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

CoDesign of a digital intervention for parents with bipolar disorder informed by integrated knowledge translation principles

OBJECTIVES

To provide detailed information on the codesign of a digital intervention to support parents with bipolar disorder (BD) who have young children. Each step of this process is reported, as well as a detailed description of the final version of the intervention in line with the TIDieR framework.

METHODS

Clinical experience and lived experience experts participated in online workshops, meetings, and remote feedback requests, informed by Integrated Knowledge Translation (IKT) principles. The IKT research group responded to each phase of recommendations from the knowledge users.

RESULTS

Five clinical experience experts and six lived experience experts engaged with the codesign process. Their recommendations for principles, content, look, and feel, and functionality of the digital intervention were structured over five iterative phases. This led to a final implemented design that was identified by the clinical and lived experience experts (referred to together as the knowledge users group) as genuinely reflecting their input.

CONCLUSIONS

The IKT principles offer an accessible structure for engaging with clinical and lived experience experts throughout a codesign process, in this case for a digital intervention for parents with BD. The resulting intervention is described in detail for transparency to aid further evaluation and development and to help other teams planning codesign approaches to intervention development.

Personal Recovery With Bipolar Disorder: A Network Analysis

BACKGROUND

Personal recovery is valued by people with bipolar disorder (BD), yet its conceptualisation is unclear. Prior work conceptualising personal recovery has focussed on qualitative evidence or clinical factors without considering broader psychosocial factors. This study used a network analysis of Bipolar Recovery Questionnaire (BRQ) responses, aiming to identify (1) independent relationships between items to identify those most "central" to personal recovery and (2) how the relationships between items reflect themes of personal recovery.

METHODS

The model was developed from BRQ responses (36 items) from 394 people diagnosed with bipolar disorder. The undirected network was based on a partial correlation matrix and was weighted. Strength scores were calculated for each node. Community detection analysis identified potential themes. The accuracy of the network was assessed using bootstrapping.

RESULTS

Two consistent communities were identified: "Access to meaningful activity" and "Learning from experiences." "I feel confident enough to get involved in things in life that interest me" was the strongest item, although the strength stability coefficient (0.36) suggested strength should be interpreted with caution. The average edge weight was 0.02; however, stronger edges were identified.

LIMITATIONS

The network showed low stability, possibly due to sample heterogeneity. Future work could incorporate demographic variables, such as time since BD diagnosis or stage of personal recovery, into network estimation.

CONCLUSIONS

Network analysis can be applied to personal recovery, not only clinical symptoms of BD. Clinical applications could include tailoring recovery-focussed therapies towards encouraging important aspects of recovery, such as feeling confident to get involved with life.

Cognitive behavioural therapy added to standard care for first-episode and recent-onset psychosis

BACKGROUND

Cognitive behavioural therapy (CBT) can be effective in the general population of people with schizophrenia. It is still unclear whether CBT can be effectively used in the population of people with a first-episode or recent-onset psychosis.

OBJECTIVES

To assess the effects of adding cognitive behavioural therapy to standard care for people with a first-episode or recent-onset psychosis.

SEARCH METHODS

We conducted a systematic search on 6 March 2022 in the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, ISRCTN, and WHO ICTRP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CBT added to standard care vs standard care in first-episode or recent-onset psychosis, in patients of any age.

DATA COLLECTION AND ANALYSIS

Two review authors (amongst SFM, CC, LK and IB) independently screened references for inclusion, extracted data from eligible studies and assessed the risk of bias using RoB2. Study authors were contacted for missing data and additional information. Our primary outcome was general mental state measured on a validated rating scale. Secondary outcomes included other specific measures of mental state, global state, relapse, admission to hospital, functioning, leaving the study early, cognition, quality of life, satisfaction with care, self-injurious or aggressive behaviour, adverse events, and mortality.

MAIN RESULTS

We included 28 studies, of which 26 provided data on 2407 participants (average age 24 years). The mean sample size in the included studies was 92 participants (ranging from 19 to 444) and duration ranged between 26 and 52 weeks. When looking at the results at combined time points (mainly up to one year after start of the intervention), CBT added to standard care was associated with a greater reduction in overall symptoms of schizophrenia (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.08, 20 RCTs, n = 1508, I2 = 68%, substantial heterogeneity, low certainty of the evidence), and also with a greater reduction in positive (SMD -0.22, 95% CI -0.38 to -0.06, 22 RCTs, n = 1565, I² = 52%, moderate heterogeneity), negative (SMD -0.20, 95% CI -0.30 to -0.11, 22 RCTs, n = 1651, I² = 0%) and depressive symptoms (SMD -0.13, 95% CI -0.24 to -0.01, 18 RCTs, n = 1182, I² = 0%) than control. CBT added to standard care was also associated with a greater improvement in the global state (SMD -0.34, 95% CI -0.67 to -0.01, 4 RCTs, n = 329, I² = 47%, moderate heterogeneity) and in functioning (SMD -0.23, 95% CI -0.42 to -0.05, 18 RCTs, n = 1241, I² = 53%, moderate heterogeneity, moderate certainty of the evidence) than control. We did not find a difference between CBT added to standard care and control in terms of number of participants with relapse (relative risk (RR) 0.82, 95% CI 0.57 to 1.18, 7 RCTs, n = 693, I² = 48%, low certainty of the evidence), leaving the study early for any reason (RR 0.87, 95% CI 0.72 to 1.05, 25 RCTs, n = 2242, I² = 12%, moderate certainty of the evidence), adverse events (RR 1.29, 95% CI 0.85 to 1.97, 1 RCT, n = 43, very low certainty of the evidence) and the other investigated outcomes.

