Psychological mechanisms and the ups and downs of personal recovery in bipolar disorder

A multicomponent positive psychology intervention for euthymic patients with bipolar disorder to improve mental well-being and personal recovery: A pragmatic randomized controlled trial

OBJECTIVE

Mental well-being and personal recovery are important treatment targets for patients with bipolar disorder (BD). The goal of this study was to evaluate the effectiveness of an 8-week group multicomponent positive psychology intervention (PPI) for euthymic patients with BD as an adjunct to treatment as usual (TAU) compared to TAU alone.

METHODS

Patients with BD were randomized to receive TAU (n = 43) or the PPI in addition to TAU (n = 54). The primary outcome was well being measured with the Mental Health Continuum-Short Form. Personal recovery was measured with the Questionnaire about the Process of Recovery. Data were collected at baseline, mid-treatment, post-treatment and 6- and 12-month follow-up. Life chart interviews were conducted at 12 months to retrospectively assess recurrence of depression and mania.

RESULTS

Significant group-by-time interaction effects for well-being and personal recovery were found favouring the PPI. At post-treatment, between-group differences were significant for well-being (d = 0.77) and personal recovery (d = 0.76). Between-group effects for well-being were still significant at 6-month follow-up (d = 0.72). Effects on well-being and personal recovery within the intervention group were sustained until 12-month follow-up. Survival analyses showed no significant differences in time to recurrence.

CONCLUSIONS

The multicomponent PPI evaluated in this study is effective in improving mental well-being and personal recovery in euthymic patients with BD and would therefore be a valuable addition to the current treatment of euthymic BD patients. The fact that the study was carried out in a pragmatic RCT demonstrates that this intervention can be applied in a real-world clinical setting.

Recovery beyond clinical improvement - Recovery outcomes measured for people with bipolar disorder between 1980 and 2020

BACKGROUND

Outcome measurement in bipolar disorder (BD) traditionally focused on clinical improvement without considering other domains. Improvement trajectories in clinical and social-functional domains are different and can simultaneously appear in one while not in other domains. Measuring personal recovery (PR) has become a priority internationally. This review explored the shift in research investigating operational recovery definitions and underpinning factors of recovery in BD over the past four decades.

METHODS

Studies defining recovery domains (other than clinical recovery) in BD were systematically reviewed; operational recovery definitions and factors assessed in association with recovery were thematically categorised and integrated in a narrative synthesis.

RESULTS

Thirty-three studies, comprising 3638 participants from 19 countries were included. Identified operational recovery definition themes included i) PR ii) social-functional (SFR), and iii) occupational-residential (ORR) recovery. Examined factors were grouped as demographic, clinical and psychosocial factors. Predominantly demographic factors were linked to ORR and clinical factors to SFR. Depressive symptomatology was the only clinical factor associated with PR. Research investigating psychosocial factors in PR is emerging and has showed that resilience and appraisals of mood seem to be associated with PR.

LIMITATIONS

Studies not available in English or examining functioning without defining recovery were excluded.

CONCLUSIONS

Earlier operational recovery definitions of ORR and SFR were often arbitrary and inconsistent, and predominantly focused on clinical and demographic underpinning factors. While research attempts to follow the significant policy shifts towards personalised care by measuring what matters to individuals and exploring broader underpinning psychosocial factors, it is still lagging behind.

The role of tenacious versus flexible goal pursuit in the vulnerability to bipolar disorder

The vulnerability to bipolar disorder is characterized by dysregulated goal-related behavior, the setting of ambitious and extreme goals, and increases in goal approach behaviors. To date, no studies have investigated the nature of goal pursuit behaviors amongst individuals at a behavioral risk for bipolar disorder in terms of whether goal pursuit is characterized by a tenacious active striving for goals or a more flexible changeable focus on goals. A non-clinical sample of 168 participants completed online measures of mood, bipolar-vulnerability, reward sensitivity, goal-related perfectionist tendencies, tenacious goal pursuit and flexible goal adjustment behaviors. Our findings demonstrate that bipolar-vulnerability is characterized by the tenacious, not flexible, pursuit of goals, in combination with low regulation of goal behavior, and tendencies towards narcissistic and self-critical perfectionism indicative of setting high ambitious standards and making overly harsh self-judgments when such standards are not met. These findings are similar to those from clinical bipolar samples where there is evidence of prolonged symptom recoveries after the experience of goal frustrations and failures. Reducing the tenacious, active striving for goals amongst at-risk individuals may be a potential avenue for early intervention.

