The Types of Psychosocial Factors Associated with Suicidality Outcomes for People Living with Bipolar Disorder: A Scoping Review.

Bipolar Disorder is associated with high rates of suicidal thoughts, behaviors, and outcomes, yet the lived experience of suicidality and Bipolar Disorder is not particularly well understood. Understanding the role of psychosocial aetiologies in suicidality outcomes for those living with Bipolar Disorder is key for developing appropriately targeted interventions focusing on factors that are amenable to change. In line with PRISMA guidance, we conducted a scoping review to identify the types of psychosocial factors studied in relation to the experience of suicidality for people living with Bipolar Disorder diagnoses. Systematic literature searches identified a sample of 166 articles from which key study data were extracted and charted. A narrative synthesis of the reviewed literature is presented ordered by the factors investigated across studies, a frequency count of the types of psychological/social aetiologies studied, and a brief overview of the key findings for each aetiology. Most of the identified literature took the form of quantitative cross-sectional studies, with only one qualitative study and 18 quantitative prospective studies. The most studied aetiologies were trauma (specifically early adverse experiences and childhood traumas) and stressful life events, impulsivity (primarily subjective self-reported trait impulsivity), social support and functioning, and personality/temperament factors. Only six studies in the final sample reported basing their research questions and/or hypotheses on an explicit theoretical model of suicide. The literature was primarily focused on using self-report measurements of key aetiologies and on factors which lead to worsened suicidality rather than focusing on potentially protective or buffering factors. Future research needs to better justify the aetiologies investigated in relation to suicidality outcomes for people living with Bipolar Disorder, including a firmer basis in theory and hypothesis testing, more prospective designs, and the use of alternative assessments of psychosocial aetiologies in addition to self-report questionnaires.

Correlation between emotion dysregulation and mood symptoms of bipolar disorder: A systematic review and meta-analysis.

BACKGROUND: Emotion dysregulation (ED) is a transdiagnostic construct characterized by difficulties regulating intense emotions. People with bipolar disorder (BD) are more likely to show ED and use maladaptive emotion regulation strategies than adaptive ones. However, little is known about whether ED in BD is a trait or it is rather an epiphenomenon of mood symptoms. METHODS: We conducted a systematic review and meta-analysis of the evidence across major literature databases reporting correlations between measures of emotion regulation (overall ED and different emotion regulation strategies) and measures of depressive and (hypo)manic symptoms in BD from inception until April 12th, 2022. RESULTS: Fourteen studies involving 1371 individuals with BD were included in the qualitative synthesis, of which 11 reported quantitative information and were included in the meta-analysis. ED and maladaptive strategies were significantly higher during periods with more severe mood symptoms, especially depressive ones, while adaptive strategies were lower. CONCLUSION: ED significantly correlates with BD symptomatology, and it mainly occurs during mood alterations. ED may be a target for specific psychotherapeutic and pharmacological treatments, according to precision psychiatry. However, further studies are needed, including patients with mood episodes and longitudinal design, to provide more robust evidence and explore the causal direction of the associations.

Key questions: research priorities for student mental health.

BACKGROUND: The high prevalence of mental distress among university students is gaining academic, policy and public attention. As the volume of research into student mental health increases, it is important to involve students to ensure that the evidence produced can translate into meaningful improvements. AIMS: For the first time, we consult UK students about their research priorities on student mental health. METHOD: This priority setting exercise involved current UK university students who were asked to submit three research questions relating to student mental health. Responses were aggregated into themes through content analysis and considered in the context of existing research. Students were involved throughout the project, including inception, design, recruitment, analysis and dissemination. RESULTS: UK university students (N = 385) submitted 991 questions, categorised into seven themes: epidemiology, causes and risk factors, academic factors and work-life balance, sense of belonging, intervention and services, mental health literacy and consequences. Across themes, respondents highlighted the importance of understanding the experience of minority groups. CONCLUSIONS: Students are interested in understanding the causes and consequences of poor mental health at university, across academic and social domains. They would like to improve staff and students' knowledge about mental health, and have access to evidence-based support. Future research should take a broad lens to evaluate interventions; considering how services are designed and delivered, and investigating institutional and behavioural barriers to accessibility, including how this varies across different groups within the student population.

