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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.

Objectives: Determining the risk for suicide is a difficult endeavour. Clinical guidance in the UK explicitly advises against using risk assessment tools and scales to determine suicide risk. Based on Freedom of Information (FoI) requests made to NHS Trusts in England, this study provides an overview of suicide risk assessment tools in use, training provided in how to use such assessments, and explores implementation of suicide risk assessment guidance in practice in English NHS Trusts., Design: A cross-sectional survey of suicide risk assessment tools and training gathered via FoI requests and subjected to a content analysis., Setting: FoI requests were submitted to NHS Trusts across England., Results: A wide variety of suicide risk assessments tools were identified as being used in practice, with several trusts reported using more than one tool to determine suicide risk. Forty-one trusts reported using locally developed, unvalidated, tools to assess risk of suicide and 18 stated they do not use a tool. Ten trusts stated they do not train their staff in suicide risk assessment while 13 reported use of specific suicide risk assessment training. Sixty-two trusts stated they do not centrally record the number of assessments conducted or how many individuals are identified as at risk. Content analysis indicated the frequent wider assessment of risk not restricted to suicide risk., Conclusions: There is wide variation in suicide risk assessment tools being used in practice and some lack of specific training for healthcare staff in determining suicide risk. Few trusts routinely record the number of assessments being conducted or the number of individuals identified at high risk. Implementation of specific training is necessary for the suicide risk assessment process to identify patient needs and develop therapeutic engagement. Routinely recording how many assessments are conducted is a crucial step in improving suicide prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Social norms are an important influence on health-related behaviours and intention formation. As both suicidal behaviour and non-suicidal self-injury (NSSI) can be motivated by intentions, perceived social norms may have an important role in suicide and NSSI outcomes, although no existing reviews of this association exist. Following the PRISMA Scoping Review extension guidance, a scoping review based on systematic searches of key databases was conducted to identify published English language studies investigating the role of perceived social norms in suicidality and NSSI. Information regarding the types of social norms studied, their relationship to suicidality/NSSI outcomes, study samples and designs was charted. Thirty-six eligible studies (31 quantitative, 4 qualitative, 1 mixed methods) sampling various populations across mostly non-clinical settings were identified and narratively synthesised. Studies varied in how social norms were operationalised, measured, and investigated/explored. Most studies focused on the role of conformity to perceived masculine social norms or to some form of subjective, descriptive, or injunctive norms; there were limited studies on female/feminine norms, pro-social/protective norms, or broader gender/sexuality norms. Most studies (n = 31) were cross-sectional (quantitative) in design, few were based on existing theories of suicide/NSSI or social norms, and none concurrently tested theories of social norms and NSSI/suicidality. Perceived social norms and stronger conformity to norms were generally associated with worse NSSI/suicidality, although some pro-social norms appeared to be protective (e.g., perceived parental norms for adolescents). Whilst conformity to restrictive perceived social norms may be related to poorer suicide and NSSI outcomes, there is a lack of consistency in the literature in how social norms are defined and measured, a lack of theory-based hypothesis testing, and few longitudinal studies. There is a need for more nuanced, theory-based, investigations of how, when, where, why, and for whom, perceived norms have a causal role in NSSI and suicidality outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Dempsey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

