Hi, my name is Cindy Walters. I am presenting a qualitative research critique on a study conducted in 2011 on people with bipolar disorder with comorbid substance use. The study is entitled “The lived experience of adults with bipolar disorder and comorbid substance use disorder” written by Terry Ward, MSN, PhD, RN. Bipolar disorder involves changes in cognition, behavior, and mood. The episodes of bipolar disorder cycle through mania and depression. Mania is described as an elevated, irritable, or expansive mood, whereas depression is the opposite or hypomania.
In the manic phase people present as euphoric, enthusiastic, and optimistic with an infectious personality. The euphoric state may suddenly may be replaced by extreme irritability if the persons needs are not met. In a manic phase the person’s speech may be rapid, loud, intrusive, and hard to follow or interrupt. If someone tries to interrupt a manic person he or she can just as quickly become, threatening, irritable or assaultive (Ebert, Loosen, Nurcombe & Leckman, 2008).
Substance abuse is the excess use of drugs such as alcohol, illicit drugs, and prescription medications. The number of people abusing drugs and alcohol is about 3.4 million. Those individuals abusing have a greater change of acquiring a mental disorder at a rate of 2.7 times more likely than a non-abuser, according to the National Survey on Drug Use and Health individuals with a psychiatric diagnosis such as bipolar disorder have 28.8% chance of substance abuse or use of drugs. Individuals using drugs with a mental disorder, within a year are diagnosed as dependent on them (Ebert, Loosen, Nurcombe & Leckman, 2008). If bipolar disorder and substance use disorder are combined, they have a devastating effect with negative outcomes for those individuals. Understanding the problem with the ability to manage bipolar disorder with the proper treatment, health care providers can improve patient outcomes and his or her outlook on life. The problem is clearly stated in the abstract and first paragraph of the study.
Several statistics of drug use are quoted to give the reader an estimate and prevalence of this addiction with an unknown cause. The author addressed four hypotheses to explain this phenomenon. The negative outcomes in the use of substances and bipolar disorder affect a person mentally, physically, and functionally. The author stated the prevalence was high and does not receive enough attention in research studies. With increased knowledge, health care providers will be able to introduce new avenues for research, education, and nursing practice. The purpose of the study is to see how the individuals perceive their day- to- day experience of living with the disorders. A study done by Cassidy et al. (2001) addressed supporting and maintaining the patient’s stability and quality of life with effective treatment. Other studies focused on pharmacotherapy, psychosocial factors, and interventions as areas of research. Little research has been done on the phenomena.
The researcher provided the broad platform for a qualitative study for individuals to share and speak freely of their experience with the hope the patients will be heard, get support, and have better outcomes. The method of this study was a descriptive and phenomenological design. “Phenomenology accepts that the truth can be revealed through the words of those that live the experience and that those words can describe the essence of that lived experience” (Thomas & Pollio, 2002, pg. 184). “Descriptive phenomenology has its emphasis on describing universal essences through direct interaction between the researcher and the objects of study” (Wojnar & Swanson, 2007, pg. 22). Conclusions could be drawn from the researcher of the subject experiences. The method adequately addressed the topic and gave credence to the subject experiences of living with a dual diagnosis. The design was consistent with qualitative studies and proved to be as descriptive and truthful as the researcher intended. Sampling was obtained over a four month period with the use of fliers.
Fliers contained inclusion criteria and were validated by expert researchers for content, reliability, and readability. Also in the fliers contents were the researcher contact information, risks, and benefits of the study. Mental health care centers were the origin for the distribution of the fliers for subjects of the study. Snowballing and referrals came from doctor’s offices and recovery centers for abuse that were also included in the distribution of flier for subjects. The credibility came from phone calls made by potential subjects calling the researcher and were given reiterated instructions of the explanation for the study, inclusion criteria, exclusion criteria, risks, and benefits. The sample consisted of 12 stable subjects not using drugs with a self-reported bipolar disorders, and not currently manic or depressed. The demographics pulled out male, female, mean age, and nationality. The description of the inclusion criteria showed the participants inferred for the sample were familiar and knowledgeable about the subject.
