We identified several key themes within each domain of enquiry
Accessibility and flexibility
The effect of illness on engagement with the programme
The importance of accessing the programme in a private environment
Clarity and quality of content
Dislike of actors’ acting
Difficulty with the interactive “life chart” exercise
Lack of activity on the forum
Presentation of lithium within the medication module
Preferences for alternatives to the computer-based format
Internet-based psychoeducation lacks the sociability of group-based learning
Groups of people with mental illness are unappealing
Internet-based psychoeducation may be more acceptable than group-based psychoeducation for those newly diagnosed
Minimal contribution to existing knowledge for those with a long-standing diagnosis
Potential greater impact for those with a recent diagnosis
Greater knowledge of bipolar disorder
Behaviour change as a result of the programme
Change in attitudes towards medication
Facilitation of greater understanding and support from others
The implementation of the programme was found to be feasible for those who had access to a computer and were willing and sufficiently able to use a computer. The programme was commended on its accessibility and ease of use. Some participants specified that they required privacy when accessing the programme and others commented that they needed to be well enough to undertake the programme in order to concentrate on it. This confirms the finding of a recent study examining the predictors of attrition of an online bipolar education programme where the most common theme arising from interviews was that the nature of the illness made it difficult for some participants to continue their involvement with the programme .
The programme was found to be acceptable to participants who were satisfied overall with the content and presentation of the programme and made suggestions for improvements. The presentation of the programme was reported to be professional and clear, and the pace of the modules and the time between modules was regarded as acceptable. Revisions of the programme should focus on the use of actors, the forum, the life chart exercise, and the content of the medication module. An alternative format of the programme, such as group-based psychoeducation or a psychoeducation manual for patients, should be offered for those who are resistant to using a computer, perhaps especially for older individuals who may not be familiar with using the internet.
We found that many participants who preferred internet-based psychoeducation for bipolar disorder felt that interacting with groups of people with mental illness was not an appealing prospect for them. These individuals did not easily identify with people whom they considered to have a serious mental illness and felt that they would be frightened or easily upset by witnessing others with a more severe form of the disorder. Additionally, we found that some participants regarded online psychoeducation as more suitable than group-based psychoeducation for those newly diagnosed, due to the accessibility, flexibility, privacy, and anonymity of online psychoeducation and the stigma associated with groups of people with mental illness. This finding supports the results of a study of computerised cognitive behavioural therapy for depression, in which freedom and anonymity were found to be motivating factors contributing to adherence to online self-help .
Participants who expressed a preference for group-based face-to-face psychoeducation preferred the sociability of group-based learning. Many of these individuals were resistant to using a computer. There were clear limitations within the forum, which was not as effective as we had hoped in providing peer and social support. A key insight from the focus groups which were held initially to develop the content and format of this intervention was that social support via an online forum was desirable . The purpose of the forum was to enable participants to discuss their experiences of the modules and their illness with a view to enhancing their learning experiences and reducing any feelings of social isolation or stigma . It is apparent that the forum did not serve this purpose, perhaps because of its lack of critical mass (only half of all trial participants in the intervention arm contributed to the forum ), its lack of input from professionals and because for some it was not viewed as an appropriate medium for social support. It is of interest that previous research in the field of internet-based cancer support interventions has identified that newly diagnosed individuals are much more likely to participate in online discussion groups rather than take part in face-to-face support groups [26–28]. Our online forum may therefore be better suited to those at an early stage of illness.
Participants’ capacity to benefit from the programme was reduced for those who had been diagnosed with bipolar disorder many years previously. For these participants the programme contributed little to their existing knowledge of bipolar disorder. The programme was found to impact to some degree upon some participants’ insight into their illness – specifically, their knowledge of self-management techniques, their self-awareness, and their acceptance of their illness. Furthermore, the programme impacted on health behaviours, lifestyles and personal routines and attitudes towards medication. Many participants chose to share the content of the programme with others, which they reported as having contributed to the quality of their personal relationships through enhanced communication and understanding.