Composition of treatment alliance in bipolar disorder: A cross-sectional study of patients’ perspectives

Table 1 Participants’ profiles

Demographic & clinical variables	Patients with BD, n = 160
Age (yr)
mean ± SD (range)	43.96 ± 13.51 (18-65)
Sex
Male, n (%)	107 (67)
Female. n (%)	53 (33)
Marital status
Currently single, n (%)	27 (17)
Currently married, n (%)	133 (83)
Year of education
mean ± SD (range)	11.85 ± 3.27 (5-18)
Occupation
Not earning, n (%)	43 (26)
Earning, n (%)	117 (74)
Family income, in rupees per month
mean ± SD (range)	36977 ± 29385 (1500-131500)
Family type
Nuclear, n (%)	106 (66)
Non-nuclear, n (%)	54 (34)
Residence
Rural, n (%)	128 (80)
Urban, n (%)	32 (20)
Middle socioeconomic class, n (%)	110 (69)
Diagnosis
BD type I, n (%)	157 (98)
BD type II, n (%)	3 (02)
Most recent episode
Manic or hypomanic1, n (%)	88 (55)
Depressive, n (%)	72 (45)
Age of onset (yr)
mean ± SD (range)	26.11 ± 09.50 (12-60)
Duration of illness (mo)
mean ± SD (range)	210.88 ± 132.73 (12-600)
Duration of treatment (mo)
mean ± SD (range)	202.05 ± 129.01 (12-570)
Duration of current remission (mo)
mean ± SD (range)	19.82 ± 38.99 (4-456)
HDRS score
mean ± SD (range)	2.24 ± 1.18 (1-7)
YMRS score
mean ± SD (range)	1.56 ± 0.830 (1-6)
Insight-YMRS item 11 score
mean ± SD (range)	0.50 ± 0.56 (0-2)
Insight-HDRS item 17 score
mean ± SD (range)	0.55 ± 0.4 (0-2)
GAF score
mean ± SD (range)	69.04 ± 11.245 (48-92)
Total number of episodes
mean ± SD (range)	6.94 ± 5.77 (1-40)
Number of manic episodes1
mean ± SD (range)	3.68 ± 3.62 (0-30)
Number of depressive episodes
mean ± SD (range)	2.73 ± 2.71 (0-12)
Most recent episode polarity
Manic or hypomanic1, n (%)	88 (55)
Depressive, n (%)	72 (45)
Average severity of manic episodes1,2, n (%)	1.77 ± 0.62 (1-3) median 2
Average severity of depressive episodes2, n (%)	1.49 ± 0.56 (0-3) median 1
Patients with at least one episode of psychotic mania, n (%)	107 (67)
Patients with at least one episode of psychotic depression, n (%)	84 (53)
Rapid cycling affective disorder, n (%)	30 (19)
Seasonal pattern, n (%)	62 (39)
Lifetime suicidal attempts, n (%)	34 (21)
Patients with any lifetime psychiatric comorbidity, n (%)	43 (27)
Patients with comorbid substance use disorders, n (%)	34 (21)
Patients with comorbid anxiety disorders, n (%)	18 (12)
Patients with lifetime comorbid physical illness, n (%)	54 (34)
Lifetime history of inadequate medication-adherence, n (%)	77 (48)
Lifetime history of relapses or breakthrough episodes, n (%)	85 (53)
Any history of hospitalization, n (%)	82 (51)
On mood stabilizer prophylaxis, n (%)	160 (100)
On lithium carbonate, n (%)	116 (73)
Average dose	720 ± 193 mg/d
On sodium valproate, n (%)	42 (27)
Average dose	1021 ± 284 mg/d
On antipsychotics, n (%)	105 (66)
On antidepressants, n (%)	40 (25)

¹Manic and hypomanic episodes have been clubbed together and referred to as mania/manic episodes.

²Severity was graded as 0-3 with 0 representing remission, 1 representing a mild episode, 2 representing a moderate episode, and 3 representing a severe episode.

BD: Bipolar disorder; GAF: Global Assessment of Functioning Scale; HDRS: Hamilton Depression Rating Scale; YMRS: Young Mania Rating Scale.

