Collaborative Disease Management Research Articles

The effects of a dyadic empowerment-based heart failure management (De-HF) programme on self-care and HRQL : a randomized controlled trial

Abstract Background The ever-growing epidemiology of heart failure (HF) and its detrimental impacts on patients’ quality of life and healthcare cost urge for effective interventions to ameliorate the modifiable prognostic factors. As substantial evidence suggests ineffective self-care as an important candidate especially for the post-discharge outcomes, various care approaches are developed to optimize this behavioral outcome. However, even family carers are heavily involved in the self-care process, dyadic approach to improve the health outcomes of both interactive partners are least applied in the HF transitional care model. Purpose To evaluate the effects of a dyadic empowerment-based heart failure management program (De-HF) on dyadic health and hospital service utilization outcomes. Methods This double-blind RCT randomized 88 HF patient-carer dyads to receive the De-HF program or a dialectic education program, after hospital discharge. Based on the Theory of Dyadic Illness Management, the 16-week De-HF Program, comprising i) a dyadic assessment, ii) five online empowerment modules and iii) follow-up telecare, integrated explicit strategies (scenario-based training, teach-back and goal-setting) to actively engage the care dyads in collaborative disease management. Figure 1 is the graphical presentation of the De-HF Program. The primary outcome is health-related quality of life (HRQL) of the care dyads. Secondary outcomes include patients’ self-care as well as shared care and perceived control of the dyad. Results The mean age of the HF patients was 76.8 (9.4). The patients were in moderate disease severity [NYHA II/II: 56/44%; mean LVEF = 42.5%]. Figure 2 shows the consort flow diagram. After adjusting the socio-demographic characteristic, two-way analysis of covariance showed that patients in the De-HF program showed significantly greater improvement in patients’ self-care domains [Mean difference in change of score (95% CI): Self-care maintenance = 7.15 (1.82-12.46),Cohen’s d = 0.26, p=0.009; Self-care management = 10.04(3.29-16.79), Cohen’s d=0.65, p=0.004; symptom perception = 15.59 (8.20-22.98), Cohen’s d=0.928, p<0.001] and Minnesota Living with Heart Failure score [Mean different in the change of score (95% CI) = -11.45 (-18.24 - -4.66). Cohen’s d = -0.742, p=0.001]. The patient-carer dyads also have significantly greater improvement in perceived control (p=0.001) and collaborative disease management in terms of joint decision-making (p=0.001) and sense of reciprocity (p=0.026). Conclusion Dyadic science has evolved in self-care research for HF. This trial provides the first evidence to inform the positive effects of a theory-based dyadic transitional care program in improving the collaborative self-care management in a family context and patient health outcome. Longer-term evaluation on the effects of De-HF program on health service utilization outcomes and cost-effectiveness will be followed.The De-HF Managment ProgramThe Consort Flow Diagram

Precision Aquaculture with Inclusion of Commodity Smart Phones and Collective Learning

The rising demand for seafood has led to a growing interest in aquaculture, requiring careful attention to aspects of the cultivation process like stocking, feeding, and safeguarding against predators and disease for success. Precision aquaculture offers promising advancements, but its high initial costs pose challenges. Collective learning and smartphone technology provide accessible solutions for all farms to benefit from data-driven insights and collaborative disease management. Despite the potential long-term benefits in terms of production efficiency and resource management, full implementation of precision aquaculture remains economically infeasible for individual and small-scale farmers. However, there are some technologies such as collective learning and commodity smartphones that offer opportunities to benefit both precision and non-precision aquaculture farms, enhancing data-driven decision-making and collaboration.

Abstract 10263: “High Blood Pressure Comes From Thinking Too Much”: Health Beliefs Among Couples With Cardiometabolic Disorders and HIV in Sub-Saharan Africa