The participants were chosen for the purpose of describing their experience of living with the dual diagnosis for this study. The criteria and descriptions were consistent for qualitative study. The sample size was small and consisted of only one male. Although facts indicate that more females have a dual diagnosis of bipolar disorder with substance use disorder (Ebert, Loosen, Nurcombe & Leckman, 2008). Data collection began with IRB approval and a written and verbal informed consent. Written consent was obtained for audiotaping of interviews with the understanding that at any time should the participant chose, the recorder could be turned off or the interview stopped. During emotional times of the participants they were asked by the researcher if they wanted the tape turned off or wish to stop the interview.
Probe questions were used by the researcher to get the participant to expand on their explanations and thoughts. Wards probe questions were “describe for me a typical day that would help me understand what your life is like” or “how did you feel when you were told you had both bipolar disorder and a substance use disorder?” seemed to prompt the participant to speak (pg. 21). During the questions the researcher jotted notes on the mood, emotion, and expression of the participant the audio would not capture. Participants also shared concerns of ridicule, health problems that complicated their lives, and the lack of acceptance from society. There was no saturation of the data described. The strategy used by the researcher obtained the information she needed for the study. There were two interviews conducted the first was a face –to-face and the second was a follow up phone interview for clarity of the findings. The data collection was obtained in a qualitative and purposeful manner, although the researcher never stated where the interview was conducted.
There was no model or framework for validation of the study except for the data interpretation of the data analysis. Data analysis was studied over and over until the themes of the participants were identified by the researcher. Analytical coding was used to describe meaning to experiences lived by the participant. When a person reflects on their experience it becomes important to the process of understanding the phenomena. Qualitative methodology was proved with peer debriefing of the analysis and techniques used in this study. Audit trails comprised the data for the participants to view and verify that the disclosed information in his or her interview was captured as they intended that proved the validity and reliability of the research. Ward (pg. 22) found six themes that defined experiences of the participants. The six themes were life is hard, feeling the effect, trying to escape, spiritual support, being pushed beyond the limits, and a negative connotation. The participants responses were elaborated on in each theme giving the reader the implications of the perceptions of the participants.
Each theme was explained and defined for easier reading and understanding. Themes indicated criminal actions, loss of jobs, homelessness, and losing the respect of others. Scientific rigor was not mentioned it could have been a useful tool. The participants lived and survived the experience they felt described as a sense of stigma, negative reactions from others, a sense of worthlessness, and a spiritual support that would help he or she feel as if there was someone they could talk to and as well as someone who would listen. The descriptions of the themes provided by the researcher gave one a visual of the feelings and emotions that a person with bipolar disorder with substance use disorder are trying to overcome on a day- to -day basis. The findings were concurrent with the way the participant felt about losing his or her ability to function in society. The diagnosis of bipolar disorder with substance use disorder kept challenges of coping and becoming productive in society at bay. Overcoming these obstacles proved to be a constant challenge.
Without acceptance and forgiveness from society the need to overcome became more challenging and nonexistent. The participants had big dreams that were diminished by the disorders of bipolar and substance use creating havoc in their daily lives that he or she could not cope with. Health care workers can apply specific plans of care for mental health patients with individualized care plans on medication use and symptom management. Alternative plans can help patients find other ways of dealing with everyday problems than using drugs. Patients need education on medication compliance and screening for suicidal ideation. Concepts found in the themes of the study help organize the descriptions of the participants to reduce risk levels and incidence of harm. The type of data used is appropriate for a qualitative method of study. The conclusion of the study revealed and suggested being heard by others affected the participant’s feelings of self- worth and the need for help and support.
Sharing with the reader the researcher makes society aware of the need for the voices of the participants to be heard. The individuals want to be heard, forgiven, and accepted by society. Increasing the awareness of mental health with nurses and the awareness of a higher power was a major accomplishment of this study. Indications for further research studies could provide healthcare workers with the tools needed to disrupt the stigma of mental illness and recognize when patients need help. Had the researcher given the benefits of this study to improving the effects of mental illness and the way society perceives it would have more benefit to the reader. This study was a good example of a qualitative study. Future studies require answers to more questions and a better and knowledgeable understanding of mental illness and substance use.
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