A high proportion of people contact healthcare services in the 12 months prior to death by suicide. Identifying people at high-risk for suicide is therefore a key concern for healthcare services. Whilst there is extensive research on the validity and reliability of suicide risk assessment tools, there remains a lack of understanding of how suicide risk assessments are conducted by healthcare staff in practice. This scoping review examined the literature on how suicide risk assessments are conducted and experienced by healthcare practitioners, patients, carers, relatives, and friends of people who have died by suicide in the UK. Literature searches were conducted on key databases using a pre-defined search strategy pre-registered with the Open Science Framework and following the PRISMA extension for scoping reviews guidelines. Eligible for inclusion were original research, written in English, exploring how suicide risk is assessed in the UK, related to administering or undergoing risk assessment for suicide, key concepts relating to those experiences, or directly exploring the experiences of administering or undergoing assessment. Eighteen studies were included in the final sample. Information was charted including study setting and design, sampling strategy, sample characteristics, and findings. A narrative account of the literature is provided. There was considerable variation regarding how suicide risk assessments are conducted in practice. There was evidence of a lack of risk assessment training, low awareness of suicide prevention guidance, and a lack of evidence relating to patient perspectives of suicide risk assessments. Increased inclusion of patient perspectives of suicide risk assessment is needed to gain understanding of how the process can be improved. Limited time and difficulty in starting an open discussion about suicide with patients were noted as barriers to successful assessment. Implications for practice are discussed., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Fedorowicz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Adolescents tend to overestimate the extent of peers' unhealthy snacking consumption and such misperceptions have been associated with increased personal unhealthy snacking. This study aims to test whether a Social Norms Approach (SNA) intervention which challenges these misperceptions of peers' unhealthy snacking will have a positive effect on students' personal unhealthy snacking behaviours, related attitudes, and behavioural intentions., Design: A quasi-experimental study tested the effectiveness of an in-school SNA intervention (n = 163) compared to a control condition (n = 95) among 11-12-year-old students., Method: Both conditions received healthy eating information, while students in the SNA intervention received additional normative feedback (outlining the discrepancies between perceived and actual unhealthy snacking of the majority based on baseline data) delivered through an interactive poster-making session. Students completed self-reported measures of personal unhealthy snacking, related-attitudes, behavioural intentions, and normative perceptions (descriptive and injunctive) at baseline, post-intervention, and at a 3-month follow-up., Results: Students who received SNA feedback were significantly less likely to overestimate peers' unhealthy snacking attitudes post-intervention (F(1,232) = 16.405, p < .001), and at 3-month follow-up consumed fewer unhealthy snacks (F(1,232) = 6.133, p = .014) and had less positive attitudes towards unhealthy snacking (F(1,198) = 8.779, p = .003). The changes in personal snacking attitudes at 3-month follow-up were mediated by changes in normative misperceptions about peers' unhealthy snacking attitudes post-intervention, which indicated that the reductions in normative misperceptions following SNA messages mediated the effect of the intervention., Conclusion: The results indicate that in-school SNA interventions which challenge normative misperceptions constitute a promising strategy for reducing unhealthy snacking in young adolescents., (© 2022 The British Psychological Society.)

Contemporary theories of suicide, such as the Schematic Appraisals Model (SAMS), hypothesize that negative perceptions of social support are implicated in the pathways to suicidal experiences. The SAMS predicts that perceived social support influences suicidal ideation through appraisals of defeat and entrapment. However, such pathways have not been investigated in people who have bipolar disorder. This prospective four-month study tested the influence of perceived social support on later suicidal ideation via changes in defeat, entrapment, and hopelessness, in a sample of eighty euthymic participants with bipolar disorder ( N = 62 at follow-up). Linear regression models tested the extent to which perceived social support at baseline predicted changes in suicidal ideation at four months directly and indirectly via changes in defeat, entrapment, and hopelessness. Perceived social support did not directly predict changes in suicidal ideation, but there was a significant indirect mediational pathway between perceived social support at baseline and changes in suicidal ideation over time, via changes in defeat, entrapment and hopelessness, supporting the SAMS. Psychological interventions which target negative perceptions of social support early, in tandem with addressing defeat, entrapment, and hopelessness over time, present a potentially effective approach to counter suicidal ideation in people who experience bipolar disorder.

Anti-vaccine conspiracy beliefs among parents can reduce vaccination intentions. Parents' beliefs in anti-vaccine conspiracy theories are also related to their perceptions of other parents' conspiracy beliefs. Further, research has shown that parents hold misperceptions of anti-vaccine conspiracy belief norms: UK parents over-estimate the anti-vaccine conspiracy beliefs of other parents. The present study tested the effectiveness of a Social Norms Approach intervention, which corrects misperceptions using normative feedback, to reduce UK parents' anti-vaccine conspiracy beliefs and increase vaccination intentions. At baseline, 202 UK parents of young children reported their personal belief in anti-vaccine conspiracy theories, future intentions to vaccinate, and their perceptions of other UK parents' beliefs and intentions. Participants were then randomly assigned to a normative feedback condition (n = 89) or an assessment-only control condition (n = 113). The normative feedback compared participants' personal anti-vaccine conspiracy beliefs and perceptions of other UK parents' beliefs with actual normative belief levels. Parents receiving the normative feedback showed significantly reduced personal belief in anti-vaccine conspiracy beliefs at immediate post-test. As hypothesised, changes in normative perceptions of anti-vaccine conspiracy beliefs mediated the effect of the intervention. The intervention, did not directly increase vaccination intentions, however mediation analysis showed that the normative feedback increased perceptions of other parents' vaccination intentions, which in turn increased personal vaccination intentions. No significant effects remained after a six-week follow-up. The current research demonstrates the potential utility of Social Norms Approach interventions for correcting misperceptions and reducing anti-vaccine conspiracy beliefs among UK parents. Further research could explore utilising a top-up intervention to maintain the efficacy., Competing Interests: The authors have declared that no competing interests exist.