Exploring the Personal Recovery Construct in Bipolar Disorders: Definition, Usage and Measurement. A Systematic Review

Personal recovery from psychiatric disorders is a journey toward a satisfying and hopeful life despite the possible persistence of symptoms. This concept has gained interest and become an increasingly important goal in mental health care programmes. Personal Recovery is well described in the context of severe mental illnesses in general, but little is known about this journey in bipolar disorders and the factors underlying it. A systematic review was conducted according to the PRISMA recommendations, focusing on studies exploring personal recovery in bipolar disorder specifically. The latter have integrated a comprehensive approach to the concept, the existing means of measurement or have explored the levers of recovery in care. Twenty-four articles were selected, including seven qualitative, 12 observational, and five interventional studies. The Bipolar Recovery Questionnaire was the only scale developed de novo from qualitative work with bipolar people. Personal recovery did not correlate very closely with symptomatology. Some elements of personal recovery in bipolar disorder were similar to those in other severe mental illnesses: meaning in life, self-determination, hope, and low self-stigma. Specific levers differed: mental relationships with mood swings, including acceptance and decrease in hypervigilance, and openness to others, including trust and closeness. The studies highlighted the role of caregiver posture and the quality of communication within care, as well as the knowledge gained from peers. The choice to exclude articles not focused on bipolar disorder resulted in the provision of very specific information, and the small number of articles to date may limit the scope of the evidence. New components of personal recovery in bipolar disorder emerged from this review; these components could be taken into account in the construction of care tools, as well as in the caregiving posture. Strengthening skills of openness to others could also be a central target of recovery-focused care.

Exploring factors associated with personal recovery in bipolar disorder

BACKGROUND

Personal recovery is increasingly recognized as important outcome for people with bipolar disorder (BD), but research addressing associated factors of personal recovery in this group remains scarce. This study aimed to explore the association of sociodemographic variables, social participation, psychopathology, and positive emotion regulation with personal recovery in BD.

METHODS

Baseline data from a randomized controlled trial and survey data were combined (N = 209) and split into a training (n = 149) and test sample (n = 60). Block-wise regression analyses and model training were used to determine the most relevant predictors. The final parsimonious model was cross-validated in the test sample.

RESULTS

In the final parsimonious model, satisfaction with social roles (β = .442, p < .001), anxiety symptoms (β = -.328, p < .001), manic symptoms (β = .276, p < .001), and emotion-focused positive rumination (β = .258, p < .001) were independently associated with personal recovery. The model explained 57.3% variance in personal recovery (adjusted R²  = .561) and performed well in predicting personal recovery in the independent test sample (adjusted R²  = .491).

CONCLUSIONS

Our findings suggest that especially social participation, anxiety and positive rumination might be relevant treatment targets when aiming to improve personal recovery.

PRACTITIONER POINTS

Personal recovery is considered an increasingly important outcome for people with chronic mental health conditions, including bipolar disorder. We found that anxiety and manic symptoms as well as positive rumination and social participation were independently associated with personal recovery in bipolar disorder. Therefore, these outcomes might be relevant treatment targets when aiming to improve personal recovery in bipolar disorder. Possible interventions to improve these outcomes are discussed, including supported employment and vocational rehabilitation for social participation and exercising with savoring strategies to increase positive rumination.

The Meaning of Recovery: The Lived Experience of Patients with Bipolar Disorder in Turkey

Recovery in mental illness refers to a process with many aspects, steps and meanings. This study aims to provide a deeper understanding of the lived experience of recovery of patients with bipolar disorder. A qualitative approach with 28 participants was performed. Data were collected through semi-structured interviews. The experiences of the individuals regarding the recovery processes were themed with the journey metaphor: the beginning of the journey, the route of the journey, a stop in the journey, the meaning of the journey. This study suggests ways clinicians must be aware of and adopted contemporary approach which recovery is defined as a process beyond treatment.

Testing Kumpfer’s Resilience Model Among Adults With Serious Mental Illness

Having a serious mental illness (SMI) is often associated with significant adversities, and people respond differently to adversities. The existing research supports that people with SMI can achieve and maintain positive life outcomes despite experiencing adversities. Resilience, the ability to cope with (or bounce back quickly from) crisis, can help buffer the negative effects of various types of adversities, including chronic illness and disability, and facilitate the psychosocial adaptation process to SMI. Kumpfer’s resilience model, a person-process-context framework, has been widely used to conceptualize, and assess for, resilience in various populations, including people with chronic illnesses and disabilities. However, the research in resilience among people with SMI is very limited. The purpose of this study was to empirically assess the utility of Kumpfer’s resilience model and its proposed predictive components for conceptualizing the adaptation process to SMI. One hundred forty-four participants completed a Qualtrics survey containing demographic questions and a series of validated instruments representing the major components of Kumpfer’s resilience model. Hierarchical regression analysis was used to analyze the data, and the final model explained 71% of the variance of the dependent variable—adaptation to disability. Avoidance coping, internalized stigma, and optimism were significant independent predictors of adaptation to disability. This study supports the utilization of Kumpfer’s resilience model to conceptualize the adaptation to disability process among people with SMI. Implications for rehabilitation counseling practices are discussed.

