Several serious mental illnesses, including bipolar affective disorder (BPAD), surface during adolescence and early adulthood when the young person is grappling with a range of delicate developmental issues (Vos & Begg 2003, Mackrell & Lavender 2004). ‘[They] are the chronic diseases of the young, with their onset and maximum impact in late adolescence and early adult life’ (McGorry & Yung 2008, p148). The prevalence rate for children under the age of 19 with serious and persistent mental illness is estimated at over 2% (Gearing & Mian 2005) and ranks first among the causes of disability in the USA and elsewhere. Mental disorders are the leading contributors to burden of disease, accounting for 24% of the non-fatal burden of disease in Australia (Australian Institute of Health & Welfare (AIHW) 2008). Amongst the top 20 disorders contributing to Australia’s burden of disease are: anxiety, depression, suicide and self-inflicted injury, alcohol dependence, personality disorders and schizophrenia (AIHW 2008).
Bipolar affective disorder (BPAD) is a serious and recurring mental health problem which, over time, produces functional deficits. Its appearance and diagnosis in the young can critically affect the development of self identity, efficacy and management (Leboyer et al. 2005). Early onset BPAD is related to a number of co-morbid conditions, such as anxiety and panic disorders, substance abuse and increased suicidal behaviour (Leboyer et al. 2005). It is important, therefore, that BPAD is treated early and that interventions include enriched programmes that focus on recovery.
Contemporary management and treatment of BPAD encompasses both the biological and psychological domains. However, little work has been undertaken with interventions that address the social domain. Common management practices consist of psychopharmacology, cognitive behavioural therapy and individual psychotherapy (Kowatch & DeBello 2006). Efficacy of treatment is largely dependent on the individual’s response to medication with or without adjunctive psychotherapies and his/her adherence to the therapeutic regimen. Gearing and Mian (2005) note that treatment adherence is well recognised as a problem among those with mental health problems (in particular, adults) and argue that the relapsing nature of BPAD requires a focused approach to treatment adherence by health professionals. Adolescents typically, are negotiating a time in their lives where compliance to anything is problematic let alone medication and therapy sessions.
Whilst much of the research pertaining to BPAD is focused on adults, this case study – as part of a larger project offers an opportunity to explore the passage through the illness not just the outcomes of the intervention. It is clear that Crowe et al. (2009) have been developing a portfolio of research focusing on the development of self in adolescents with bipolar disorder and the management of young people with the disorder as well as arguing that outcomes are hindered by the lack of attention to the development issues facing adolescents.
Interpersonal Social Rhythm Therapy (IPSRT) is a therapeutic intervention combining a self-report (the Social Rhythm Matrix) with interpersonal psychotherapy and is used in conjunction with medication. It is particularly useful in addressing the interplay between life stressors, interference with social patterns and lack of observance with medication (Goodwin & Jamieson 1990). Crowe et al. present an interesting profile of a 15-year-old girl (the youngest participant) in a RCT comparing IPSRT with specialist support care (SSC) using case-study methodology. The choice of this participant, Crowe et al. explain, is that she is representative of the extreme or atypical case. Unfortunately, they provide no criteria or description of what constitutes the extreme or atypical other than age.
Case study research is well documented (Flyvbjerg 2006) and is an essential component for the scientific development of the broad range disciplines using it. Whilst current research is biased in favour of large samples, case studies – when thorough and well executed – produce the exemplar that can be used for hypothesis generation and testing as well as training. Further, Ruddin (2006) argues, it is possible to generalise from case studies. In particular, the fact that they are published indicates that the authors believe they are useful to others in that they can apply the learnings to their own field of inquiry (Ruddin 2006). Crowe et al. comment on the limitation of the method in their article, but I would counter that with the argument that case studies form a strong resonance with clinicians and that the accumulation of cases creates adds weight to treatment choices.
The researchers use Yin’s (2003) method and, whilst they justify this with regard to the nature of the questions asked, the amount of control the investigator has over events and the contemporary real-life context, they do not provide data from a variety of sources other than the transcripts of the therapy sessions and the results of the SRM. Yin (2003) notes that case studies bring together data from more than one source to triangulate and draw conclusions. An interview with the participant exploring her own interpretations of the therapy might have produced some alternative opinions that would enrich the data, as would interviews with parents.
Crowe et al. offer a stimulating report of an intervention that is usually adult-focused, being successfully used with a 15 year old. They describe the process for the young person and this is the most important part of the study: while the outcomes were positive, having an understanding of the process provides a unique insight into the workings of an otherwise private and personal journey.