'You're on the waiting list': An interpretive phenomenological analysis of young adults' experiences of waiting lists within mental health services in the UK.

Waiting lists in mental health services are currently considered too long. Lengthy waits of up to 18 weeks are commonly reported in the UK. Waiting lists have long been associated with a variety of negative psychological responses, however there is little understanding behind young adults' personal experiences of such delays within mental health services. The current study aimed to explore young adults' experiences of waiting lists in mental healthcare in the UK. Seven young adults were interviewed in the current study (aged 19-22). Interpretive phenomenological analysis was utilised to explore participant accounts. Three super-ordinate themes were generated: Reliance on Alternative Methods of Support; Inability to Function Sufficiently; and Emergence of Negative Beliefs, Emotions and Thoughts. Participants primarily reported a variety of negative psychological and behavioural consequences associated with waiting lists in mental health services, as well as exacerbated existing physical and psychological health issues. In accordance with the limited number of previous studies, waiting lists are considered by patients to be barriers to mental health support and intervention. Future direction is advised.

Psychological therapy for mood instability within bipolar spectrum disorder: a randomised, controlled feasibility trial of a dialectical behaviour therapy-informed approach (the ThrIVe-B programme).

BACKGROUND: A subgroup of those with bipolar spectrum disorders experience ongoing mood fluctuations outside of full episodes. We conducted a randomised, controlled feasibility study of a Dialectical Behavioural Therapy-informed approach for bipolar mood fluctuations (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). Our study aimed to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. Participants were required to meet diagnostic criteria for a bipolar spectrum disorder and report frequent mood swings outside of acute episodes. They were randomised to treatment as usual (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points were at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point. To evaluate feasibility and acceptability we examined recruitment and retention rates, completion rates for study measures, adverse events and feedback from participants on their experience of study participation and therapy. RESULTS: Of the target 48 participants, 43 were recruited (22 in the intervention arm; 21 in the control arm), with a recruitment rate of 3.9 participants per month. At 9 months 74% of participants engaged in research follow-up assessment, exceeding the pre-specified criterion of 60%. There were no serious concerns about the safety of the research procedures or the intervention. On one of the four candidate primary outcome measures, the 95% CI for the between-group mean difference score excluded the null effect and included the minimal clinically important difference, favouring the intervention arm, whilst on no measure was there evidence of deterioration in the intervention arm relative to the control arm. Attendance of the intervention (50% attending at least half of the mandatory sessions) was below the pre-specified continuation criterion of 60%, and qualitative feedback from participants indicated areas that may have hampered or facilitated engagement. CONCLUSIONS: It is broadly feasible to conduct a trial of this design within the population of people with frequent bipolar mood swings. Changes should be made to the therapy to increase uptake, such as simplifying content and considering individual rather than group delivery. Trial registration ISRCTN: ISRCTN54234300. Registered 14th July 2017, http://www.isrctn.com/ISRCTN54234300.

Mental Well-Being in UK Higher Education During Covid-19: Do Students Trust Universities and the Government?

This paper draws upon the concept of recreancy to examine the mental well-being of university students during the Covid-19 pandemic. Briefly, recreancy is loss of societal trust that results when institutional actors can no longer be counted on to perform their responsibilities. Our study of mental well-being and recreancy focuses on the role of universities and government regulators within the education sector. We surveyed 600 UK students attending 161 different public higher education providers in October 2020 during a time when many UK students were isolated in their residences and engaged in online learning. We assessed student well-being using the Short Warwick-Edinburgh Mental Well-being Scale (scored 7-35) and found the mean score to be 19.9 [95% confidence interval (CI) 19.6, 20.2]. This level of well-being indicates that a significant proportion of UK students face low levels of mental well-being. Structural equation modeling (SEM) analysis indicates that high recreancy-measured as a low trust in universities and the government-is associated with low levels of mental well-being across the student sample. While these findings are suggestive, they are also important and we suggest that government and university leaders should not only work to increase food and housing security during the Covid-19 pandemic, but also consider how to combat various sector trends that might intensify recreancy.

