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Background: Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy. Methods: This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months. Results: 107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes. Limitations: Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample. Conclusions: Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

Background Maladaptive perfectionism is a transdiagnostic risk and maintaining factor for a range of mental health conditions, including bipolar disorder (BD). Self-compassion represents a potential protective factor against maladaptive perfectionism, however no studies to date have examined the relationship of these constructs in BD. The aim of the present study was to examine associations between maladaptive perfectionism, self-compassion and symptoms among individuals with BD. Methods Baseline data were collected from 302 participants with a DSM-IV diagnosis of BD participating in an international randomised controlled trial. Participants completed measures of maladaptive perfectionism, self-compassion, symptom severity and emotion regulation difficulties. Clinician-administered measures of depression and mania severity were additionally collected. Correlation and mediation analyses were conducted. Results Maladaptive perfectionism was positively associated with depression, anxiety and emotion regulation difficulties. Lower levels of self-compassion correlated with greater self-reported depression, anxiety and emotion regulation difficulties. Self-compassion partially mediated relationships between maladaptive perfectionism, depression, anxiety and emotion regulation difficulties. Limitations The cross-sectional design limits conclusions about causal relationships between study variables. Results may not be generalizable to other BD populations. The role of maladaptive perfectionism and self-compassion in elevated mood states of BD remains unclear. Conclusion Self-compassion represents one mechanism through which maladaptive perfectionism influences symptoms of depression, anxiety and emotion regulation difficulties in BD. Self-compassion represents a modifiable treatment target; individuals with BD exhibiting maladaptive perfectionistic tendencies may benefit from interventions fostering self-compassion.

Background: The prevalence rate of completed suicide in bipolar disorder is estimated to be as high as 19%. Social factors or influences, such as stigmatisation and family conflict, contribute to the development of suicidal ideation in clinical and non-clinical populations. Yet, there is a lack of studies examining suicidality from a psychosocial perspective in people who experience bipolar disorder.\ud \ud Method: Semi-structured interviews were used to collect qualitative data from 20 participants with bipolar disorder. The interview focused on the effects of social factors upon participants‟ experiences of suicidality (suicidal thoughts, feelings or behaviours). A thematic analysis was used to understand the data.\ud \ud Results: Social or interpersonal factors which participants identified as protective against suicidality included, 'the impact of suicide on others' and, 'reflecting on positive social experiences'. Social factors which triggered suicidal thoughts included, 'negative social experiences' and, 'not being understood or acknowledged'. Social factors which worsened suicidal thoughts or facilitated suicidal behaviour were, 'feeling burdensome,‟ and 'reinforcing negative self-appraisals'.\ud \ud Limitations: Some participants had not experienced suicidal thoughts for many years and were recalling experiences which had taken place over ten years ago. The accuracy and reliability of these memories must therefore be taken into consideration when interpreting the results.\ud \ud Conclusions: The themes help to enhance current understanding of the ways in which social factors affect suicidality in people who experience bipolar disorder. These results highlight the importance of considering the social context in which suicidality is experienced and incorporating strategies to buffer against the effects of negative social experiences in psychological interventions which target suicide risk in bipolar disorder.

BACKGROUND: Bipolar Disorder (BD) is a severe mental health problem. Psychological interventions are recommended by the National Institute for Health and Care Excellence (NICE) but patients experience severe inequalities in access. This study assessed the feasibility and potential effectiveness of a recovery informed web-based self-management intervention for people with BD. METHODS: An online randomised controlled trial (n=122) compared treatment as usual (TAU) plus the 'Living with Bipolar' (LWB) intervention with a waiting list control (WLC) group. RESULTS: The study recruited to target and the retention rates were high. Participants engaged with the approach. Compared with the WLC, those receiving LWB showed the most robust improvement in psychological and physical domains of quality of life, wellbeing and recovery at the end of the intervention. LIMITATIONS: The trial was not definitive and requires further investigation. CONCLUSIONS: There is preliminary evidence that a web-based treatment approach in BD is feasible and potentially effective. Such interventions could form part of the Improving Access to Psychological Therapy (IAPT) initiative in severe mental health.

Background: Bipolar disorder is often only partially treated by medication alone, which has led to recent developments in the adjunctive psychological treatment of bipolar disorder. This paper aims to examine the current evidence for effectiveness of psychological interventions for bipolar disorder and to identify issues for future research in this area. Method: A review of outcome studies of psychological interventions reported since 1990, including psychoeducation, cognitive-behavioural, interpersonal and social rhythm and psychoanalytic therapy. Results: The research to date indicates that a range of psychological approaches appear to benefit people with bipolar disorder. The clearest evidence is for individual CBT which impacts on symptoms, social functioning and risk of relapse. Limitations: Many studies lack appropriate control groups and standardised measures of symptoms and diagnosis. Better designed studies would reduce the risk of over-estimates of effect sizes and subsequent failure to replicate. Further developments of psychotherapy need to be based on clear theoretical models of bipolar disorder. Conclusions: Many current studies are uncontrolled and of poor quality leading to a risk of over-estimating effectiveness of some interventions. Suggestions are made for future research including improving quality of studies, basing treatment developments on clear theoretical models and identifying specific treatment components for particular phases of the bipolar illness course.

