Psychosocial Interventions for Psychosis and Bipolar (PDF)

**Psychosocial Interventions for Psychosis and Bipolar:** *Prof Sonia Johnson* **Notes:** **Psychosocial Interventions in Psychosis and Bipolar Disorder** **What does research tell us about:** - The difficulties people with psychosis/bipolar face in their lives and the evidence on the cou...

**Psychosocial Interventions for Psychosis and Bipolar:** *Prof Sonia Johnson* **Notes:** **Psychosocial Interventions in Psychosis and Bipolar Disorder** **What does research tell us about:** - The difficulties people with psychosis/bipolar face in their lives and the evidence on the course of their illnesses. - Potential approaches to improving the prognosis of psychosis and bipolar disorder and to promoting recovery? - Potential approaches to improving improve social participation and quality of life among people with psychosis and bipolar disorder **The course of psychosis/schizophrenia** - *Lally et al (2017)*: Systematic review and meta-analysis of studies of psychosis outcome after first onset -- 19,000 people in total in above studies - **Remission** (getting better (back to normal) following first episode): pooled rate 58% - Poor remission in studies before 1976, but little change since then. - **Recovery**: Sustained period of at least 2 years good functioning and few or no symptoms: pooled estimate 38% had recovered after mean follow-up 7 years. - High rates of recovery in USA, lower in Europe - Hadn't changed over time - possibly worse - Better outcome reported from lower and middle income countries, but uncertainty about methods (continuing debate) - Huxley et al. (2021): 21st century studies: - Prognosis better for first episode psychosis than 20th century - Annual remission rate after multiple episodes declining, especially after 2008 financial crash (long-term outcome had become worse) - Lower and Middle Income Countries - outcomes similar or better, especially employment (tend to have higher employment rates, possibly easier to get jobs and less specialist jobs) - Employment rates have declined in higher income countries for those with mental illness - though previously may have been paid a low wage and doing 'basic' jobs **The course of Bipolar Disorder** Research is not strong not as much bipolar research available compared to psychosis (diagnostic problems hamper), but: - Most have relapsing/remitting course - continue to have episodes across lifetime though make a good recovery in-between - A Stage model of bipolar recently discussed - Approx. 15% **chronically unwell** on long-term follow-up (e.g. 15 yrs -- *Coryell et al., 1999*) - **16% in remission (been well) for 5 years** on 40 year follow up (*Angst and Preiseg, 1994*): - **Median time being ill**: 20% - 44% (*Carlson et al. 2012; Keck et al., 2003*). - Majority of time depressed when not functioning well the rest of the time. - Little evidence of change in prognosis in past few decades **A Challenge** - Not much evidence of progress in achieving substantial change in mental health outcomes for people with severe mental health problems such as psychosis and bipolar - Introduction of **antipsychotics(Lithium)/deinstitutionalisation** may have been **last significant shift** (1950s) - Many common physical long-term conditions (Cancer, CVD) have seen steady progress - Outcomes may still be better, or at least as good, in countries with little mental health care (*but disputed* ) - We really still need to start moving the needle on psychosis/bipolar outcomes, for clinical populations not just trial participants **Why have we not done better?** - Neuroscience/Pharmacology: Still investing and waiting for the great leap forward - Understand the basis a lot better from these perspectives than previously - Psychology: Small benefits so far from interventions that have been hard to implement widely - Difficult to find larger effects in Psychosis and Bipolar seems more difficult - Innovative service models: Benefits from EI, but short term. Changing service organisation may not sufficiently change content of care. - Large scale implemented model may have the best evidence at the moment - The implementation gap: translation of positive findings to practice often slow/doesn't occur - Observation is across healthcare/MHC - there's many years before wide role out of interventions found to be effective in trials - Still research into the barriers of implementation - E.g. Family Intervention in Psychosis - lots of studies supporting large impacts at an early stage in psychosis to reduce high expressed emotion - though not greatly implemented - Social determinants of mental health: hard to mitigate impacts of austerity, inequality etc. - Inequality has risen in the world in the last few decades - A lot of traumatic events have happened in the world - Problems of injustice/lack of compassion in services - A lack of quality in care - Stigma/lack of equity with physical health **What could be done to improve outcomes/promote recovery among people with Psychosis\*\*?\*\*** - Better pharmacological and psychological interventions - Better implementation of the treatments we already have (1) - Improvements to teams and services (2) - Focus on service users' own definitions of recovery (3) - Focus on the social part of the biopsychosocial triad (4) **Routes to improving outcomes (1): Implementing what we already know to work** - Failure to implement models as intended or to deliver evidence-based interventions pervades mental health care: - E.g. \