Individual psychological therapy for bipolar disorder and substance use

INTERVENTION: Purpose: To explore the feasibility of a psychological treatment, (motivational interviews (MI) and cognitive behaviour therapy (CBT)), on substance use and clinical outcome in bipolar patients. The study aims to establish the feasibility of using the therapeutic integration of MI and CBT for this patient group. Participants with the dual diagnosis of bipolar disorder and substance use will be recruited for this research and form two groups, one group receiving standard psychiatric care and the other psychiatric care and psychological therapy. Bipolar disorder (BD) is a devastating mental illness characterised by a recurring relapsing course, high risk of self harm and suicide (1‐3), and considerable subclinical psychopathology outside full episodes (4, 5). The World Health Organization has identified bipolar disorder as the 6th leading cause of disability adjusted life years in the world among people aged 15‐44 years (6), and estimated total costs to the UK per annum amount to approximately £2 billion (7). Lithium is an effective drug in prophylaxis, but fails to help about 20‐40% of bipolar patients (8‐11). The disorder is characterised by high rates of substance misuse, with studies in psychiatric and community settings reporting rates of 48‐70% (12, 13). Such substance misuse can have profound effects on mood and behaviour which worsen the course, outcome and morbidity of bipolar disorder (14). For example, drugs and alcohol may disrupt sleep and circadian rhythms (15, 16), which can worsen prodromal symptoms and hence increase risk of relapse (17, 18). Furthermore, impulsiveness, which has been shown to be particularly elevated in bipolar patients with co morbid substance abuse (19), has been proposed as a possible factor in the significantly poorer treatment outcome and increased risks of suicide and violence observed in individuals with co morbid substance misuse compared to those bipolar disorder alone (14, 20, 21). Despite the high prevalence of substance u CONDITION: Mental and Behavioural Disorders: Bipolar disorders ; Mental and Behavioural Disorders ; Bipolar disorders PRIMARY OUTCOME: The feasibility of a psychological treatment comprising of motivational interviews and cognitive behaviour therapy, in terms of acceptability for this patient group and retention of participants. Effect size for therapy outcomes will be determined to so that a definitive trial can be planned which is appropriately powered with respect to the primary outcome measures. Primary Therapy Outcome Measures: number of bipolar relapses and frequency and severity of substance.; misuse. SECONDARY OUTCOME: Measures of bipolar symptomatology and time to relapse will be estimated. Also, in line with the key targets of the planned intervention, we will assess stabilisation of social rhythms and reduction in impulsiveness as a result of treatment. Self report vs collateral outcome measures will be compared for the assessment of time to bipolar relapse, frequency and duration of relapse and severity and frequency of substance misuse. Comparisons will be made with respect to completeness of data sets in each case and will indicate the most appropriate outcome measures to use for a definitive trial. INCLUSION CRITERIA: 1. Bipolar inclusion criteria will be as follows: bipolar disorder I or II according to DSM‐IV criteria and not meeting current episode criteria for mania or major depression 2. Substance use inclusion criteria are: alcohol and/or substance abuse or dependence according to DSM‐IV criteria, alcohol use exceeding 28 units for males/21 units for females on at least half of the weeks of the previous 3 months and/or use of illicit drugs on at least two days per week in at least half the weeks in the 3 months prior to assessment 3. General inclusion criteria includes: current contact with mental health services, all participants will be 18 years or older, have no evidence of organic brain disease or learning disability, not be currently actively suicidal, they must be able to provide informed consent and having a fixed abode