Self-Regulatory Goal Motivational Processes in Sustained New Year Resolution Pursuit and Mental Wellbeing.

Recent research suggests people typically "give up" pursuing their New Year resolutions within the first month. The present study investigated goal features proposed to be implicated in promoting both mental wellbeing and sustained New Year resolution pursuit. Australian and UK participants (n = 182) took part in an online longitudinal study, including four timepoints over a two-month period. At baseline, participants listed the New Year resolution to which they were most committed, and completed self-report measures to assess mental wellbeing, goal flexibility and tenacity. At the follow-up surveys, participants completed the wellbeing measure and their New Year resolution commitment, effort and stickability. As predicted, flexibility predicted wellbeing across time, however, tenacity did not. Counter to prediction, neither flexibility nor tenacity reported at baseline predicted "sticking" with one's New Year resolution. The predicted interaction between flexibility and tenacity was not significant. New Year resolutions focused predominantly on "diet" and "exercise" were predominantly the same resolutions previously pursued and tended to be relatively abstract. Although goal flexibility predicted greater wellbeing, the findings overall tend to support the view that people are not particularly good at sticking with their New Year resolutions. Implications of the findings are discussed.

University student well-being in the United Kingdom: a scoping review of its conceptualisation and measurement.

BACKGROUND: Well-being is a multifaceted construct, and measuring well-being, both within particular groups and at a national level, is a priority for policy and practice. This national agenda on measuring well-being is mirrored in the Higher Education sector. This is the first conceptual review of how well-being is measured among university students in the UK. AIMS: The aims of the review were to identify (i) the definitions or conceptualisations of well-being guiding the selection of well-being indicators for research within this population and (ii) measures of well-being used in university students in the UK. METHODS: A scoping review method was used. RESULTS: Twenty-eight validated indicators used to measure well-being in UK students were identified. While many were direct measures of (primarily mental or psychological) well-being, indirect "proxy" indicators, including measures of mental health symptoms, were identified. CONCLUSIONS: This review has highlighted that there are inconsistencies in defining and measuring university student well-being, and the measures that have been used in this population are focused on subjective experience. These findings are in line with reviews of well-being measures in the general population. Implications for further research are discussed.

Are context-specific measures of positive emotion regulation more predictive of mania risk and mood symptoms than trait measures?

BACKGROUND: A number of strategies used to regulate positive affect (i.e. dampening and positive rumination) have been identified as having particular relevance to hypomanic personality (a proxy measure of mania risk). However, previous findings have been mixed and it is suggested that this may be the result of lack of consideration of the context in which emotion regulation (ER) is occurring. AIMS: This study aimed to investigate (a) if use of specific ER strategies predicts mood across social- and goal-related contexts, and (b) if the relationship between hypomanic personality and mood is moderated by greater use of ER strategies. METHOD: One hundred and seventy-four participants (mean age 20.77 years, SD = 2.2) completed an online survey assessing (i) hypomanic personality, (ii) self-reported tendencies to use ER strategies for positive emotion, (iii) tendencies to use these strategies in response to both high- and moderate-intensity positive affect in personally generated social- and goal-related contexts, and (iv) current affect. RESULTS: Trait use of ER strategies was more predictive of hypomanic personality and mood symptoms than context-specific measures; however, this relationship did not hold up for hypomanic personality and mood symptoms when accounting for current affect. Trait dampening was predictive of low mood symptoms but did not moderate the relationship between hypomanic personality and low mood. DISCUSSION: While trait measures of ER were more predictive of mania risk and mood symptoms than context-specific measures, further work is needed using experience sampling methods in order to capture the regulatory processes individuals are using in particular contexts, in real-time.