Objectives People in the late stage of bipolar disorder (BD) experience elevated relapse rates and poorer quality of life (QoL) compared with those in the early stages. Existing psychological interventions also appear less effective in this group. To address this need, we developed a new online mindfulness-based intervention targeting quality of life (QoL) in late stage BD. Here, we report on an open pilot trial of ORBIT (online, recovery-focused, bipolar individual therapy). Methods Inclusion criteria were: self-reported primary diagnosis of BD, six or more episodes of BD, under the care of a medical practitioner, access to the internet, proficient in English, 18–65 years of age. Primary outcome was change (baseline – post-treatment) on the Brief QoL.BD ( Michalak and Murray, 2010 ). Secondary outcomes were depression, anxiety, and stress measured on the DASS scales ( Lovibond and Lovibond, 1993 ). Results Twenty-six people consented to participate (Age M=46.6 years, SD=12.9, and 75% female). Ten participants were lost to follow-up (38.5% attrition). Statistically significant improvement in QoL was found for the completers, t(15)=2.88, 95% CI:.89–5.98, p=.011, (Cohen׳s dz=.72, partial η2=.36), and the intent-to-treat sample t(25)=2.65, 95% CI:.47–3.76, (Cohen׳s dz=.52; partial η2=.22). A non-significant trend towards improvement was found on the DASS anxiety scale (p=.06) in both completer and intent-to-treat samples, but change on depression and stress did not approach significance. Limitations This was an open trial with no comparison group, so measured improvements may not be due to specific elements of the intervention. Structured diagnostic assessments were not conducted, and interpretation of effectiveness was limited by substantial attrition. Conclusion Online delivery of mindfulness-based psychological therapy for late stage BD appears feasible and effective, and ORBIT warrants full development. Modifications suggested by the pilot study include increasing the 3 weeks duration of the intervention, adding cautions about the impact of extended meditations, and addition of coaching support/monitoring to optimise engagement.

BACKGROUND: People with bipolar disorder may be at increased risk of suicidal behaviour but there are few prospective studies of self-harm in this group. Our aim was to describe the characteristics and outcome (in terms of repetition) for individuals with bipolar disorder who presented to hospital following self-harm. METHOD: A nested case-control study was carried out using a large prospective self-harm database (1997-2010) in Manchester, UK. Characteristics of bipolar cases and non-bipolar controls were compared using conditional logistic regression, and outcomes were assessed via survival analyses. RESULTS: Bipolar cases (n=103) were more likely to repeat self-harm than controls (n=515): proportion with at least one repeat episode 58% vs. 25%, HR 3.08 (95% CI; 2.2-4.18). Previous self-harm, unemployment, contact with psychiatric services and sleep disturbance were all more common in cases than controls. Even after adjustment for known risk factors, the risk of repetition remained higher in the bipolar group (adjusted HR 1.68; 95% CI; 1.10-2.56). LIMITATIONS: The study covers cases from hospital sites in Manchester, UK, and therefore only includes self-harm that was serious enough to present at hospital emergency departments. CONCLUSION: People with bipolar disorder who self-harm have a higher risk of repetition than people who self-harm more generally. Adjusting for some known risk factors moderated, but did not abolish, this finding. Other factors, such as impulsivity, may also be important.

Background: The importance of personal recovery in mental health is increasing widely recognised. However, there is no measure available to assess recovery experiences in individuals with a diagnosis of bipolar disorder. This paper reports on the development of the Bipolar Recovery Questionnaire (BRQ) to aid recovery informed developments in research and clinical practice. Methods: A draft 45 item BRQ was developed based on prior literature review and qualitative research. In the current study a panel of clinicians, academics and consumers rated draft items on recovery relevance and comprehensibility leading to the 36 item questionnaire subjected to psychometric evaluation. 60 participants with bipolar disorder completed BRQ along with measures of mood, quality of life, functioning and personal growth. Results: BRQ was internally consistent and reliable over a month long test–retest period. BRQ scores were significantly associated with lower depression and mania scores and with higher wellbeing. BRQ was also significantly associated with better functioning, better mental health quality of life and personal growth. Regression analysis indicated that depression, wellbeing and personal growth were all uniquely associated with BRQ. Limitations: Sample size did not permit exploration of the factor structure of BRQ. The sample is drawn from the North West of England thus it is not clear how these findings might generalise beyond this group. Conclusions: BRQ is designed to assess personal experiences of recovery in bipolar disorder. The present study indicates that it is reliable and valid, being associated with both symptomatic and functional outcomes consistent with established definitions of recovery.

