Anthony P Morrison, Heather Law, Christine Barrowclough, Richard P Bentall, Gillian Haddock, Steven H Jones, Martina Kilbride, Elizabeth Pitt, Nicholas Shryane, Nicholas Tarrier, Mary Welford, and Graham Dunn.
Southampton (UK): NIHR Journals Library; 2016 May
Abstract
Background:
Recovery
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.
Objectives:
To
facilitate understanding and promotion of recovery in psychosis and bipolar
disorder (BD), in a manner that is empowering and acceptable to service users.
Method:
There
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.
Results:
Measurement
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).
Conclusions:
This
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.
Funding:
The
National Institute for Health Research Programme Grants for Applied Research
programme.
Plain
English summary
Psychosis
(including disorders such as schizophrenia, which are characterised by hearing
voices or paranoid beliefs) and bipolar disorder (BD) (characterised by mood
swings) are common forms of serious mental health problems. Clinical services
typically define recovery in terms of absence of symptoms. In contrast, service
users conceptualise recovery as a unique process rather an end point, with key
themes including hope, rebuilding self and rebuilding life. Our research aimed
to understand and promote recovery in psychosis and BD, in a manner that is
acceptable to and empowering of service users. Six linked projects were
conducted using a variety of methods to develop new ways of measuring recovery;
to understand what recovery means to service users and what factors promote
recovery; to understand how recovery, symptoms and psychological well-being are
related; to examine what sort of factors predict recovery; and to test three
new interventions. All projects were conducted in collaboration with service
users and the research team included two service user researchers. Our research
has made significant additions to our understanding and promotion of recovery,
including the development of two new measures which were shown to be valid and
acceptable to service users. We have shown that we can measure recovery, that
factors such as reduced negative emotions, increased self-esteem and hope are
predictive of recovery judgements and that the new interventions tested showed
promising benefits to people with psychosis and suicidal thinking and people
with BD. These findings have important implications for future research and for
clinical practice.
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