Barriers to older adults' uptake of mobile-based mental health interventions.

BACKGROUND: To address increasing demand of mental healthcare treatments for older adults and the need to reduce delivery costs, healthcare providers are turning to mobile applications. The importance of psychological barriers have been highlighted in the uptake of mobile-based mental health interventions and efforts have been made to identify these barriers in order to facilitate initial uptake and acceptance. However, limited research has focused on older adults' awareness of these applications and factors that might be hindering their use. OBJECTIVE: The purpose of this study was to explore the perceived barriers that older adults experience in the uptake of mobile-based mental health interventions. METHODS: Semi-structured interviews were conducted with a sample of 10 older adults, 50 years or older (female = 7, mean age = 68 years), who experienced periods of low mood. National Health Service applications were demonstrated to facilitate conversation and explore participants' understanding of mental health and mobile-based mental health interventions. Thematic analysis was used to analyse the interview transcripts. RESULTS: The social ecological model was adopted as an organising framework for the thematic analysis which identified six distinct barriers to older adults' uptake of mobile-based mental health interventions: mental electronic-health (e-health) awareness, interaction with technology, discontinuation, 'seeing' facilitates therapeutic alliance, incongruent role of the general practitioner and privacy and confidentiality. CONCLUSIONS: Older adults experience a number of barriers to uptake ranging from the individual level to a macro, organisational level. The practical implications of these barriers are discussed such as the need for increased awareness of mobile-based mental health interventions among older adults.

Beliefs about the automaticity of positive mood regulation: examination of the BAMR-Positive Emotion Downregulation Scale in relation to emotion regulation strategies and mood symptoms.

Emotion regulation is a topic of great interest due to its relevance to navigating everyday life, as well as its relevance to psychopathology. Recent research indicates that beliefs about the automaticity of mood regulation are critical to psychological health. In the present study we assessed beliefs about the automaticity of positive mood regulation in relationship to self-reported mood symptoms and explicit emotion regulation strategies. Participants (n = 200) completed an online survey including a scale assessing beliefs about automatic downregulation of positive emotions (i.e. BAMR-PED), beliefs about automatic mood regulation for negative emotions, mood symptoms, and emotion regulation strategies. Results suggested that beliefs about automatic positive emotion regulation were associated with unhelpful emotion regulation strategies and reduced negative affect as well as fewer depressive, manic, and anxiety symptoms. Test-retest of the novel BAMR-PED measure was tested with a further sample (n = 46) and found to be acceptable. Future research should explore how these automatic beliefs have relevance to clinical disorders characterised by positive emotion disturbance, such as bipolar disorder.

Emotion regulation strategies in mania risk: A systematic review.

OBJECTIVES: Difficulties in emotion regulation may contribute to the development of mania. This review aimed to assess how emotion regulation strategies reported by individuals at risk of mania compare with clinical and nonclinical controls. METHODS: Search terms relating to mania risk and emotion regulation were entered into three databases. Sixteen studies were included. RESULTS: Mania risk was typically associated with overall endorsement of emotion regulation strategies, particularly dampening, and positive and negative rumination. CONCLUSIONS: Findings were limited by overall lack of evidence for individual strategies, lack of consideration of key mediating factors and reliance upon self-report designs.

Web-based indicated prevention of common mental disorders in university students in four European countries - Study protocol for a randomised controlled trial.