Introduction: People living with HIV are at increased risk for cardiometabolic disorders (CMD) due to chronic inflammation, immune activation, and antiretroviral therapy. In high HIV prevalence areas of sub-Saharan Africa, little is known about how HIV patients and their partners understand CMD and how health services could leverage partner support. Objective: To explore health beliefs among HIV patients with CMD and primary partners Methods: We conducted a qualitative study with 25 couples recruited from 3 HIV care clinics in Zomba, Malawi. Patients managing HIV and CMD (hypertension and/or diabetes) were enrolled first, followed by their primary partners. Semi-structured interviews were conducted separately with partners to elicit health beliefs around causality, prevention, and management of CMD. Dyadic data were coded for patterns and themes within couples and between couples, and data matrices were created to compare and contrast the findings. Results: Most participants believed that the main causes of CMD were diet, aging, and genetics, but some believed CMD was sexually transmitted or caused by viruses such as HIV. Within couples, diet and stress were the most commonly agreed-upon cause, and over half of couples believed “thinking too much” due to stress or couple conflict was a cause of CMD. Prevention beliefs included a healthy diet, exercise, avoiding HIV, using condoms, and keeping stress levels low. Management beliefs included dietary changes, taking medication or herbs, exercising, and reducing stress. Within couples, the most agreed-upon belief was that diet, particularly salt reduction, was important for prevention and management; however, within-dyad disagreement and incorrect beliefs around other aspects of a heart-healthy diet were common. Conclusion: While lifestyle factors were correctly identified as important for prevention and management of CMD, misconceptions remained around transmission through a virus or sex. Partners often differed in their views of CMD, which could interfere with CMD management. Health education programs are critically needed and involving partners may offer an opportunity to solidify knowledge in couples and foster collaborative disease management around CMD.

Polypharmacy and Clinical Outcomes in Hospitalized Patients With Acute Decompensated Heart Failure.

Polypharmacy is a common problem among patients with acute decompensated heart failure (ADHF) who often have multiple comorbidities. The aim of this study was to define the number of medications at hospital discharge and whether it is associated with clinical outcomes at 1 year. We evaluated the number of medications in 2578 patients with ADHF who were ambulatory at hospital discharge in the Kyoto Congestive Heart Failure Registry and compared 1-year outcomes in 4 groups categorized by quartiles of the number of medications (quartile 1, ≤ 5; quartile 2, 6-8; quartile 3, 9-11; and quartile 4, ≥ 12). At hospital discharge, the median number of medications was 8 (interquartile range, 6-11) with 81.5% and 27.8% taking more than 5 and more than 10 medications, respectively. The cumulative 1-year incidence of a composite of death or rehospitalization (primary outcome measure) increased incrementally with an increasing number of medications (quartile 1, 30.8%; quartile 2, 31.6%; quartile 3, 39.7%; quartile 4, 50.3%; P < .0001). After adjusting for confounders, the excess risks of quartile 4 relative to those of quartile 1 remained significant ( P = .01). In the contemporary cohort of patients with ADHF in Japan, polypharmacy at hospital discharge was common, and excessive polypharmacy was associated with a higher risk of mortality and rehospitalizations within a 1-year period. Collaborative disease management programs that include a careful review of medication lists and an appropriate deprescribing protocol should be implemented for these patients.

An interprofessional experience in diabetes management for pharmacy and medical students

Background and purposeThe 2016 Standards of the Accreditation Council for Pharmacy Education state that curricula must include opportunities for interprofessional education (IPE). This report describes a collaborative effort between a pharmacy program and a school of medicine to develop, implement, and evaluate an interprofessional workshop focused on collaborative disease management. Educational activity and settingA medical school course in diabetes management was identified as optimal for an IPE approach. One class session was designed to highlight the advantages of team-based care in diabetes management and describe the roles of members of an interprofessional healthcare team. Students were divided into groups to discuss cases and demonstrate diabetic device counseling. Students were surveyed before and after the IPE experience to examine their attitudes towards interprofessional learning. FindingsWe obtained matched pre and post-evaluations from 168 participants (138 medical students and 30 pharmacy students). Learner attitudes were positive overall, and improved from pre-test (M = 80.28, SD = 10.29) to post-test (M = 82.83, SD = 9.40, F = 14.92, df = 1, p < .001), suggesting more favorable attitudes to interprofessional learning after completing the class. Multivariate analysis indicated a significant main effect for learner profession, suggesting pharmacy students had more positive attitudes to interprofessinal learning both before and after the workshop. SummaryAdding an IPE dimension to an existing medical school course had a positive impact on student perceptions of interprofessional practice, particularly for the pharmacy students who could demonstrate the value of their role on a team for patient care.

Management of Cardiovascular Disease in Women With Breast Cancer.

