Psychological Therapies and the Bipolar Disorder ‘Iceberg’: Going Deeper Than Current Mood and Relapse Prevention Planning

Bipolar Disorders · 2026-03-01

Psychological therapies for bipolar disorder can operate at different levels. While addressing ‘surface-level’ issues such as current mood episodes, understanding of bipolar disorder and relapse prevention is key, therapies would be enhanced if ‘under the surface’ issues such as psychiatric comorbidities, childhood trauma and perfectionism are also incorporated. Bipolar disorder (BD) is linked to high levels of disability, significantly impacting functioning and quality of life. In recent years, there has been increasing research supporting the efficacy of psychological therapies, together with medication, to ameliorate mood symptoms and reduce relapse risk. Aside from these two core treatment targets, there are often psychiatric comorbidities and underlying psychological vulnerabilities, which are not addressed by currently available therapies for BD. As a result, such underlying issues are neither assessed nor addressed in terms of research or clinical practice. This clinical care article outlines our collective clinical, lived experience and academic views on the underlying or ‘deeper’ issues common to individuals with BD, why these should be addressed, and how. An iceberg metaphor is used throughout to illustrate this concept: Some ‘surface level’ issues are the most obvious and clearly visible, but there are remaining difficulties often hidden ‘under the surface’ which nonetheless ‘support’ (or serve to maintain) the current difficulties (see Figure 1). We do not use the term ‘surface level’ in a disparaging way and emphasise our simple hope to encourage clinicians and academics to think ‘deeper’ than these presenting problems. In using the term ‘surface level’ we are referring to the issues that are described as pressing concerns for service users with BD, or immediately visible to clinicians, such as acute symptoms of depression or (hypo)mania. This term also refers to work which may be prioritised due to a stronger evidence base, or restrictions such as session limits. Guideline-recommended psychological interventions for BD include Cognitive Behavioural Therapy (CBT), Interpersonal and social rhythm therapy (IPSRT), group-based psychoeducation, and family-focused therapies. Although there are individual nuances, these interventions share a focus on reducing current mood symptoms; the therapist will often focus on current thinking patterns (e.g., self-critical thoughts) and behaviours (e.g., excessive sleeping, withdrawal) which are maintaining the mood episode. Another common presenting concern addressed by current evidence-based interventions is relapse prevention (also referred to as staying well), through strategies such as understanding triggers for an episode, identifying early warning signs and symptoms, finding behavioural strategies to reduce risk of relapse and developing a shared relapse prevention plan. These treatments address misconceptions, anxieties and questions that the service user may wish to discuss such as ‘Why do I have bipolar disorder?’ and ‘Is there anything I can do besides take medication to stop getting manic?’. As such, these interventions collectively prioritise psychoeducation. Namely, sharing reliable information on the disorder, its triggers and treatments to support acceptance of the diagnosis, medication adherence and engagement in self-management strategies. These ‘surface level’ issues of current mood and relapse prevention are often a key focus in therapy given their strong evidence base. The largest meta-analysis to date of 39 randomised controlled trials showed that psychological therapies, when used in conjunction with medication, reduce the risk of relapse by 44% [1]. Psychoeducation delivered in a group or family format was shown to reduce risk of relapse compared to individual therapy and CBT, family therapy and interpersonal therapy were found to reduce acute symptoms of depression [1]. Further, the review identified specific skills of cognitive restructuring (a core component of CBT), communication training and regulating daily rhythms which appeared to improve depression symptom severity [1]. The evidence is less clear for (hypo)mania, and therapy conducted during an acute manic episode is challenging, but nonetheless the review also found that cognitive restructuring was linked to manic symptom stabilisation [1]. Thus, there is clear and robust evidence that psychological therapies can improve these ‘surface’ level issues of current mood episodes (and linked thinking patterns), as well as reducing relapse risk. In our clinical experience, as therapy progresses, the service user and clinician will often identify additional difficulties and issues which contribute to the ‘surface level’ presenting problems. These are often less visible or ‘hidden’ when compared to more acute concerns such as preventing another relapse or stabilising mood. Nonetheless, in a similar way to an iceberg where the hidden component underlies and ‘supports’ that which can be seen on the surface, these underlying issues are interlinked and when not addressed, maintain acute mood episodes and trigger relapses (as illustrated by Figure 1). An example may be that a client wants to work on preventing a manic relapse in the future; however, with time it becomes clear through therapy and the collaborative development of a psychological formulation that two driving factors for past relapses are (1) the belief that they are fun and productive when manic, and (2) underlying perfectionism and high standards which drive excessive goal-focused activity and destabilises mood. Thus, developing a relapse prevention plan will only go so far unless these underlying issues are tackled. Psychiatric comorbidities may represent difficulties which may be less obvious in therapy and may ‘fuel’ current mood difficulties. A recent systematic review [2] found that 38.9% of those with BD have another psychiatric diagnosis, with rates significantly higher than in the general population. Most common comorbidities are anxiety disorders (40.4%), with high rates for specific anxiety disorders such as Post-Traumatic Stress Disorder (8.2%), social anxiety (10.6%), Generalised Anxiety Disorder (13.1%) and panic disorder (14.9%). The review also found high levels of comorbid substance use disorder (30.7%), Attention-Deficit Hyperactivity Disorder (18.6%) and eating disorders (9.3%) [2]. It is thus vital to address comorbidities, especially given the availability of evidence-based psychotherapies for each respective condition, with targeted approaches (e.g., exposure, safety planning) that could be integrated into existing BD psychotherapies. In addition to formal psychiatric comorbidities, research has demonstrated a clear psychological profile of BD, which may underpin current mood difficulties. Those with BD have been shown to have high levels of impulsivity, low and variable self-esteem, elevated perfectionism and dysfunctional attitudes (high standards), low self-compassion, high levels of childhood abuse and high levels of shame [3]. Use of unhelpful emotional coping strategies such as rumination is common amongst people with BD, as is emotional dysregulation during episodes [3]. In addition, those with BD have positive views about extreme mood elevation and a reluctance to ‘give up’ manic episodes (e.g., enjoying the creativity of (hypo)mania), and a positive bias for personal abilities and ambitions to become famous or wealthy [3]. Finally, client-valued goals such as personal recovery and quality of life may also be at odds with the emphasis of ‘surface level’ treatment frameworks. For example, relapse prevention/staying well work may not be as a high priority for some service users as compared to restoration of occupational and social functioning or dealing with self-stigma and a disrupted sense of identity. These issues may both represent vulnerabilities that contribute to ‘surface level’ issues, as well as strengths that may be drawn on to guard against future relapses. This may mean that potential perpetuating or protective factors are missed when therapeutic frameworks centre symptom management alone. Furthermore, integration of service user valued goals may promote therapeutic alliance, thereby laying the groundwork for engagement in treatments that focus on key ‘surface level’ issues. Whilst research has demonstrated the high prevalence of comorbidities, and a clear psychological profile of BD, there is much less evidence examining whether psychological therapies can address these comorbidities and psychological mechanisms which may impact the ‘surface level’ presenting problems. A review of publication trends [4] around anxiety disorders in BD found 310 papers published between 2011 and 2020, but only 25 (8.1%) of these were focused on psychological therapies specifically. As a result, whether psychological therapies can reduce anxiety and anxiety disorder comorbidity in BD is less than clear. A similar pattern is observed for other comorbidities such as substance use, and for psychological mechanisms underlying BD such as perfectionism and positive beliefs about (hypo)mania, where there is little or no research on psychological therapies to target these specific mechanisms. Psychological therapies have been shown to be effective for addressing ‘surface level’ issues in BD, namely reducing acute mood symptoms and reducing the risk of future relapse. This work is important and should continue, and there is still work to be done to understand treatment moderators and improving access to these therapies [5]. However, we encourage clinicians to think about the ‘deeper’ issues which underly these presenting problems, even if these are not readily bought into therapy by the service user, or are deemed out of the remit of a service or particular therapy. We encourage academics to focus research on better understanding these underlying mechanisms and developing novel psychological therapies to help reduce the impact of difficulties such as childhood trauma and positive beliefs about (hypo)mania. Doing so may lead to longer term, ‘deeper’ and more sustainable changes for those with BD. The authors has nothing to report.