Table 2 Components of treatment alliance: Scores on the four scales

Scores	Patients with BD, n = 160, mean ± SD (range)
WAI-Client scores
Total WAI-Client scores	222.82 ± 20.14 (142-252)
Goal subscale	72.24 ± 7.97 (45-84)
Bond subscale	76.94 ± 7.97 (44-84)
Task subscale	73.64 ± 7.55 (49-84)
PCP scores1
Total PCP scores	40.34 ± 5.86 (22-60)
Emotional support subscale	14.45 ± 3.23 (8-33)
Informational support subscale	6.5 ± 1.03 (4-8)
SDM subscale	9.68 ± 1.57 (5-12)
Supportive behaviour (support) subscale	9.69 ± 1.35 (4-12)
TRIP scores
Total TRIP scores	10.12 ± 1.45 (8-12)
I completely trusted my doctors	3.40 ± 0.50 (2-4)
I had the impression that the doctors are very competent	3.38 ± 0.51 (2-4)
With the doctors in this hospital one is in good hands	3.40 ± 0.50 (2-4)
PSQ scores
Total PSQ scores	9.39 ± 1.99 (6-12)
Satisfied with places and times of appointment	2.30 ± 0.59 (1-3)
Satisfied with time available for talking about problems	2.31 ± 0.55 (1-3)
Feel confident that members of service are competent to deal with problems	2.39 ± 0.49 (2-3)
Pleased with the care received from the service so far	2.38 ± 0.50 (1-3)
Correlations between scores on different scales and subscales	Pearson’s coefficients2
Goal and Task subscale scores of the WAI-Client	0.81a
Bond and Task subscale scores of the WAI-Client	0.69a
Bond and Goal subscale scores of the WAI-Client	0.66a
Total TRIP scores and WAI-Client total scores	0.28b
Total TRIP scores and WAI-Client Task subscale scores	0.29b
Total PCP scores and WAI-Client Task subscale scores	0.28b
PCP-SDM subscale scores and WAI-Client total scores	0.28b
PCP-SDM subscale scores and WAI-Client Goal subscale scores	0.28b
Total scores on the TRIP and the PSQ	0.45a

^aP < 0.0001.

^bP < 0.01.

¹Weighted mean scores were highest on the “Supportive behavior” subscale (subjective perceptions of support by physicians), followed by the subscales measuring emotional support, shared decision-making and informational support.

²Only significant associations that persisted after the Bonferroni corrections are shown. Significant associations were also noted between the Working Alliance Inventory-client version (WAI-Client) total and subscale scores and the Trust in Physicians scores, between the WAI-Client total and subscale scores and the Psychosocial Care by Physicians total and subscale scores, but these did not cross the Bonferroni threshold.

BD: Bipolar disorder; PCP: Psychosocial Care by Physicians; PSQ: Patient Satisfaction Questionnaire; SDM: Shared decision-making; TRIP: Trust in Physicians; WAI-Client: Working Alliance Inventory-client version.

Table 3 Components of treatment alliance: Results of factor analysis

Components	Initial eigen values1			Rotation sums of squared loadings1
	Total	Percentage of variance	Cumulative percentage	Total	Percentage of variance	Cumulative percentage
1	2.789	46.482	46.482	2.459	40.980	40.980
2	1.336	22.272	68.754	1.666	27.774	68.754
Components2	Factor 1			Factor 2
WAI-Client Task scores	0.913			-
WAI-Client Goal scores	0.903			-
WAI-Client Bond scores	0.850			-
PCP total scores	0.552			-
TRIP total scores	-			0.820
PSQ total scores	-			0.795

¹Bartlett’s Test of Sphericity - χ² = 356.39; df = 15; P < 0.001; Kaiser-Meyer-Olkin measure = 0.72 - this indicated that factor analysis was appropriate for the data.

²Only factors with Eigen values of > 1 were retained and loadings that were ≥ 0.4 were identified as significant loadings for each factor. The Scree plot tailed off at 2 factors.

PCP: Psychosocial Care by Physicians scale; PSQ: Patient Satisfaction Questionnaire; TRIP: Trust in Physicians; WAI-Client: Working Alliance Inventory-client version.