Cardio-oncology is a rapidly developing field which seeks to improve patient outcomes through enhanced clinical and research collaboration across the disciplines of oncology and cardiology. Breast cancer (BC) is the most common cancer diagnosis among women in the United States and, as decades of research have resulted in decreased mortality rates, there has been an increasing focus on reducing short- and long-term treatment toxicity and improving morbidity among survivors. Preexisting or emergent cardiovascular disease in a patient with BC requires a multidisciplinary, team-based approach to balance the need for curative cancer treatment while preventing increased cardiovascular disease morbidity and mortality. Given the overlap in risk factors for BC and cardiovascular disease, such as smoking, sedentary lifestyle, and obesity, there are opportunities for cardiovascular disease prevention and detection before, during, and after BC treatment. Cardiology providers also play an important role in preventing, diagnosing, and treating cardiac dysfunction and other cardiovascular complications that may develop as a result of BC treatment. A number of recent clinical practice guidelines address approaches to cardiotoxicity, however, they focus on specific agents or treatment modality, rather than on collaborative disease management. In this review we present cardiovascular concerns associated with contemporary, multimodality BC treatment and illustrate how current guideline recommendations apply to clinical cardiology and oncology questions. We provide a cardio-oncology team-based approach to cardiovascular assessment and management of patients with BC from diagnosis through treatment and in survivorship.

Personalized Technologies in Chronic Gastrointestinal Disorders: Self-monitoring and Remote Sensor Technologies.

With increased access to high-speed Internet and smartphone devices, patients have started to use mobile applications (apps) for various health needs. These mobile apps are now increasingly used in integration with telemedicine and wearables to support fitness, health education, symptom tracking, and collaborative disease management and care coordination. More recently, evidence (especially around remote patient monitoring) has started to build in some chronic diseases, and some of the digital health technologies have received approval from the Food and Drug Administration. With the changing healthcare landscape and push for value-based care, adoption of these digital health initiatives among providers is bound to increase. Although so far there is a dearth of published evidence about effectiveness of these apps in gastroenterology care, there are ongoing trials to determine whether remote patient monitoring can lead to improvement in process metrics or outcome metrics for patients with chronic gastrointestinal diseases.

Medical Internet of Things and Big Data in Healthcare.

ObjectivesA number of technologies can reduce overall costs for the prevention or management of chronic illnesses. These include devices that constantly monitor health indicators, devices that auto-administer therapies, or devices that track real-time health data when a patient self-administers a therapy. Because they have increased access to high-speed Internet and smartphones, many patients have started to use mobile applications (apps) to manage various health needs. These devices and mobile apps are now increasingly used and integrated with telemedicine and telehealth via the medical Internet of Things (mIoT). This paper reviews mIoT and big data in healthcare fields.MethodsmIoT is a critical piece of the digital transformation of healthcare, as it allows new business models to emerge and enables changes in work processes, productivity improvements, cost containment and enhanced customer experiences.ResultsWearables and mobile apps today support fitness, health education, symptom tracking, and collaborative disease management and care coordination. All those platform analytics can raise the relevancy of data interpretations, reducing the amount of time that end users spend piecing together data outputs. Insights gained from big data analysis will drive the digital disruption of the healthcare world, business processes and real-time decision-making.ConclusionsA new category of "personalised preventative health coaches" (Digital Health Advisors) will emerge. These workers will possess the skills and the ability to interpret and understand health and well-being data. They will help their clients avoid chronic and diet-related illness, improve cognitive function, achieve improved mental health and achieve improved lifestyles overall. As the global population ages, such roles will become increasingly important.

Use of CLIA-waived point-of-care tests for infectious diseases in community pharmacies in the United States

Review of point-of-care (POC) testing in community pharmacies, availability and specifications of CLIA-waived infectious disease POC tests, and provide recommendations for future community pharmacy POC models in an effort to improve patient outcomes while reducing antibiotic resistance. PubMed and Medscape were searched for the following keywords: infectious disease, community pharmacy, rapid diagnostic tests, rapid assay, and POC tests. All studies utilizing POC tests in community pharmacies for infectious disease were included. Studies, articles, recommendations, and posters were reviewed and information categorized into general implementation of POC testing in community pharmacies, CLIA-waived tests available, Influenza, Group A Streptococcus pharyngitis, Helicobacter pylori, HIV and Hepatitis C. POC testing provides a unique opportunity for community pharmacists to implement collaborative disease management programmes for infectious diseases and reduce over-prescribing of antibiotics and improve patient outcomes through early detection, treatment and/or referral to a specialist.