BACKGROUND: Mental disorders and their symptoms are highly prevalent in the university student population, and the transition from secondary to tertiary education is associated with a rise in mental health problems. Existing web-based interventions for the prevention of common mental disorders in student populations often focus on just one disorder and have not been designed specifically for students. There is thus a need for transdiagnostic, student-specific preventative interventions that can be widely disseminated. This two-arm, parallel group randomised controlled trial aims to evaluate the effectiveness and cost-effectiveness of a web-based transdiagnostic mental health problem prevention programme (PLUS) across several universities in four countries. METHOD: Students (N = 5550) will be recruited through a variety of channels and asked to complete a personality assessment to determine whether they are at high risk for developing common mental disorders. Students at high risk will be randomly allocated to either PLUS or a control intervention, which provides practical support around issues commonly experienced at university. Students at low risk will be allocated to the control intervention. Both intervention groups will be assessed at baseline, 4 weeks, 3 months, 6 months and 12 months after randomisation. Depression and generalised anxiety, assessed using the Patient Health Questionnaire and the Generalised Anxiety Disorder scales, will form the primary outcomes in this study. Secondary outcome measures include alcohol and drug use, eating behaviour, self-esteem, and quality of life. The cost-effectiveness of the intervention will also be evaluated. CONCLUSIONS: This study will contribute to understanding the role of transdiagnostic indicated web-based interventions for the prevention of common mental disorders in university students. It will also be one of the first studies to investigate the cost-effectiveness of such interventions. TRIAL REGISTRATION: This trial was registered in the ISRCTN register (ISRCTN15570935) on 12th February 2016.

Emotion regulation strategies in bipolar disorder: A systematic and critical review.

BACKGROUND: Theoretical frameworks emphasise associations between interpretations and responses to affect and bipolar disorder (BD). This review (PROSPERO CRD42016043801) investigated which emotion regulation (ER) strategies have been applied to BD, are elevated in BD compared to clinical and non-clinical controls, and are associated with clinical and functional outcomes in BD METHODS: Search terms relating to emotion regulation, coping and bipolar disorder were entered into Embase, MedLine and PsycInfo. Quantitative studies investigating relationships between ER strategies and BD were eligible for this narrative synthesis RESULTS: A large volume of research (n = 47) investigated specific ER strategies in BD. Maladaptive strategies such as rumination and dampening were elevated in BD compared to controls and these particular strategies had a detrimental impact on outcomes such as mood symptoms. BD had a similar profile of ER strategies to unipolar depression, but there was limited comparison to other clinical groups. People with BD did not generally have deficits in using adaptive strategies, as evidenced by comparisons with controls and experimental studies LIMITATIONS: Methodological heterogeneity and a lack of ecologically valid ER assessments CONCLUSIONS: Empirical literature is critiqued in line with contemporary theories of BD and of emotion regulation more generally, in order to inform future research recommendations. This includes investigation of the importance of context in the impact of ER strategies, and discrepancies between trait and state use of ER strategies, particularly through experience sampling.

The clinical and cost effectiveness of adapted dialectical behaviour therapy (DBT) for bipolar mood instability in primary care (ThrIVe-B programme): a feasibility study.

BACKGROUND: In bipolar spectrum disorder, some individuals experience ongoing, frequent fluctuations in mood outside of affective episodes. There are currently no evidence-based psychological interventions designed to address this. This feasibility study is a phase II evaluation of a dialectical behavioural therapy-informed approach (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). It seeks to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. METHODS/DESIGN: Patients will be randomised 1:1 to either treatment as usual only (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points will be at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point for the candidate primary outcome measures. We aim to recruit 48 individuals meeting diagnostic criteria for a bipolar spectrum disorder and reporting frequent mood swings outside of acute episodes, through primary and secondary care services and self-referral. To evaluate feasibility and acceptability, we will examine recruitment and retention rates, completion rates for study measures and feedback from participants on their experience of study participation and therapy. DISCUSSION: Proceeding to a definitive trial will be indicated if the following criteria are met: (1) trial participation does not lead to serious negative consequences for our participants; (2) any serious concerns about the acceptability and feasibility of the trial procedures can be rectified prior to a definitive trial; (3) follow-up data at 9 months are available for at least 60% of participants; (4) at least 60% of patients in the ThrIVe-B arm complete treatment. TRIAL REGISTRATION: ISRCTN, ISRCTN54234300 . Registered on 20 July 2017.