Background Bipolar Disorder (BD) can have highly detrimental effects on the lives of people with the diagnosis and those who care about them. However, growing evidence suggests that aspects of bipolar experiences are also highly valued by some people. Method We aimed to understand how participants with a diagnosis of BD made sense of what they took to be positive about their bipolar experiences. Interpretative Phenomenological Analysis was used in the collection and analysis of data from 10 individuals in the UK. Results Positive aspects were numerous, highly valued and participants welcomed the opportunity to discuss them. Three important themes emerged: 1) Direct positive impact of bipolar experiences on everyday life including amplification of internal states, enhanced abilities and more intense human connectedness; 2) Lucky to be bipolar – the sense of having been given a special gift; 3) Relationship between the self and bipolar experiences. Limitations Given the small size, further research is needed to explore how widely positive aspects of BD are experienced. Conclusions These themes highlight the need to invite people to talk about the positive aspects of their bipolar experiences as well as the difficulties they face. This may help us to understand ambivalence to current treatment and to develop interventions that minimise the negative impacts, whilst recognising and potentially retaining some of the positives.

Background The Mood Disorder Questionnaire (MDQ) was designed as a screening questionnaire for bipolar disorder. Previous research has raised questions about the suitability of the MDQ structure for screening for bipolar II disorder. This study investigated the optimal sensitivity and specificity cut-off thresholds for the MDQ in bipolar I and bipolar II patients in a UK sample. Methods The MDQ was administered to patients before attending a tertiary mood disorders clinic. Diagnostic interviews were used to determine DSM-IV diagnoses and these were used as the gold standard against which to investigate the performance of the MDQ. Results 54 patients with bipolar spectrum disorder and 73 patients with unipolar depressive disorder completed the MDQ. With the original scoring criteria (symptoms and supplementary questions) the sensitivity for bipolar disorder was 0.76 (bipolar I disorder 0.83, bipolar II disorder 0.67) with specificity 0.86. The optimal cut-off score in the current sample was a score of 9 or more endorsed symptoms without applying the supplementary questions (sensitivity of 0.90 and 0.88 for bipolar I and bipolar II groups respectively with a specificity of 0.90). Limitations The sample was drawn from a tertiary mood disorders clinic. Conclusions The MDQ appears to be a useful screening tool for bipolar spectrum disorder in UK psychiatric practice with sensitivity for bipolar II disorder improved by dropping the supplementary sections. Further investigation of the optimal cut-off scores of the MDQ is needed to determine its utility in non-specialist and community based samples.

Background: Despite developments in cognitive behavioural therapy for bipolar disorder, little is known about the specific dysfunctional beliefs that may predispose individuals to mania. Therefore a measure was specifically designed for this purpose based on a cognitive approach. The measure is called the Hypomanic Attitudes and Positive Predictions Inventory (HAPPI). Method: Fifty-six individuals with a diagnosis of bipolar disorder and 39 matched healthy controls completed a brief version of the HAPPI (Brief-HAPPI), the Internal State Scale, and the Hypomanic Interpretations Questionnaire (HIQ). Results: The bipolar group scored higher on the overall Brief-HAPPI scale, higher on the forward items of the Brief-HAPPI, lower on the reverse items and no different on the filler items. The group differences in overall score remained when controlling for current self-reported symptoms of mania and depression, and recent history of hypomanic symptoms, yet within the bipolar group, Brief-HAPPI score was positively correlated with the level of symptoms. The Brief-HAPPI showed a sizeable correlation with the HIQ, yet each scale showed a significant and independent association with bipolar disorder. Conclusion: The Brief-HAPPI assesses dysfunctional beliefs that are associated with a diagnosis of bipolar disorder.

Background This paper reports two studies concerned with the development and validation of the Hypomania Interpretations Questionnaire (HIQ) designed to assess positive self-dispositional appraisals for hypomania-relevant experiences. Methods Study 1: 203 late adolescent participants completed the HIQ along with additional measures of general symptom interpretation, dysfunctional attitudes and hypomanic personality. Study 2: 56 adults with a self-reported diagnosis of bipolar disorder and 39 controls completed a revised HIQ and a measure of current mood symptoms. Results Study 1: The final 10 item HIQ had two subscales: a) positive self-dispositional appraisals (HIQ-H); and b) normalising appraisals (HIQ-NE). Internal and test–retest reliability were adequate. Hypomanic personality scores were significantly and uniquely predicted by recent hypomania-relevant experiences and HIQ-H score. Study 2: HIQ remained internally reliable within this sample. Bipolar participants (BD) reported more subsyndromal mood symptoms than controls (C) and scored significantly higher on HIQ-H even after covarying for these. HIQ-H was the primary predictor of diagnostic group. Its ability to discriminate BD from C was confirmed by ROC analysis. Limitations The studies are cross-sectional and did not include non-bipolar psychiatric control groups. Conclusions HIQ appears to be a reliable and valid measure for the assessment of positive self-dispositional appraisals which seem to be linked to both hypomanic personality and bipolar disorder. The relevance of such appraisals for symptom exacerbation, relapse and psychological treatment would merit future investigation.