An Investigation into the Role of Mobile Technology in Collaborative Disease Management for Persons Living with Type 2 Diabetes

Diabetes and other chronic non-communicable diseases represent a leading threat to health care and human development. The authors discusses how mobile technology can achieve collaborative disease management (CDM) within a population living with Type 2 diabetes. We introduces a framework for CDM using mobile technologies. While it can be applied to the management of any disease, we describe a specific instance for diabetes peer-support. In this paper, we validate the framework through the development and testing of a Mobile Health initiative called Mobile Diabetes Self-Management Support (DSMS). It allows persons living with diabetes to learn from each others’ experiences through a virtual support group. The paper presents two user studies conducted. The first study captured the participants’ initial perceptions of the application in a controlled environment and the second study investigated system usage and collaboration when the application was used in their personal settings.

Nurse-coordinated collaborative disease management improves the quality of guideline-recommended heart failure therapy, patient-reported outcomes, and left ventricular remodelling.

Heart failure (HF) pharmacotherapy is often not prescribed according to guidelines. This longitudinal study investigated prescription rates and dosages of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers, and mineralocorticoid receptor antagonists (MRA), and concomitant changes of symptoms, echocardiographic parameters of left ventricular (LV) function and morphology and results of the Short Form-36 (SF-36) Health Survey in participants of the Interdisciplinary Network Heart Failure (INH) programme. The INH study evaluated a nurse-coordinated management, HeartNetCare-HF(TM) (HNC), against Usual Care (UC) in patients hospitalized for decompensated HF [LV ejection fraction (LVEF) ≤40% before discharge). A total of 706 subjects surviving >18 months (363 UC, 343 HNC) were examined 6-monthly. At baseline, 92% received ACEi/ARB, (HNC/UC 91/93%, P = 0.28), 86% received beta-blockers (86/86%, P = 0.83), and 44% received MRA (42/47%, P = 0.07). After 18 months, beta-blocker use had increased only in HNC (+7.6%, P < 0.001). Guideline-recommended target doses were achieved more frequently in HNC for ACEi/ARB (HNC/UC: 50/25%, P < 0.001) and beta-blockers (39/15%, P < 0.001). The following variables were more improved and/or better in subjects undergoing HNC compared with UC: LVEF (47 ± 12 vs. 44 ± 12%, P = 0.004, change +17/+14%, P = 0.010), LV end-diastolic diameter (59 ± 9 vs. 61 ± 9.6 mm, P = 0.024, change -2.3/-1.4 mm, P = 0.13), New York Heart Association class (1.9 ± 0.7 vs. 2.1 ± 0.7, P = 0.001, change -0.44/-0.25, P = 0.002) and SF-36 physical component summary score (41.6 ± 11.2 vs. 38.5 ± 11.8, P = 0.004, change +3.3 vs. +1.1 score points, P < 0.02). Prescription rates and dosages of ACEi/ARB and beta-blockers improved more in HNC than UC patients. Concomitantly, participation in HNC was associated with significantly better clinical outcomes and more favourable echocardiographic changes after 18 months.

Cost-effectiveness and cost-utility of a structured collaborative disease management in the Interdisciplinary Network for Heart Failure (INH) study.

Non-pharmacological treatment programmes are being developed, in which specialised nurses take care of heart failure (HF) patients. Such disease management programmes might increase survival and quality of life in HF patients, but evidence on their cost-effectiveness remains limited. A prospective economic evaluation piggy-backed onto the randomised controlled Interdisciplinary Network for Heart Failure (INH) Study weighted costs of the intervention HeartNetCare -HF™ (HNC) regarding effectiveness, mortality and quality-adjusted life years (QALYs). To consider uncertainty sensitivity analyses were performed. Compared to usual care (UC), HNC revealed 8,284 <euro> per death avoided within the 6 month study follow-up period. The cost-utility analysis showed additional costs of 49,335 <euro> per QALY. Although HNC did not reduce short-term re-admission rates of HF patients hospitalised for cardiac decompensation within the first 180days after discharge, HNC might reduce mortality and increase quality of life in these patients at reasonable costs. Therefore, long-term HNC-effects deserve further evaluation.

