Recovering from first episode psychotic mania: The experience of people diagnosed with bipolar disorder

Early intervention for people diagnosed with bipolar disorder is a priority, but little is known about how recovery from first episode psychotic mania is experienced by this group. This study aimed to explore the experience of recovery from first episode psychotic mania for people diagnosed with bipolar disorder.

In the UK, recovery for people following first episode psychotic mania is likely to be managed within early intervention psychosis (EIP) services (Marwaha et al., 2016). Estimates suggest that people with first episode BD make up 5-20% of service caseloads (Henry et al., 2007;Macneil et al., 2011). EIP services aim to reduce the duration of untreated psychosis, prevent relapse and hospitalization (National Institute for Health and Clinical Excellence, 2014). However, EIP interventions, have largely been developed in line with evidence from studies focusing on first-episode schizophrenia and are not specifically tailored for BD (Jauhar et al., 2019). More recently, EIP staff have emphasized the need for better understanding of first episode BD to optimize care (Marwaha et al., 2018).
The predominant focus in the qualitative literature has been on recovery from first episode psychosis (FEP) for young people diagnosed with schizophrenia or schizoaffective disorder. While some studies have focused on service-related and relational factors that facilitate recovery, others have examined how recovery is perceived by young people following FEP. Recovery from FEP is multi-faceted, encompassing the alleviation of symptoms (Eisenstadt et al., 2012), the development of agency and control (Bjornestad et al., 2017;Connell et al., 2015;de Wet et al., 2015), promoting a sense of hope (Bonnett et al., 2018;Romano et al., 2010;Windell et al., 2012), along with establishing autonomy, a positive identity and social relationships (Eisenstadt et al., 2012).
Key meanings underpinning personal recovery from FEP, such as the development of agency, autonomy and a positive identity, partly rely on social integration and are realized through the rediscovery of abilities, work activities and hobbies (Connell et al., 2015;de Wet et al., 2015;Jordan et al., 2017). Re-engaging in previous aspirations and establishing new short-term goals also promotes hope and normalcy (Bonnett et al., 2018;Lam et al., 2010;Romano et al., 2010).
To date, no study has explored the experience of recovering from first episode psychotic mania for people diagnosed with BD. And yet a better understanding of this aspect for this group has important clinical implications for the development of optimal care within EIP services. This study will, therefore, explore how young people experience recovery following first episode psychotic mania.

| Recruitment and setting
Participants were sought from two NHS EIP services within East London Foundation Trust. EIP staff screened for study criteria and invited participants to contact the researcher.

| Participants
The sampling strategy aimed for a homogenous sample. Inclusion criteria included a current diagnosis of bipolar disorder, a recent first episode of psychotic mania, age-range of 18 to 35, and sufficient fluency in English to conduct an interview. Exclusion criteria included co-morbid psychiatric conditions. 11 participants (eight men, three women) aged between 21 and 35 (mean: 26 years), diagnosed with bipolar disorder, and who recently had a first episode of psychotic mania, were recruited (See Table 1, below).

| Ethical considerations
Ethical approval was given by NHS ethics and by the Psychology Department Research Ethics Committee.

| Data collection
Interpretative Phenomenological Analysis (IPA) semi-structured interviews were conducted by the first author within 24 months following first episode and in English. Participants were asked about their experience of recovery from first episode within the EIP service. The researcher was guided by the interview schedule (see Appendix A), but participants were encouraged to talk about their own concerns.
Interviews were conducted in a private room at the EIP service, lasted between 52 and 88 min (mean: 74 min) and were audio-recorded.
Interviews were then transcribed and anonymised.

| Analysis
The data was analysed using IPA following the procedure set out in Smith et al. (2009). The analysis is conducted on case-by-case basis, with themes generated for each individual case. The first case was analysed in depth searching for points of descriptive, linguistic and conceptual note. These notes were then translated into emergent T A B L E 1

| Coping with compromise
Although the desire to realize their aspirations motivated participants to maintain their mental health, the strategies they adopted to stay well could also instil feelings of compromise. While some persisted with these strategies, others felt they could not accept it and initiated risky periods of respite.
Take Karen, whose sense of loss arose from a need to monitor thoughts, which she no longer felt she could trust:

| Manic relapse: Pressure and proving self
Participants' goal-striving could also lead to an escalation of pressure driven by a need to prove themselves or manage new challenges. For three participants, this was seen to lead to manic relapse. Dave is motivated to learn his job, but feels the task is beyond him.
Notice his use of the words 'can't compute it', suggesting that, in his eyes, his brain is not working as it should. All the while, his stress and frustration begins to mount. He feels overwhelmed by having to balance 'studying', 'learning' and 'a social life' which he finds 'too, intense'. Although he wants the opportunity to 'relax' 'a little bit', the stress he feels in trying to fit it all in, 'just got on top of' him and leads to his 'second admission'.