Lived Experiences of a Sustained Mental Health Recovery Process Without Ongoing Medication Use

Serious mental health conditions have historically been considered lifelong conditions, with substantial literature supporting pharmaceutical approaches to remission. More recently, the recovery movement has emphasized lasting recovery, which can occur through a variety of pathways. With the traditional focus on medication, less is known about the recovery process of persons who achieve sustained recovery without ongoing medication use. This qualitative study used a grounded theory approach to explore the recovery process of 19 participants with diagnoses of schizophrenia, bipolar disorder, or major depression who were in recovery and not taking medications for at least twelve months. Participants identified internal recovery processes (cognitive changes, emotional processes, and spirituality/faith) leading to a perspective change about self and symptoms. Participants also identified external recovery processes including both support received and productive ways of giving back. The study findings highlight the importance of self-efficacy, emotion management, and social giving in mental health recovery.

Assessment of illness representations in mental disorders: A mini review

Health beliefs, and especially illness representations, have been widely used to understand clinical outcomes and psychosocial adjustment in people with physical diseases. However, this area of research has been under-explored in the field of mental health, and the few studies that have been conducted have used very different methods. Therefore, the aim of our study was to identify the tools and methods that have been used to evaluate illness representations in psychiatry. To this end, a mini review has been conducted and 58 articles were retained. This mini review highlights that the quantitative method is the most used, and that the scales mobilised are often adapted for the study, but not validated. Indeed, multiple modifications and adaptations have been made by the authors (e.g. deletion of subscales, addition of items), which lead to questions about the reliability of what is measured. In the future, it is essential to have a validated generic tool for mental disorders, which could be based on the Illness perceptions questionnaire for schizophrenia.

Psychological factors in personal and clinical recovery in bipolar disorder

BACKGROUND

Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy.

METHODS

This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months.

RESULTS

107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes.

LIMITATIONS

Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample.

CONCLUSIONS

Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

Social media recruitment for mental health research: A systematic review

BACKGROUND

Social media holds exciting promise for advancing mental health research recruitment, however, the extent and efficacy to which these platforms are currently in use are underexplored.

OBJECTIVE

A systematic review was conducted to characterize the current use and efficacy of social media in recruiting participants for mental health research.

METHOD

A literature review was performed using MEDLINE, EMBASE, and PsychINFO. Only non-duplicative manuscripts written in the English language and published between 1/1/2004-3/31/2019 were selected for further screening. Data extracted included study type and design, participant inclusion criteria, social media platform, advertising strategy, final recruited sample size, recruitment location, year, monetary incentives, comparison to other recruitment methods if performed, and final cost per participant.

RESULTS

A total of 176 unique studies that used social media for mental health research recruitment were reviewed. The majority of studies were cross-sectional (62.5%) in design and recruited adults. Facebook was overwhelmingly the recruitment platform of choice (92.6%), with the use of paid advertisements being the predominant strategy (60.8%). Of the reviewed studies, substance abuse (43.8%) and mood disorders (15.3%) were the primary subjects of investigation. In 68.3% of studies, social media recruitment performed as well as or better than traditional recruitment methods in the number and cost of final enrolled participants. The majority of studies used Facebook for recruitment at a median cost per final recruited study participant of $19.47. In 55.6% of the studies, social media recruitment was the more cost-effective recruitment method when compared to traditional methods (e.g., referrals, mailing).

CONCLUSION

Social media appears to be an effective and economical recruitment tool for mental health research. The platform raises methodological and privacy concerns not covered in current research regulations that warrant additional consideration.

Relationship Between Illness Representations, Psychosocial Adjustment, and Treatment Outcomes in Mental Disorders: A Mini Review

Understanding and improving the psychosocial adjustments (e.g., quality of life, depression) and treatment outcomes (e.g., adherence, beliefs about treatments) of people with mental disorders are major health issues. The self-regulation model (SRM) postulates that illness representations play a central role on adjustment and treatment of people with physical illnesses. Recently, the SRM has been used with people with mental disorders. However, the manifestations of somatic and psychiatric disorders can be very different. Therefore, the use of SRM in the field of mental health is very complex. This difficulty, as well as the growing interest for illness representations in the field of mental health, justifies the utility to conduct a review on this topic. The current review shows that illness representations are related to psychosocial adjustment and/or treatment outcomes for people with various mental disorders [e.g., psychotic disorders, mood disorder, posttraumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD)]. However, some limitations to the applicability of SRM to mental disorders have been highlighted. These limitations should be considered in future studies.