Effects of structured heart failure disease management on mortality and morbidity depend on patients' mood: results from the Interdisciplinary Network for Heart Failure Study

Depression is common in heart failure (HF) and associated with adverse outcomes. Randomized comparisons of the effectiveness of HF care strategies by patients' mood are scarce. We therefore investigated in a randomized trial a structured collaborative disease management programme (HeartNetCare-HF™; HNC) recording mortality, morbidity, and symptoms in patients enrolled after hospitalization for decompensated systolic HF according to their responses to the 9-item Patient Health Questionnaire (PHQ-9) during an observation period of 180 days. Subjects scoring <12/≥12 were categorized as non-depressed/depressed, and those ignoring the questionnaire as PHQ-deniers. Amongst 715 participants (69 ± 12 years, 29% female), 141 (20%) were depressed, 466 (65%) non-depressed, and 108 (15%) PHQ-deniers. The composite endpoint of mortality and re-hospitalization was neutral overall and in all subgroups. However, HNC reduced mortality risk in both depressed and non-depressed patients [adjusted hazard ratios (HRs) 0.12, 95% confidence interval (CI) 0.03-0.56, P = 0.006, and 0.49, 95% CI 0.25-0.93, P = 0.03, respectively], but not in PHQ-deniers (HR 1.74, 95% CI 0.77-3.96, P = 0.19; P = 0.006 for homogeneity of HRs). Average frequencies of patient contacts in the HNC arm were 12.8 ± 7.9 in non-depressed patients, 12.4 ± 7.1 in depressed patients, and 5.5 ± 7.2 in PHQ-deniers (P < 0.001). Early after decompensation, HNC reduced mortality risk in non-depressed and even more in depressed subjects, but not in PHQ-deniers. This suggests that differential acceptability and chance of success of care strategies such as HNC might be predicted by appropriate assessment of patients' baseline characteristics including psychological disposition. These post-hoc results should be reassessed by prospective evaluation of HNC in larger HF populations.

Exploring the nature of power distance on general practitioner and community pharmacist relations in a chronic disease management context

To improve collaboration in Australian primary health care, there is a need to understand aspects of the general practitioner (GP)/community pharmacist relationship, its influence on collaborative chronic disease management (CDM) and if this influence can be explained by a pre-existing theory or concept. Adopting a grounded theory approach, 22 GP and 22 community pharmacist semi-structured interviews were undertaken. Analysis of the transcripts identified common themes regarding the GP/community pharmacist relationship. Trustworthiness of the themes identified was tested through negative case analysis and member checking. Hofstede’s (in 1980) phenomenon of power distance was employed to illuminate the nature of GP/community pharmacist relations. The majority of GPs and community pharmacists described the characteristics of this phenomenon. The power distance was based on knowledge and expertise and was shown to be a barrier to collaboration between GPs and community pharmacists because GPs perceived that community pharmacists did not have the required expertise to improve CDM above what the GP could deliver alone. Power distance exists within the GP/community pharmacist relationship and has a negative influence on GP/community pharmacist collaborative CDM. Understanding and improving GP awareness of community pharmacist expertise has important implications for the future success of collaborative CDM.

O087 Leveraging existing HIV/AIDS infrastructure for rheumatic heart disease care in Uganda: a collaborative disease surveillance and management program

O087 Leveraging existing HIV/AIDS infrastructure for rheumatic heart disease care in Uganda: a collaborative disease surveillance and management program

Mode of Action and Effects of Standardized Collaborative Disease Management on Mortality and Morbidity in Patients With Systolic Heart Failure

Background— Trials investigating efficacy of disease management programs (DMP) in heart failure reported contradictory results. Features rendering specific interventions successful are often ill defined. We evaluated the mode of action and effects of a nurse-coordinated DMP (HeartNetCare-HF, HNC). Methods and Results— Patients hospitalized for systolic heart failure were randomly assigned to HNC or usual care (UC). Besides telephone-based monitoring and education, HNC addressed individual problems raised by patients, pursued networking of health care providers and provided training for caregivers. End points were time to death or rehospitalization (combined primary), heart failure symptoms, and quality of life (SF-36). Of 1007 consecutive patients, 715 were randomly assigned (HNC: n=352; UC: n=363; age, 69±12 years; 29% female; 40% New York Heart Association class III-IV). Within 180 days, 130 HNC and 137 UC patients reached the primary end point (hazard ratio, 1.02; 95% confidence interval, 0.81–1.30; P =0.89), since more HNC patients were readmitted. Overall, 32 HNC and 52 UC patients died (1 UC patient and 4 HNC patients after dropout); thus, uncensored hazard ratio was 0.62 (0.40–0.96; P =0.03). HNC patients improved more regarding New York Heart Association class ( P =0.05), physical functioning ( P =0.03), and physical health component ( P =0.03). Except for HNC, health care utilization was comparable between groups. However, HNC patients requested counseling for noncardiac problems even more frequently than for cardiovascular or heart-failure–related issues. Conclusions— The primary end point of this study was neutral. However, mortality risk and surrogates of well-being improved significantly. Quantitative assessment of patient requirements suggested that besides (tele)monitoring individualized care considering also noncardiac problems should be integrated in efforts to achieve more sustainable improvement in heart failure outcomes. Clinical Trial Registration— URL: http://www.controlled-trials.com . Unique identifier: ISRCTN23325295.