| DISCUSSION
This study provides fresh insight into the way young people recovering from first episode psychotic mania balance goals, staying well, managing compromise and risk of manic relapse. This is shown to be a difficult balancing act. On becoming well, the participants expressed a sense of purpose through engaging with activities and goals that also motivated their efforts to stay well. The strategies they learnt to manage their moods could create feelings of compromise that not all were prepared to accept. Although realizing aspirations helped alleviate their sense of compromise, for some it created pressure that was seen to contribute to manic relapse.
The importance of establishing purpose as part of personal recovery from first episode is increasingly recognized in qualitative studies on FEP (Lam et al., 2010;Romano et al., 2010;Windell et al., 2012).
Resuming work activities, hobbies and goals are key, promoting agency, positive identity, and social integration (Bjornestad et al., 2017;Connell et al., 2015;de Wet et al., 2015;Eisenstadt et al., 2012), and the formation of new priorities can be a facet of post-traumatic growth (Jordan et al., 2017). This study also emphasized the importance of career aspirations and goals for creating purpose in recovery, but also highlighted a further benefit. For these participants, it also motivated their efforts to stay well.
In the BD literature, the formation of a hopeful future is one of the four factors that promote BD mood balance and prevent mania (Michalak et al., 2016). Following BD diagnosis, meaningful activities, including remaining in the workforce, was found to be a primary factor that helped young people manage their moods (Nicholas et al., 2017).
This study, similarly, emphasizes the significance of fulfilling social roles and activities following first episode BD in promoting mood management.
Hope was particularly important given the sense of compromise that was also expressed by participants. Although, they felt motivated to use strategies to stay well, such as monitoring thoughts and taking medication, these could also instil feelings of loss due to anxiety over their thoughts and suppression of positive emotion. Although the value of mood monitoring in the wider BD literature is well endorsed, the problems of increased anxiety, dampening positive emotions and restrictive lifestyles have been related to lower quality of life or mood deterioration, pointing to the need for individually tailored interventions (Edge et al., 2012;Palmier-Claus et al., 2021). Consistent with this, the present study suggests that mood awareness, though seen as important for maintaining wellness, can lead to feelings of compromise.
For most participants, identifying goals and valued activities contributed to a meaningful recovery, but for a minority they created additional stress or goal-striving that may have fuelled manic relapse.
BD is associated with a high frequency of stressful life events and goal-directed behaviour that have been found to predict episode recurrence (Alloy et al., 2012;Gilman et al., 2015;Lex et al., 2017).
Qualitative accounts also suggest that work-related stressors can contribute to manic relapse (Borg et al., 2011). Current study findings, however, point to a tension between the need for purpose during recovery and the risk of manic relapse.

| Strengths and limitations
The primary strength is that this is the first study to examine the experience of recovery from first episode psychotic mania for people diagnosed with BD. Additionally, interviews were analysed case-bycase thereby capturing the idiographic meaning of recovery. Due to the use of an in-depth qualitative approach, findings are not generaliz- able. Yet insights provide implications for understanding FEP recovery for this group. Timing of the interviews ranged from 3-24 months following first episode, and interview latency may have influenced participants' interpretation of recovery experiences over different time scales.

| Clinical implications
The study offers novel findings that translate into pointers for clinical practice within EIP services including the importance of promoting goals and career-related opportunities to facilitate meaningful recovery and motivate prioritization of mood stability. Strategies for maintaining wellness, such as monitoring thoughts, feelings and taking medication, were seen to protect future aspirations, but also created feelings of compromise. Findings, therefore, point to the potential benefit of individually tailored or flexible interventions to help alleviate this aspect. Additionally, the need to consider the role of goalrelated events and identity meanings in contributing to manic relapse is indicated. This may be particularly pertinent for young people with BD following first episode.