Phase 1: Qualitative Analysis of Recovery in Bipolar Disorder

Background

Although there is an increasing recovery literature for individuals with experience of psychosis, there has been little or no research of this type specifically targeted at individuals with a diagnosis of bipolar disorder. As with psychosis in general most individuals with a bipolar diagnosis will continue to experience psychiatric symptoms despite psychiatric treatment (Judd et al., 2003). However, as the recovery literature increasingly shows, individual definitions of recovery are diverse and rarely focus on eradication of symptoms.

Study

In this phase a qualitative approach will be employed to identify the key themes associated with recovery in individuals who have a diagnosis of bipolar disorder. This phase will; 1) Explore the subjective experience of recovery; 2) Elicit service user definitions of recovery; and 3) Identify themes for the recovery process.

Recruitment for this phase completed in July 2009

Phase 2: Development and Evaluation of the Bipolar Recovery Questionnaire (BRQ)

Background

It is important that we have appropriate tools for the assessment of recovery relevant outcomes in individuals with bipolar disorder so that new interventions and routine service outcomes can be assessed with respect to factors which are valued by individual service users.

Study

On the basis of the information collected in Phase 1 a self-report questionnaire will be constructed to provide a quantitative measure of recovery from bipolar disorder (the Bipolar Recovery Questionnaire; BRQ). Each of the items in the BRQ will reflect the themes elicited in phase 1. The validity of the BRQ will be assessed in this phase and it will be explored whether recovery themes endorsed are related to, or indeed independent of, measures of symptoms and functioning.

Recruiting for this phase between November 2009 and April 2010

Phase 3: An Exploratory Randomised Controlled Trial of a CBT-based Recovery Intervention for First Diagnosis Bipolar Disorder

Background

Recently the National Institute for Clinical Excellence Bipolar Guideline recommended that individual structured psychological treatment is offered to individuals with a diagnosis of bipolar disorder (NICE, 2006). Their review of the evidence concluded that psychological interventions (primarily CBT) are associated with reductions in relapse risk in individuals with a diagnosis of bipolar disorder. However the most recent study of CBT for relapse prevention in bipolar disorder found that there was a significant interaction between number of episodes and outcome, with only those with fewer episodes benefiting significantly (Scott et al., 2006). To date no cognitive behaviour therapy interventions have been specifically designed for delivery to individuals early in their illness course. Our group has therefore devised an adapted CBT intervention for individuals after first diagnosis of bipolar disorder. This has proved to be acceptable and feasible in a single case series of 7 bipolar participants.

Study

Phase 3 of the project will therefore further develop this cognitive behavioural approach for individuals with a first diagnosis of bipolar disorder by evaluating an exploratory RCT for an individual CBT-based recovery intervention for individuals with a first diagnosis of bipolar disorder. In particular the elements of the intervention will be adapted in accordance with findings from the evaluation of recovery themes from the initial phase of the study and recovery will constitute a primary outcome for this new intervention.

Individual Recovery Focused CBT Intervention

The detail of the proposed individual intervention will be finalised by a multidisciplinary group of mental health professionals and service users. The elements of the intervention will be informed by current evidence for components of effective CBT interventions including mood monitoring and awareness, regularisation of routines, enhancing prodromal coping and problem solving training (Jones, 2004). In addition, our experience from our case series study of first diagnosis bipolar clients indicates the importance of maintaining a very flexible engagement approach, allowing time for full consideration of meaning of diagnosis to the client, engaging in coping skills reviews around subsyndromal exacerbations as well as prior episodes and considering the role of appraisals of fluctuations in affect. The finalised intervention will also incorporate additional recovery relevant elements agreed by the multidisciplinary group.

The intervention will be delivered by mental health professionals trained to BABCP accreditation level in CBT. Therapy will consist of up to 18 sessions delivered over a period of approximately six months.