Mood Monitoring in Bipolar Disorder – Have we done it correctly?

“To be evenminded is the greatest virtue” – Heraclitus

This quote hit particularly strong as it came from Heraclitus, a.k.a “the weeping philosopher”, as later scholars speculate the great mind could be long troubled by depression. To be evenminded, calm, undisturbed is the virtue Heraclitus sought after all his lifetime. People now refer to Heraclitus’ school of thoughts as “early-stoicism”, which some regarded as the philosophical basis for modern cognitive (behavioural) therapy (CBT). CBT is built around the idea of dissecting and challenging the thoughts, belief and behaviours that maintained one’s mental illness. To develop insight (read my MSc Dissertation on the topic), or the awareness of the mental illness, is said to be the first step that is necessary for CBT. Lack of insight – at least the illness recognition components of insight – could not blissful within this framework.

Mood Monitoring is widely used in treatment and self management of mood disorders.
Mood Monitoring is widely used in treatment and self management of mood disorders.

For mood disorders such as bipolar disorders, this idea of mood monitoring is widely used in treatment and self-management. This follows the stream of thought that better awareness of one’s mood changes would prepare one better to account for potential relapses. Jasper Palmier-Claus and colleagues (2021) has recently published an article evaluating whether mood monitoring is Always helpful in people with a diagnosis of bipolar disorder.

The authors cited qualitative evidence that mood monitoring could induce counter-effective pre-occupying thoughts, such that people could not tell whether their day-to-day moods are an early sign of an extreme mood state, or are merely a “normal” fluctuation in mood. Authors also cited the MONARCA single-blind Randomised-control trial that mood-monitoring alone does not on itself reduce depressive or manic symptoms. It seems that mood monitoring alone might not deliver the proposed clinical benefits, and are certainly not without risks. As I quote from Jasper’s twitter thread,

We suggest that an individualised, collaborative and normalising approach to mood monitoring may be optimal and reduce potential limitations.

@JPalmierClaus on Twitter

Authors have identified several knowledge gaps in mood monitoring, I am summarising and adding my 5 cents on the topic.

a) Awareness itself isn’t enough, what we do with the new-found awareness is key.

Authors suggested clinicians to develop pre-agreed coping strategies to increase perceived control over foreseeable problems. This means that mood monitoring shouldn’t be used as a plug-and-play band aid for every one, but a tailored intervention plan that is closely followed-up by trained clinicians.

b) We do not know what is within the normal mood variations We have to understand how mood variation patterns and cycles differ in remission, recurrence and relapse, and how it differs inter and intra-individually.

Both of the trials cited above measured changes in mood once a day. In the same cited qualitative study, a common feedback described the limited flexibility of a daily mood measurement to represent the context and variability of mood within a day. But this could go on further, what really is the meaningful time lapse between each measurement? Or is there a meaningful time lapse for each person? Or, whether it depends on other ancillary factors such as – context?

Studies of bipolar disorder using Ecological Momentary Assessment (EMA) methods have explored a lot of different time lapses, from daily, twice-daily, to three times a day. Time-gap between each assessment varied across individuals within study, and between studies. It wasn’t always clear in the papers what the rationale, and the theory behind such decisions. A rational approach to the question would be first establishing a representative norm. The ERC-supported WARN-D project (led by Eiko Fried) is set to investigate what a “normal” biopsychosocial mood systems might look like. I am excited to hear more from the project in near future!

c) The fault may lie in the tools of the trades

Set aside the theoretical complexities, another factor that might hamper people from benefiting from the mood monitoring experience could be the poorly designed digital apps. From a recent review of bipolar disorder related apps, of the 98 included apps, 12 were rated as capable of causing harm to a user, by offering potentially triggering information that goes against the treatment guidelines. Only 1 app had supporting feasibility and efficacy studies, but no people with bipolar disorder was involved in those studies. These publicly accessible yet unregulated apps might undermine the efficacy of properly managed and delivered mood monitoring interventions. With the vast boom of self-help and mental health apps on the market in the last couple years, I feel there is an imminent need for relevant regulating bodies to rigorously assess the boundaries of these self-help apps.

“The only thing constant in life is change.” – Heraclitus

Change is only thing that remains to be always, Heraclitus surely helped us avoid all ceiling effects in psychometric surveys! May He enjoy his fair share of even-mindedness in peace.