Younger adolescents are at an age where they have increasing control of their diet, and where peers become an important social reference for acceptable and normative dietary behaviours. These normative perceptions are often inaccurate and can lead to the development of unhealthy eating practices; although, the role of normative misperceptions of peers' unhealthy snacking behaviours in younger adolescents' personal snacking behaviours is not clear. The current study was a cross-sectional analysis of baseline data from a social norms-based healthy eating intervention sampling two secondary schools in deprived areas of England. Students aged 11-12 years (n = 252) completed self-report measures of their demographic characteristics and personal behaviours, attitudes, intentions, and normative perceptions (descriptive and injunctive norms), relating to unhealthy snacking. Results indicated students overestimated peers' daily unhealthy snacks consumption by approximately 3.2 portions, misperceived peers to have more positive attitudes towards unhealthy snacking and more negative attitudes towards reducing snacking. The greater these misperceptions of peers' behaviours and attitudes, the more likely students were to consume unhealthy snacks and have positive attitudes about unhealthy snacking. Girls had a stronger intention to reduce their snacking behaviours if they had more positive attitudes to reducing snacking behaviours and misperceived peers to also have a positive attitude. In summary, 11- to 12-year-olds misperceive the snacking behaviour and attitudes of their peers, and such normative misperceptions are associated with students' own snacking behaviours and attitudes. Interventions which challenge these misperceptions may assist in reducing the social acceptability of unhealthy snacking and in reducing unhealthy snacking amongst young adolescents., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: University students are a risk group for heavy substance use and the experience of various potentially severe negative substance use consequences which may impact on their health, social, and academic functioning. Whilst the experience of negative consequences of substance use is well understood in North American student samples, there is little data on these experiences in European students. In order to develop effective harm prevention and reduction interventions for students' substance use, there needs to be an understanding of the types of consequences experienced in European student samples., Objectives: The aim of the study was to investigate the prevalence and predictors of the experience of negative substance use-related consequences amongst university students in 7 European countries., Methods: University students (n = 4,482) in Belgium, Denmark, Germany, the Slovak Republic, Spain, Turkey, and the UK completed an online survey of their substance use behaviours and the experience of associated negative consequences., Results: European students reported that experiencing a hangover or illness, missing class, being short of money, and experiencing memory loss were the most commonly experienced negative consequences of substance use. Not living with other students and using alcohol, cannabis, sedatives, and cocaine were also associated with higher odds of experiencing these negative consequences., Conclusions: In contrast to North American data, European university students tended to experience consequences that are associated with lower level health risks rather than more severe consequences (e.g., drink-driving and physical injury). Harm prevention and reduction interventions for students should be targeted towards those consequences that are most salient to the target group to ensure feedback is relevant and potentially more effective in changing students' substance use behaviours., (© 2020 The Author(s). Published by S. Karger AG, Basel.)

This study investigated how wheelchair-using individuals with paraplegia and chronic pain make sense of the factors associated with quality of life based on interviews using photo-elicitation and interpretative phenomenological analysis. Three superordinate themes emerged in the analysis: experiencing quality of life through the perception of self and identity, interpersonal relationships as facilitators and barriers to quality of life and life in a wheelchair: pain experience and management. Quality of life for those living with paraplegia and chronic pain is experienced as a complex interaction across several life domains. The use of photographs may improve the communication of pain-related experiences and understanding by healthcare staff.

Childhood obesity is a global health concern, which has both short- and long-term health consequences for the individual, and is a potential burden on health care services and the wider economy. The school environment is a setting where changes can be applied to dietary behaviours, as schools have direct and intensive contact with children. This systematic review evaluated school-based interventions designed to improve dietary behaviours among adolescents (11- to 16-year-olds). The aims were to review types of interventions delivered, dietary behaviours targeted, and interventions' effectiveness in improving dietary behaviour and associated intervention components. Twenty-nine school-based interventional studies with this population were identified for review. The data were synthesized by identifying and comparing individual studies' results, intervention components, and characteristics. Interventions appeared more effective when they involved peers, used educational media to deliver health messages, increased availability of healthy foods in school, and incorporated computer-based individualized feedback with normative information on eating behaviours. A limitation of the review was the lack of description in certain reviewed studies and the nonfeasibility of conducting a meta-analysis owing to study heterogeneity. Future interventions with this population could consider including the aforementioned components, gender-specific feedback, and both short- and long-term follow-ups as change may not be apparent immediately and to determine if changes are sustained., (© 2018 World Obesity Federation.)