The highs and lows: Cannabis use and positive valence bipolar mood and emotion processes in emerging adults

Journal of Affective Disorders · 2026-03-16

Feasibility and acceptability of Interpersonal Social Rhythm Therapy (IPSRT) for perinatal bipolar disorder

Journal of Affective Disorders · 2026-05-06

The perinatal period, pregnancy through postpartum, is destabilizing for people with bipolar disorder (BD). Few studies have examined adjunctive psychotherapy for perinatal BD despite its potential benefits for managing symptoms, psychosocial stress, sleep disturbance, and medication adherence. The goal of this pilot study was to develop an adaptation of Interpersonal and Social Rhythm Therapy (IPSRT) as an intervention for perinatal BD and test feasibility and acceptability (primary) and mood symptom change (secondary) outcomes in an open trial design. Modifications to the 20-session IPSRT included perinatal specific psychoeducation, strategies to increase social support, and focus on sleep-wake interruptions associated with newborn care. Participants were enrolled during pregnancy. Depressive and manic symptoms were assessed at the end of treatment (4 months postpartum) and at 2-month follow-up (6 months postpartum). Feasibility and participant satisfaction were also assessed. A total of 14 pregnant women were enrolled and ten (71%) completed follow-up assessments. The average number of sessions attended was 14 out of 20. Participant satisfaction was high (31.25 out of 32). Depressive symptoms were significantly lower at the end of treatment and 2-month follow-up relative to baseline. IPSRT shows potential as an adjunctive intervention for managing mood in patients with perinatal BD. Future research is needed to examine benefits of flexible intervention delivery and patient engagement. IPSRT for BD directly targets known correlates of mood destabilization during the perinatal period, interpersonal functioning and circadian rhythm disruption. Further examination of IPSRT during the perinatal period is imperative. • We adapted Interpersonal Social Rhythm Therapy by including perinatal specific psychoeducation, skills, and strategies. • Participants were highly satisfied with the intervention, and most were able to complete the minimum number of sessions. • Improvements in depressive and manic symptoms were observed, though interpreted cautiously in this pilot study. • Future trials of IPSRT for perinatal bipolar disorder will likely require multi-site collaboration to increase feasibility.