Differences in beliefs about mood between people with and without bipolar disorder

Psychological models of bipolar disorder (BD), such as the self-regulation model (SRM; Leventhal, Nerenz, & Steele, 1984), highlight the crucial role of beliefs about mood in relapse vulnerability. To date, no studies have directly compared these beliefs between people with and without BD. Based on the SRM, the current research examined beliefs about mood in people with and without BD and explored the impact of current affect on these beliefs. Fifty euthymic people with a diagnosis of BD and 50 controls were recruited through an online screening study, clinical services, and support organizations. Experience sampling methodology (ESM) was used to assess beliefs (according to the Brief Illness Perceptions Questionnaire; Broadbent, Petrie, Main, & Weinman, 2006) across a typical week of everyday life. Data were analysed using multilevel modelling. Forty-two people with a diagnosis of BD and 50 controls were included in the analyses. Results indicated that the BD group reported less control over mood, a shorter duration of mood, and less understanding of mood and were more likely to report the cause of depressive symptoms as something internal, compared with controls. When controlling for current affect, the BD group also reported more positive consequences, made more internal attributions for hypomanic symptoms, and reported less concern about mood, compared with controls. Findings suggest important differences in beliefs about mood between people with and without BD that are not the result of current affect. These beliefs may be particularly important in understanding underlying vulnerability to future relapse into depression and/or mania.

Use of the Functioning Assessment Short Test (FAST) in defining functional recovery in bipolar I disorder. Post-hoc analyses of long-term studies of aripiprazole once monthly as maintenance treatment

PURPOSE

There is growing agreement that definitions of "recovery" in bipolar-I disorder (BP-I) should include functional outcomes beyond sustained symptomatic remission. In this post-hoc analysis, we assessed functional recovery rates according to the validated Functioning Assessment Short Test (FAST) in participants with BP-I after 52 weeks of maintenance treatment with aripiprazole once monthly (AOM).

PATIENTS AND METHODS

Rates of functional recovery with AOM 400 were investigated in two 52-week studies. NCT01567527 was a placebo-controlled, double-blind, randomized-withdrawal study and NCT01710709 was an open-label study. Functional recovery, assessed at the end of the respective maintenance phases, was defined as a total FAST score of ≤11 for 8 consecutive weeks.

RESULTS

Post-hoc analyses included 229 patients from the randomized-withdrawal study (AOM 400 n=116; placebo n=113). The open-label study included 402 patients (including 321 de novo patients and 81 rollover patients who had completed the randomized-withdrawal study). In the randomized-withdrawal study, functional recovery was achieved by 30.2% (n=35) of the AOM 400 group compared with 24.8% (n=28) in the placebo group. The difference was not statistically significant (p=0.39). In the open-label study, 36% (n=116) of de novo patients and 43% (n=35) of rollover patients had functionally recovered after 52 weeks of AOM 400 treatment.

CONCLUSION

These data highlight the utility of a sustained FAST total score of ≤11 as a definition of recovery and emphasize the possibility of achieving this ambitious treatment goal with effective long-term treatment.

Coping with amplified emotionality among people with bipolar disorder: A longitudinal study

BACKGROUND

The amplified emotionality characteristics of bipolar disorder (BD) may interfere with goal pursuit in the recovery process. This is the first study to test the coping flexibility model empirically among people with BD. Finding ways to cope with goal-striving life events should shed light on managing elevated mood states.

METHODS

Using a 12-month longitudinal follow-up design, this study examined the stability in coping flexibility with experimentally-devised Behavioral Approach System (BAS) activating life events and mood states at 6- and 12-month time points for individuals with BD (n = 83) and healthy controls (n = 89). Hierarchical linear modeling tested the individual growth model by studying the longitudinal data.

RESULTS

The findings showed fluctuations in different components of coping flexibility and mood states across time. They confirmed the amplified emotionality characteristics of BD. Moreover, coping flexibility took precedence over BAS sensitivity and psychosocial functioning levels in predicting mood states.

LIMITATIONS

Measurements of BAS sensitivity may focus on trait nature only and prone to subjective bias. The assessment of mood or coping flexibility may not accurately capture actual experience in daily life. Lack of respective data on bipolar subtypes and significant differences in some dimensions between the BD and control groups are further limitations of the study.

CONCLUSIONS

The study's findings have implications for coping with amplified emotionality within the personal recovery process for people with BD. Judicious application of coping strategies and adjustment of perceived controllability are crucial for individuals to reach goals pertinent to personal recovery and manage potential manic mood symptoms.