Introduction: The use of non-prescribed prescription sedatives and sleeping pills (NPPSSP) among university students has been described as an important public health issue. However, the impact of perceived social norms on students' use and attitudes towards use of NPPSSP is still unclear. Our aim was to investigate whether perceptions of peer use and approval of use are associated with students' personal use and approval of NPPSSP use., Methods: Cross-sectional data from the Social Norms Intervention for the prevention of Polydrug Use (SNIPE) project containing 4482 university students from seven European countries were analyzed to investigate self-other discrepancies regarding personal use and attitudes towards NPPSSP use. Associations between personal and perceived peer use and between personal and perceived approval of use were examined using multivariable logistic regression., Results: The majority (51.0%) of students perceived their peers' NPPSSP use to be higher than their personal use. 92.6% of students perceived their peers' approval of NPPSSP use to be identical or higher than their personal approval. Students perceiving that the majority of peers had used NPPSSP at least once displayed higher odds for personal lifetime use (OR: 1.95, 95% CI: 1.49-2.55). Perceived peer approval of NPPSSP use was associated with higher odds for personal approval (OR: 5.49, 95% CI: 4.63-6.51)., Conclusions: Among European university students, perceiving NPPSSP use and approval of use to be the norm was positively associated with students' personal NPPSSP use and approval of use, respectively. Interventions addressing perceived social norms may prevent or reduce NPPSSP use among university students. Final trial registration number: DRKS00004375 on the 'German Clinical Trials Register'., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The Social Norms Approach is a widely used intervention strategy for promoting positive health-related behaviors. The Approach operates on the premise that individuals misperceive their peers' behaviors and attitudes, with evidence of under- and over-estimations of behaviors and peer approval for a range of positive and negative behaviors respectively. The greater these misperceptions, the more likely an individual is to engage in negative behaviors such as consuming heavier amounts of alcohol and other substances and reduce positive behaviors such as eating healthily and using sun protection. However, there are many complexities associated with the use of social norms feedback in interventions and empirical studies. Many social norms interventions do not attempt to change misperceptions of social norms or measure changes in normative perceptions pre- and post-intervention. This has led to a conflation of generic social norms interventions with those that are explicitly testing the Approach's assumptions that it is misperceptions of peer norms which drive behavior. The aim of the present review was to provide a critical appraisal of the use of the Social Norms Approach as an intervention strategy for health-related behaviors, identify the current issues with its evidence base, highlight key opportunities and challenges facing the approach, and make recommendations for good practice when using the approach. There are three core challenges and areas for improved practice when using the Social Norms Approach. Firstly, improvements in the methodological rigor and clarity of reporting of 'social norms' research, ensuring that studies are testing the approach's assumption of the role of misperceptions on behaviors are differentiated from studies investigating other forms of 'social norms.' Secondly, the need for a more explicit, unified and testable theoretical model outlining the development of normative misperceptions which can be translated into interventional studies. Finally, a need for a more robust evaluation of social norms interventions in addition to randomized controlled trials, such as the inclusion of process evaluations, qualitative studies of participant experiences of social norms feedback, and alternative study designs better suited for real-world public health settings. Such improvements are required to ensure that the Social Norms Approach is adequately tested and evaluated.

Objective: Perceptions of peer behavior and attitudes exert considerable social pressure on young adults to use substances. This study investigated whether European students perceive their peers' cannabis use and approval of cannabis use to be higher than their own personal behaviors and attitudes, and whether estimations of peer use and attitudes are associated with personal use and attitudes., Method: University students (n = 4,131) from Belgium, Denmark, Germany, the Slovak Republic, Spain, Turkey, and the United Kingdom completed an online survey as part of the Social Norms Intervention for Polysubstance usE in students (SNIPE) Project, a feasibility study of a web-based normative feedback intervention for substance use. The survey assessed students' (a) personal substance use and attitudes and (b) perceptions of their peers' cannabis use (descriptive norms) and attitudes (injunctive norms)., Results: Although most respondents (92%) did not personally use cannabis in the past 2 months, the majority of students thought that the majority of their peers were using cannabis and that their peers had more permissive attitudes toward cannabis than they did. When we controlled for students' age, sex, study year, and religious beliefs, perceived peer descriptive norms were associated with personal cannabis use (odds ratio [OR] = 1.42; 95% CI [1.22, 1.64]) and perceived injunctive norms were associated with personal attitudes toward cannabis use (OR = 1.46; 95% CI [1.09, 1.94])., Conclusions: European students appear to possess similar discrepancies between personal and perceived peer norms for cannabis use and attitudes as found in North American students. Interventions that address such discrepancies may be effective in reducing cannabis use.