A Medical Education Model for Collaborative Chronic Disease Management

Purpose: The purpose of this study was to evaluate the impact of a curriculum enhancement project on physician assistant (PA) students’ abilities, attitudes, and preparedness to provide collaborative disease management. Method: The authors identified competencies needed for collaborative chronic disease management and developed curriculum interventions. The interventions were piloted with a single cohort of PA students at the Jefferson College of Health Sciences. Full implementation and evaluation was conducted with a separate cohort of students. Students self-reported their (1) previous exposure to chronic disease; (2) abilities related to collaborative disease management; (3) attitudes towards chronic disease patients and collaborative disease management; (4) preparedness to provide chronic disease care; (5) perceptions of the benefit of the community medicine rotation and; (6) self-efficacy to support patient self-management. Results: Significant improvements (p < .05) were noted in all 10 ability areas. Few significant changes in attitudes occurred though many attitudes were positively maintained. Significant changes were found for students’ preparedness for chronic disease care. Students also reported a high level of self-efficacy to provide patient self-management support. Conclusions: Findings indicate that curriculum interventions can positively affect PA students’ collaborative disease management abilities and sense of preparedness to manage patients with chronic disease. While curriculum enhancement may not significantly improve attitudes, the study suggests that interventions may be supportive of already favorable attitudes. Further study is needed to determine the most time- and cost-effective methods for facilitating improvement in both ability and attitude. J Physician Assist Educ 2008;19(2):18-29

Physicians' satisfaction with a collaborative disease management program for late-life depression in primary care

Objective This study describes physicians' satisfaction with care for patients with depression before and after the implementation of a primary care-based collaborative care program. Method Project Improving Mood, Promoting Access to Collaborative Treatment for late-life depression (IMPACT) is a multisite, randomized controlled trial comparing a primary care-based collaborative disease management program for late-life depression with care as usual. A total of 450 primary care physicians at 18 participating clinics participated in a satisfaction survey before and 12 months after IMPACT initiation. The preintervention survey focused on physicians' satisfaction with current mental health resources and ability to provide depression care. The postintervention survey repeated these and added questions about physician's experience with the IMPACT collaborative care model. Results Before intervention, about half (54%) of the participating physicians were satisfied with resources to treat patients with depression. After intervention, more than 90% reported the intervention as helpful in treating patients with depression and 82% felt that the intervention improved patients' clinical outcomes. Participating physicians identified proactive patient follow-up and patient education as the most helpful components of the IMPACT model. Conclusions Physicians perceived a substantial need for improving depression treatment in primary care. They were very satisfied with the IMPACT collaborative care model for treating depressed older adults and felt that similar care management models would also be helpful for treating other chronic medical illnesses.

Psychological treatment of bipolar disorder

Part I: Overview of Bipolar Disorder. Johnson, Defining Bipolar Disorder. Hammen, Cohen, Psychosocial Functioning. Altman, Differential Diagnosis and Assessment of Adult Bipolar Disorder. Youngstrom, Findling, Feeny, Assessment of Bipolar Spectrum Disorders in Children and Adolescents. Johnson, Meyer, Psychosocial Predictors of Symptoms. Part II: Therapy and Treatment Issues. Goldberg, The Changing Landscape of Psychopharmacology. Leahy, Cognitive Therapy. Frank, Swartz, Interpersonal and Social Rhythm Therapy. Miklowitz, Family Therapy. Bauer, Supporting Collaborative Practice Management: The Life Goals Program. Scott, Treatment Outcome Studies. Part III: Special Issues in Treatment. Ramirez Basco, Merlock, McDonald, Treatment Compliance. Newman, Suicidality. Lefley, Vogel-Scibilia, Consumer Advocacy and Self-Help: Interface with Professionals. Leahy, Conclusions. Appendix 1. Altman Self-Rating Scale for Mania (ASRM). Appendix 2. Mood Chart. Appendix 3. Evaluation of Suicidal Risk. Appendix 4. Recommended Books for Consumers and their Families. Appendix 5. Outline of Collaborative Disease Management Strategies. Index.