AUTHORS' CONCLUSIONS

This review synthesised the latest evidence on CBT added to standard care for people with a first-episode or recent-onset psychosis. The evidence identified by this review suggests that people with a first-episode or recent-onset psychosis may benefit from CBT additionally to standard care for multiple outcomes (overall, positive, negative and depressive symptoms of schizophrenia, global state and functioning). Future studies should better define this population, for which often heterogeneous definitions are used.

Developing an International Standard Set of Patient-Reported Outcome Measures for Psychotic Disorders

OBJECTIVE

The objective of this project was to develop a set of patient-reported outcome measures for adolescents and adults who meet criteria for a psychotic disorder.

METHODS

A research team and an international consensus working group, including service users, clinicians, and researchers, worked together in an iterative process by using a modified Delphi consensus technique that included videoconferencing calls, online surveys, and focus groups. The research team conducted systematic literature searches to identify outcomes, outcome measures, and risk adjustment factors. After identifying outcomes important to service users, the consensus working group selected outcome measures, risk adjustment factors, and the final set of outcome measures. International stakeholder groups consisting of >100 professionals and service users reviewed and commented on the final set.

RESULTS

The consensus working group identified four outcome domains: symptoms, recovery, functioning, and treatment. The domains encompassed 14 outcomes of importance to service users. The research team identified 131 measures from the literature. The consensus working group selected nine measures in an outcome set that takes approximately 35 minutes to complete.

CONCLUSIONS

A set of patient-reported outcome measures for use in routine clinical practice was identified. The set is free to service users, is available in at least two languages, and reflects outcomes important to users. Clinicians can use the set to improve clinical decision making, and administrators and researchers can use it to learn from comparing program outcomes.

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.

Caring for caregivers: Understanding and meeting their needs in coping with first episode psychosis

AIM

The first episode of psychosis is a challenging time for both patients and those who care for them. Although literature on treatment is plentiful, literature on how to best support caregivers is more scarce. This review was undertaken to better understand the caregiver experience, determine which interventions most effectively alleviate their burden and examine which other factors may affect outcomes.

METHODS

Articles were retrieved from PubMed and OVID using the following search terms: first episode psychosis (FEP), schizophrenia, caregiver, intervention and burden in various combinations. Only peer-reviewed articles germane to FEP caregiver experience and interventions written in English were included.

RESULTS

Caregivers can experience grief, guilt and anxiety during this time. While concerned for their loved one, their own lives take a back seat and their mental and physical health are adversely affected. Some are better prepared to cope and are typically warm, decisive, confident and optimistic. Their families are organized and flexible. Others are less prepared and are more likely to have poor self-esteem, use avoidant coping strategies and be overly critical. Their families are controlling and have difficulty with communication and balance. These caregivers stand to benefit most from interventions.

CONCLUSIONS

Effective interventions incorporate psychoeducation, problem solving strategies, peer support and clinician guidance. A higher level of interaction with facilitators and peers is associated with better results. Benefits include decreases in caregiver burden, depressive and anxious symptoms and feelings of shame and isolation. Although the literature has yet to isolate the key factors of a successful intervention, this review provides practical suggestions for clinicians and further illustrates the need for more research.

Relationships between psychiatric symptoms, functioning and personal recovery in psychosis

BACKGROUND

Recovery from psychosis is increasingly being viewed as a combination of symptomatic, functional, and personal recovery. Negative and depressive symptoms have been linked to community functioning, and negative affect has been linked to personal recovery. The current study examines differential associations of symptoms with functional and personal recovery, and the interaction of cognitive and emotional components of psychotic experiences in predicting recovery.

METHODS

Baseline data from four studies of individuals with schizophrenia-spectrum disorders were amalgamated for the current analyses. All studies utilized the Positive and Negative Syndrome Scale, Psychotic Symptom Rating Scale, Personal and Social Performance Scale, and the Questionnaire about the Process of Recovery.