Internalised stigma in mental health: An investigation of the role of attachment style.

Internalised stigma is associated with a range of negative outcomes, yet little is known about what determines the internalisation of stigma. In this study we examined the potential role of adult attachment style in the internalisation process in a transdiagnostic sample of adults with experience of recent mental health service use (n = 122), using an online survey. Associations between internalised stigma and perceived public stigma were tested. We also examined whether anxious and avoidant (insecure) attachment styles were positively associated with a significant amount of variance in internalised stigma when controlling for other variables, and whether the relationship between perceived public stigma and internalised stigma was moderated by anxious and avoidant attachment. We found that internalised stigma, perceived public stigma and insecure attachment were commonly reported and that internalised stigma was positively associated with perceived public stigma. However, neither anxious or avoidant attachment were associated with a significant amount of variance in internalised stigma and we found no moderating effect on the relationship between perceived public stigma and internalised stigma for insecure attachment. Despite mixed results, the strength of association between anxious attachment and internalised stigma suggests further research, which addresses some limitations of the current study, is warranted.

Users' experiences of an online intervention for bipolar disorder: important lessons for design and evaluation.

BACKGROUND: The evidence base for digital interventions for physical and mental health, including severe and enduring mental health difficulties, is increasing. In a feasibility trial, web-based Enhanced Relapse Prevention (ERPonline) for bipolar disorder demonstrated high recruitment and retention rates. Relative to participants in the waitlist control group, those who received ERPonline showed increased monitoring for early warning signs of relapse and had developed more positive illness models. OBJECTIVE: To understand users' motivations and barriers for taking part in an online/telephone-based trial, and for engagement with ERPonline. METHODS: Participants from the trial who had been allocated to receive ERPonline were purposively sampled to participate in telephone-based, in-depth qualitative interviews about their experiences. Interviews (n=19) were analysed using framework analysis to identify themes relevant to study aims. FINDINGS: Participants took part due to the convenient, flexible and rewarding aspects of the trial design, as well as a desire to improve the mental health of themselves and others. Barriers included extensive assessments, practical difficulties and mood. ERPonline was was generally considered to be accessible, relevant and straightforward, but there were individual preferences regarding design, content and who it was for. Several participants reported positive changes, but there was a sense that digital interventions should not replace routine care. CONCLUSIONS: There are a number of barriers and facilitators to consider when evaluating and implementing digital interventions. Individual preferences and human contact were key factors for both trial design and engagement with an online intervention. CLINICAL IMPLICATIONS: Digital interventions should be co-produced, personalised, interactive and embedded as one component in a broader package of care. TRIAL REGISTRATION NUMBER: ISRCTN56908625; Post-results.

"When my Moods Drive Upward There Is Nothing I Can Do about It": A Review of Extreme Appraisals of Internal States and the Bipolar Spectrum.

The integrative cognitive model provides a comprehensive account of bipolar disorder (BD) that, if empirically supported, has important potential implications for psychological therapies. This article is the first to review the evidence for this model. We evaluate the evidence (up to 2017) for four hypotheses derived uniquely from the model: extreme positive and negative appraisals of internal states are associated with (1) risk of developing BD; (2) BD diagnosis; (3) relevant clinical and functional outcomes including hypomanic and depressive mood symptoms; and (4) outcomes over time. Research involving individuals with diagnosed mood disorders as well as non-clinical populations is reviewed. The hypotheses were broadly supported and several consistent findings were not accounted for by alternative psychological models of BD. The evidence base is limited by a relative paucity of prospective studies; only 6 of the 31 studies identified. Implications for theory, research and clinical practice are discussed.