Bipolar disorder (BD) has a prevalence rate of 1.5%  affecting over 1 million people in England alone . In addition to repeated periods of mania and depression most individuals with BD experience extended periods of distressing subsyndromal mood symptoms between episodes [3–5]. Consequently BD has significant impact emotionally and functionally  and constitutes a substantial financial burden to society: McCrone recently estimated cost to the English economy at £5.2 billion per annum .
The National Institute for Clinical Excellence has recommended the provision of structured psychological therapy for individuals with bipolar disorder . To date, controlled trials of structured psychological therapy have focused on individuals with a chronic bipolar disorder. For example, participants in the Lam et al.  cognitive behaviour therapy (CBT) trial had experienced a mean of 5.8 depressive and 5.5 manic episodes, whilst in Miklowitz et al.’s  comparison of CBT with Family Focussed Therapy and Interpersonal and Social Rhythm Therapy two thirds of the sample had more than 10 episodes of mania and depression at baseline assessment. Although it might seem logical to focus an intervention requiring significant therapist time on individuals with an established illness course recent psychological models of bipolar disorder suggest otherwise. It has been argued by several researchers that associative mechanisms build up over repeated mood episodes in BD such that later episodes are both more readily triggered by psychosocial circumstances previously linked to mood changes and are also less likely to be mediated by cognitive processes [10–12]. This suggests that cognitive-behavioural interventions may be more powerful when applied earlier in the illness course before strong associative links to bipolar emotional states are established. Consistent with this research a recent study of CBT for relapse prevention in bipolar disorder found a significant benefit only for those with fewer episodes in a post hoc analysis . Additionally, there is evidence that individuals with earlier onset of bipolar disorder tend to have worse clinical outcomes, leading to calls for more timely detection and intervention [14, 15].
Despite the arguments in favour of earlier treatment there have to date been no RCT evaluations of CBT for bipolar disorder specifically targeted at individuals early in their illness course. The current study will fill this gap employing an adapted CBT intervention for individuals within the first five years since onset of bipolar disorder. An earlier version of this intervention has already proved to be acceptable and feasible in a single case series of 7 bipolar participants . Substantial reductions in subsyndromal symptoms were observed during intervention and six month follow-up along with changes in appraisal styles and stability of sleep/wake cycles. This suggests that psychological intervention for individuals early in their course of bipolar disorder is both effective and acceptable to service users.
The present trial builds on this pilot work in a RCT feasibility study but also extends the intervention to incorporate a clear focus on recovery outcomes (Recovery focused CBT; RfCBT). Recovery in relation to mental health has been defined as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness” . Consistent with this individuals with severe mental health issues including bipolar disorder have highlighted the importance of increased hope, sense of control and sense of social connectedness in recovery in contrast with a traditional psychiatric focus on symptomatic outcomes [18–21]. Recovery informed interventions are now encouraged by the UK Government as a mechanism for improving service provision in mental health through personalised care based on individual needs [22, 23]. Key elements of this approach include choice, self-determination and self-management  through which the client is supported to plan their own route to recovery .
Research into recovery and quality of life shows that individuals with bipolar disorder highlight the importance of functional as well as symptom outcomes [21, 25]; with a particular focus on engaging or re-engaging in valued activities including employment. Since the very high societal cost of bipolar disorder is driven in large part by loss to the workplace of individuals who could otherwise contribute significantly, supporting individuals in their recovery goals could have clear societal as well as individual benefits. The intervention described in this study was therefore developed based on evidence-based principles for effective psychological interventions for bipolar disorder , our pilot case series work and through qualitative interviews, focus group work and consultation with individuals with experience of bipolar disorder.
In this study we evaluate the feasibility and acceptability of delivering RfCBT to individuals with bipolar disorder within 5 years of diagnosis. As a feasibility study we primarily evaluate recruitment into the study and consent to participate, adherence to the intervention, retention within both arms across assessment, intervention and follow-up periods and outcome parameter estimates. From this we will be able to assess the acceptability of the intervention to service users. In addition, the trial will also provide preliminary indications of the impact of RfCBT on self-reported recovery, bipolar relapse, mood symptoms and functioning to inform the selection of primary outcomes for a future definitive RCT.