RESULTS

971 individuals participated across the four studies. Affective symptoms were most strongly associated with personal recovery, accounting for 30% of the variance in personal recovery and only 2% of the variance in objective functioning. Negative and disorganized symptoms were related to both functional and personal recovery, excitement symptoms were only related to personal recovery, and broad measures of positive symptoms were not associated with either functional or personal recovery. Cognitive interpretations of psychotic experiences were more strongly related to objective functioning, and emotional components of psychotic experiences were more strongly related to personal recovery; cognitive interpretations moderated the relationship between emotional characteristics and recovery measures.

CONCLUSIONS

Functional and personal recovery are distinct domains of recovery with differential relationships to symptomatology. Interventions that target cognitive interpretations of psychotic experiences and negative affect may be more likely to affect multiple domains of recovery.

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.

Delivery of cognitive-behaviour therapy for psychosis: a service user preference trial

BACKGROUND

Clinical guidelines recommend cognitive behaviour therapy (CBT) for people with psychosis, however, implementation is poor and not everyone wishes to engage with therapy. Understanding service user (SU) preferences for receiving such treatments is a priority for services.

AIMS

To explore SU preferences and outcomes of different methods of delivering CBT for psychosis.

METHOD

SUs experiencing psychosis could choose between treatment as usual (TAU); TAU plus telephone-delivered CBT with self-help, CBT recovery manual (TS); high support CBT (HS - TAU plus TS plus group sessions) or randomisation. Participants received their option of choice and were followed-up on several outcomes over 9 and 15 months.

RESULTS

Of 89 people recruited, three chose to be randomised and 86 expressed a treatment preference (32 chose TAU, 34 chose TS, 23 chose HS). There were few differences between those who chose therapy compared to those who chose TAU. Those who had more positive impacts from their symptoms were significantly more likely to choose TAU.

CONCLUSIONS

Most people had strong preferences about treatment delivery and a substantial number did not wish to receive additional therapy. These findings have to be considered when planning and allocating resources for people with psychosis.

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

OBJECTIVES

The aim of the current study was to inform ongoing attempts to identify clinically meaningful subcategories of auditory verbal hallucination (AVH), and to evaluate evidence that might pertain to the suitability of current psychological interventions for people with bipolar disorder (BD) who experience psychotic symptoms.

METHODS

A comprehensive synthesis of findings on the phenomenology of AVH and delusions in BD is included, alongside a critical review of clinical and cognitive correlates. Studies published in the previous 20 years, until December 2016, were retrieved from the following databases: Embase, CINAHL, MEDLINE, PsycINFO and Web of Science. Thirty-two articles were reviewed after applying a set of predetermined inclusion criteria.

RESULTS

Psychotic symptoms were common in both manic and depressive phases, although higher frequencies were indicated in mania. Few detailed characterizations of AVH phenomenology were identified. Delusions with persecutory, grandiose and referential themes were the most common in BD. AVHs were associated with delusions and there was evidence to suggest that delusion subtype may vary according to mood state and type of AVH. Data on clinical correlates of AVH in BD were sparse. However, the results indicated that cognitive appraisals or interpretations of voices might be different in BD from those established to be predictive of clinical outcomes in schizophrenia spectrum disorders.

CONCLUSIONS

Clear gaps exist in our current understanding of the first-person experience of AVH in BD and the potential relationship to co-occurring symptoms, including delusions. Further research into cognitive interpretations of AVH in BD might inform adapted psychological interventions for psychotic symptoms in this population.

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

OBJECTIVES

Numerous antimanic treatments have been introduced over the past two decades, particularly second-generation antipsychotics (SGAs). However, it is not clear whether such newer agents provide any advantage over older treatments.

METHODS

A historical cohort design investigated the nationwide population of outpatients with bipolar disorder treated in the Department of Veterans Affairs who were newly initiated on an antimanic agent between 2003 and 2010 (N=27 727). The primary outcome was likelihood of all-cause hospitalization during the year after initiation, controlling for numerous demographic, clinical, and treatment characteristics. Potential correlates of effect were explored by investigating time to initiation of a second antimanic agent or antidepressant.

RESULTS

After control for covariates, those initiated on lithium or valproate monotherapy, compared to those beginning SGA monotherapy, were significantly less likely to be hospitalized, had a longer time to hospitalization, and had fewer hospitalizations in the subsequent year. Those on combination treatment had a significantly higher likelihood of hospitalization, although they also had a longer time to addition of an additional antimanic agent or antidepressant.

CONCLUSIONS

The present analysis of a large and unselected nationwide population provides important complementary data to that from controlled trials. Although various mechanisms may be responsible for the results, the data support the utilization of lithium or valproate, rather than SGAs, as the initial antimanic treatment in bipolar disorder. A large-scale, prospective, randomized, pragmatic clinical trial comparing the initiation of SGA monotherapy to that of lithium or valproate monotherapy is a logical next step.