institute of Psychiatry at King's College London, the mecca of psychiatry. Day after day, trial after trial, that I worked my way up from a lowly research assistant to a PhD graduate, I couldn't help but wondering why we cannot offer this level of care and quality of clinical work to everybody. My grandiosity, of course, to be able to deliver this level of care to all bipolar patients was fueled by my personal experiences with my father, who suffered for many decades by a treatment resistant bipolar disorder. He also suffered and paid dearly with his health, and later life, the inefficiencies of the greek mental health system. Patients at the time were treated fairly poorly, were not educated about their disorder, and treatment was most of the times coercive.
Hence, when the time was right I founded BipolarLab.com: the first private evidence-based clinical e-practice for bipolar patients in the world.
Of course setting up a true evidence-based e-practice is easier said than done. It took nearly 2 years (7 years including my PhD work) to develop our clinical services that are all based on data driven research, and it will take many more years of clinical work and refinement to achieve all the benefits this endeavour can really deliver.
It also takes patients who can understand and truly appreciate what's on offer here. Time after time, my colleagues tell me we need to better communicate the novelty of BipolarLab. This is not just another private clinical practice, it’s not even another specialist clinical practice; it’s an evidence-based specialist clinical practice. It may not be the right kind of practice for everybody, but our ongoing evaluation of our services will demonstrate whether this approach is working or not.
It definitely feels great when well funded professors from Harvard approach you with similar ideas, and then you see them working hard to develop similar services, but I will feel much better when we manage to communicate the novelty and importance of this work to every single bipolar patient who visits our website. I will feel even better when we manage to deliver our services to enough patients to have our own effectiveness data.
So how do we do it?
Here is our secret recipe for everybody to copy:
1. We focus on a specific clinical population: Bipolar disorder.
In our case, we deliver our clinical services only to patients with Bipolar disorder and depression. It’s usually hard to separate the two given that most depressive disorders are often highly recurrent, and most bipolar disorders are dominated by depression. Hence, we will consider taking on any patient with a recurrent affective disorder.
2. We use cutting edge research instruments for the diagnosis and measurement of our patients.
We use research instruments like the SCID, HDRS, YMRS, NIMH-LCM and many others to accurately diagnose our patients and measure their status throughout all steps of our clinical care. Our patients also become fairly familiar with these research instruments, and learn to recognise how valuable they are in their ongoing clinical care.
3. We provide our services remotely across the world. We love e-health!
Being an e-practice helps us have a much wider pool of patients to carefully screen and decide whether they are suitable for our evidence-based services (we do have two local sites - one in London, UK and another one in Athens, Greece but we prefer the e-way). We also use many new technologies to help us deliver our services (we love google plus, actigraphy, pedometers, and electronic mood diaries - see MoodChart our recent addition to our e-arsenal - it’s open to the public). We bring our services right into your home, no matter where you live.
4. We use strict inclusion and exclusion criteria.
We provide our services only to bipolar patients who meet our specific inclusion criteria. We derive these criteria from the studies that each of our services has been based upon. It's painful to exclude patients, but it's even more painful to deliver services to patients we know aren't going to benefit from them. Our initial consultation meeting will give us both a fairly good idea about our suitability for each other.
5. We have developed and provide services that are truly evidence-based.
We work hard to follow the protocols and methods of the trials all our services have been based upon. For instance our CBT therapy programme is based on the bipolar trial of Professor Dominic Lam at the Institute of Psychiatry, and is suited to bipolar patients who are currently fairly well (euthymic) or mildly symptomatic, and wish to prevent further relapses. For bipolar patients who are currently depressed, we use the CBT protocol of the STEP-BD trial that gave great results with this group, and also a new briefer behavioral treatment that I've been developing for bipolar depression (BATMAN: Behavior Activation Therapy for MANic Depressive illness) over the last few years.
6. We ignore the bipolar fairy tales.
We have developed our services based on the latest knowledge that we have about bipolar disorder - not on bipolar fairy tales. We like the bipolar fairy tales, they make people feel good, but in the long run they are anything but helpful. For instance, since the relapse literature demonstrates that mild bipolar symptoms are the best predictor of relapse, we take special care in explaining this to our patients and provide treatment for them, not more fairy tales about how helpful these symptoms are for their lives. Ignoring the fairy tales often makes us unpopular, and it's bad for business (see the comments from my previous article) but we're not a commercial enterprise, and definitely don't run for the bipolar white house.
7. We collect data and evaluate the effectiveness of all our services.
We do this even more for pioneering clinical services, such as our Bipolar and Fit programme or our behavioral activation therapy for bipolar depression - both relatively new even in the clinical research world. Our symptom monitoring services have been designed to monitor the effectiveness of all our clinical interventions, and most importantly to give our patients a good indication of where they are with their therapy and current mood status.
8. We work as a clinical research group.
All our senior associates, psychologists and psychiatrists, have at least a research PhD that helps them appreciate and value this type of work, and gives them the necessary experience to deliver our evidence-based services properly. Mind you, we are a clinical e-practice of independent clinicians working together - not some major corporation, funded by pharma or guided by commercial interests. We have no association with any drug company!
9. We collaborate with local doctors and other local mental health professionals.
Many of our services have been designed to assist the work of local mental health professionals. For instance, our symptom monitoring programmes provide the most accurate and comprehensive measure of the daily, weekly, and monthly course of any recurrent affective disorder. This can help you and your psychiatrist to better evaluate the progress of your treatment, sometimes clarify your diagnosis, and have an ongoing bipolar thermometer in your life. Our CBT and Life Style Support programmes also work best along with medication treatments. All these are specialist services that can rarely be found locally, and psychiatrists who provide medication treatments don't have the time, resources or training to offer them. Our small but growing network of local mental health professionals are grateful for the added value our services provide to the treatment of their patients.
10. Last but not least, we love our work, our patients and our results.
We are as maniacally enthusiastic as any clinical research team starting a new project. The glowing results of many clinical trials are always helped by this kind of attitude. We do our best to keep this research spirit alive! In many ways, we're like the Apple of 1984, having a vision to put evidence-based services in every bipolar home.
We welcome you, whether you are a patient, relative or a mental health professional to join our cause!