Psychological approaches to understanding and promoting recovery in psychosis and bipolar disorder: a mixed-methods approach

Abstract

BackgroundRecovery in mental health is a relatively new concept, but it is becoming more accepted that people can recover from psychosis. Recovery-orientated services are recommended for adult mental health, but with little evidence base to support this.ObjectivesTo facilitate understanding and promotion of recovery in psychosis and bipolar disorder (BD), in a manner that is empowering and acceptable to service users.MethodThere were six linked projects using qualitative and quantitative methodologies: (1) developing and piloting a service user-defined measure of recovery; (2) a Delphi study to determine levels of consensus around the concept of recovery; (3) examination of the psychological factors associated with recovery and how these fluctuate over time; (4) development and evaluation of cognitive–behavioural approaches to guided self-help including a patient preference trial (PPT); (5) development and evaluation of cognitive–behavioural therapy (CBT) for understanding and preventing suicide in psychosis including a randomised controlled trial (RCT); and (6) development and evaluation of a cognitive–behavioural approach to recovery in recent onset BD, including a RCT of recovery-focused cognitive–behavioural therapy (RfCBT). Service user involvement was central to the programme.ResultsMeasurement of service user-defined recovery from psychosis (using the Subjective Experience of Psychosis Scale) and BD (using the Bipolar Recovery Questionnaire) was shown to be feasible and valid. The consensus study revealed a high level of agreement among service users for defining recovery, factors that help or hinder recovery and items which demonstrate recovery. Negative emotions, self-esteem and hope predicted recovery judgements, both cross-sectionally and longitudinally, whereas positive symptoms had an indirect effect. In the PPT, 89 participants entered the study, three were randomised, 57 were retained in the trial until 15-month follow-up (64%). At follow-up there was no overall treatment effect on the primary outcome (Questionnaire about the Process of Recovery total;p = 0.82). In the suicide prevention RCT, 49 were randomised and 35 were retained at 6-month follow-up (71%). There were significant improvements in suicidal ideation [Adult Suicidal Ideation Questionnaire; treatment effect = –12.3, 95% confidence interval (CI) –24.3 to –0.14], Suicide Probability Scale (SPS; treatment effect = –7.0, 95% CI –15.5 to 0) and hopelessness (subscale of the SPS; treatment effect = –3.8, 95% CI –7.3 to –0.5) at follow-up. In the RCT for BD, 67 participants were randomised and 45 were retained at the 12-month follow-up (67%). Recovery score significantly improved in comparison with treatment as usual (TAU) at follow-up (310.87, 95% CI 75.00 to 546.74). At 15-month follow-up, 32 participants had experienced a relapse of either depression or mania (20 TAU vs. 12 RfCBT). The difference in time to recurrence was significant (estimated hazard ratio 0.38, 95% CI 0.18 to 0.78;p < 0.006).ConclusionsThis research programme has improved our understanding of recovery in psychosis and BD. Key findings indicate that measurement of recovery is feasible and valid. It would be feasible to scale up the RCTs to assess effectiveness of our therapeutic approaches in larger full trials, and two of the studies (CBT for suicide prevention in psychosis and recovery in BD) found significant benefits on their primary outcomes despite limited statistical power, suggesting definitive trials are warranted.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Characterizing the experience of auditory verbal hallucinations and accompanying delusions in individuals with a diagnosis of bipolar disorder: A systematic review

“…mood appraisals, sleep, coping styles or psychotic experiences) . Indeed, there are very few high‐quality, randomized controlled trials of targeted psychological interventions that have been completed early in the course of BD . This is despite current cognitive models indicating that psychological interventions in BD may be more efficacious if delivered prior to the complicating effects of subsequent mood episodes .…”

“…81 Indeed, there are very few high-quality, randomized controlled trials of targeted psychological interventions that have been completed early in the course of BD. 82,83 This is despite current cognitive models indicating that psychological interventions in BD may be more efficacious if delivered prior to the complicating effects of subsequent mood episodes. 82 Yet evidence is growing to improve our understanding of experiences early in the course of BD 84 and studies are emerging that will specifically assess the suitability and efficacy of targeted psychological interventions during the early phases of illness; e.g.…”

“…82,83 This is despite current cognitive models indicating that psychological interventions in BD may be more efficacious if delivered prior to the complicating effects of subsequent mood episodes. 82 Yet evidence is growing to improve our understanding of experiences early in the course of BD 84 and studies are emerging that will specifically assess the suitability and efficacy of targeted psychological interventions during the early phases of illness; e.g. 85 33,89 It may be that fewer omnipotent/malevolent appraisals of voices in BD simply reflect less disturbance from AVH experiences when out of an acute mood episode, and therefore a limited requirement for intervention.…”

A population‐based study of the comparative effectiveness of second‐generation antipsychotics vs older antimanic agents in bipolar disorder

“…Although we controlled for many variables that may have an impact on outcome, it is plausible that SGA and lithium or valproate initiators differed in terms of unmeasured covariates. It is conceivable, for instance, that the groups differed in characteristics independently related to likelihood of hospitalization, such as neuropsychological function or attitudinal, self‐management, or other features more amenable to qualitative analysis …”

“…It is conceivable, for instance, that the groups differed in characteristics independently related to likelihood of hospitalization, such as neuropsychological function 35 or attitudinal, self-management, or other features more amenable to qualitative analysis. 36 Nonetheless, these population-based results provide complementary information to data from randomized controlled trials which are carried out under stringent protocol controls, with highly selected samples of volunteer participants. In postmarketing surveillance for drug safety, the optimistic story told by published clinical trials often contrasts with less favorable data from more inclusive populationbased studies, as has been shown for antipsychotics 37,38 and other drugs.…”