Introduction: Research conducted in North America suggests that students tend to overestimate tobacco use among their peers. This perceived norm may impact personal tobacco use. It remains unclear how these perceptions influence tobacco use among European students. The two aims were to investigate possible self-other discrepancies regarding personal use and attitudes towards use and to evaluate if perceptions of peer use and peer approval of use are associated with personal use and approval of tobacco use., Methods: The EU-funded 'Social Norms Intervention for the prevention of Polydrug usE' study was conducted in Belgium, Denmark, Germany, Slovak Republic, Spain, Turkey and United Kingdom. In total, 4482 students (71% female) answered an online survey including questions on personal and perceived tobacco use and personal and perceived attitudes towards tobacco use., Results: Across all countries, the majority of students perceived tobacco use of their peers to be higher than their own use. The perception that the majority (>50%) of peers used tobacco regularly in the past two months was significantly associated with higher odds for personal regular use (OR: 2.66, 95% CI: 1.90-3.73). The perception that the majority of peers approve of tobacco use was significantly associated with higher odds for personal approval of tobacco use (OR: 6.49, 95% CI: 4.54-9.28)., Conclusions: Perceived norms are an important predictor of personal tobacco use and attitudes towards use. Interventions addressing perceived norms may be a viable method to change attitudes and tobacco use among European students, and may be a component of future tobacco control policy., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The objective of this study was to explore perceptions of peer substance use and related attitudes among European students. Challenging perceptions about peer substance use has become the basis of a form of prevention and intervention known as the social norms approach, which can be delivered using personalized online feedback. This article reports baseline alcohol use and attitudes data for university students across Europe collected as part of the Social Norms Intervention for the prevention of Polydrug usE project (Project SNIPE)., Method: Students from universities in Belgium, Denmark, Germany, the Slovak Republic, Spain, Turkey, and the United Kingdom were recruited to take part in an online survey by the use of email invitations, social media, classroom announcements, flyers, and stalls in social areas, such as in cafeterias and bars on campus. A total of 4,482 students agreed to participate., Results: Overall, respondents reported both perceived alcohol use and perceived acceptance of alcohol use among their peers that were higher than their own use or acceptance. Perceived peers' behaviors and attitudes were found to be predictive of personal behaviors and attitudes, with some variation across countries and by sex., Conclusions: The results suggest that students at the participating institutions across selected European countries exhibit overall similar patterns of perceptions as have been found on American college campuses. In conjunction with the finding that the perceived norm is predictive of personal behavior and attitudes, this research provides support to the view that the social norms approach may be a viable method to reduce alcohol consumption among students at European universities.

Overgeneral autobiographical memory recall has been associated with the diagnosis of bipolar disorder, but the role of overgenerality in the vulnerability to bipolar disorder remains under-researched. While a previous study suggested that high-risk individuals for bipolar disorder recall emotionally negative memories in specific detail, this is in contrast to memory recall patterns noted in bipolar samples. The Autobiographical Memory Test (AMT) used in previous non-clinical studies has also been criticised for not being sensitive to overgenerality due to its repetition of specificity instructions and practice trials. The traditional AMT format may allow some individuals to override their trait-based tendencies to be overgeneral. The current study used a sentence completion task to assess memory specificity in groups of students at a low and high trait-based vulnerability for bipolar disorder. In contrast to previous research, high-risk individuals recalled fewer specific positive memories and greater numbers of overgeneral negative memories than low-risk individuals. These results support the notion that the vulnerability for bipolar disorder might be associated with similar recall biases as demonstrated in bipolar samples, and that the AMT might not be sufficiently sensitive to detect overgenerality in non-clinical groups. The implications of these findings and directions for future research are discussed.

Specific forms of ruminative cognitive styles and self-appraisals have been implicated in the development of bipolar symptomatology. This study investigated the associations between measures of positive and negative forms of appraisals and rumination with vulnerability to hypomania, and also investigated the conceptual overlap between these measures in terms of the responses to emotional experiences captured. Hypomania vulnerability was predicted by measures of positive cognitive styles, whilst current depressive symptoms were explained by scores on measures of negative cognitive styles in an analogue sample of 353 participants. A principal components analysis conducted upon the rumination and appraisal measures yielded three components representing positive and negative cognitive styles, and a normalizing of symptoms component. The implications of these results are discussed., (© 2011 Wiley Periodicals, Inc.)