Highest Columbia-Suicide Severity Rating Scale (C-SSRS) Screener Item Endorsed by Individuals who Attempted Suicide

2025-02-28

Objectives : The Columbia Suicide Severity Rating Scale (Posner et al., 2011; C-SSRS) is a widely used measure, both in research and clinical practice, for the detection of suicide risk. The current study examines responses to the C-SSRS by individuals who attempted suicide in the 30 days before pre-trial jail detention. Methods : Data were analyzed from the Suicide Prevention Intervention for at-Risk Individuals in Transition (SPIRIT) trial, which was conducted from May 2016 to November 2018 and included 800 individuals in pretrial jail detention with the primary inclusion criterion being endorsement of suicidal ideation with some intent to act (endorsement of C-SSRS C4 or C5) and/or a suicide attempt in the past month. This paper focuses on the first five screener items of the C-SSRS, which assess the highest level of suicidal ideation in the past month. Results : Most (65%) individuals who reported making a past 30-day suicide attempt indicated their highest level of suicidal ideation at the time of attempt was at the C4 (active suicidal ideation with some intent to act, without specific plan), rather than the C5 level (active suicidal ideation with specific plan and intent). Conclusion : Fewer than one third of individuals who had made at least one past 30-day suicide attempt in our sample had made specific plans. Findings highlight the unplanned nature of many suicide attempts and the risk for suicide among individuals without detailed suicide plans.

Considerations and Challenges When Using Clinical and Vital Record Review for Suicide Research

Journal of Patient Safety · 2025-02-10 · 1 citations

Suicide Risk Screening in Jails: Protocol for a Pilot Study Leveraging the Mental Health Research Network Algorithm and Health Care Data

JMIR Research Protocols · 2025-05-28 · 1 citations

BACKGROUND: Suicide in local jails occurs at a higher rate than in the general population, requiring improvements to risk screening methods. Current suicide risk screening practices in jails are insufficient: They are commonly not conducted using validated screening instruments, not collected by clinically trained professionals, and unlikely to capture honest responses due to the chaotic nature of booking areas. Therefore, new technologies could improve such practices. Several studies have indicated that machine learning (ML) models considerably improve accuracy and have positive predictive value in detecting suicide risk compared with practice as usual (PAU). This study will use administrative data and ML modeling to improve suicide risk detection at jail booking. OBJECTIVE: This study is primarily focused on gathering preliminary information about the feasibility and practicality of using administrative data and ML modeling for suicide risk detection but also incorporates elements of hypothesis testing pertaining to clinical outcomes. METHODS: The study uniquely contributes to our understanding of suicide risk by further validating an existing ML model developed and previously validated by the Mental Health Research Network using Medicaid outpatient health care claims data. This validation uses complete claims data on a sample of approximately 6000 individuals booked into 2 diverse jails in a midwestern state. This model validation uses 313 unique demographic and clinical characteristics from 5 years of historical health care data. It detects suicide risk in jails and postrelease by using merged jail, Medicaid, and vital records data. The study will use jail administrative data for September 1, 2021, through February 28, 2022; Medicaid records data for September 1, 2016, through March 31, 2023; and vital records data for March 1, 2022, through March 31, 2023. RESULTS: First, the algorithm will be validated on the data gathered for the jail sample using the C-statistic and area under the receiver operating characteristic curve. Second, the resulting model will be compared with the jails' suicide identification PAU to assess risk and detection of identified suicide attempts and deaths from intake through 120 days and 13 months after jail release. The funding timeline for this project is August 1, 2022, through July 31, 2025. The algorithm's predictions and actual event incidence will be linked and validated in the spring of 2025, with results ready for publication in the fall of 2025. CONCLUSIONS: The study will also investigate implementation factors, such as feasibility, acceptability, and appropriateness, to optimize jail uptake. Interview data on the implementation factors will be gathered in the summer of 2025, with expected dissemination in 2026. We hypothesize that a combination of intake screening PAU and the ML model will be the optimal approach, in that the combination will be more accurate and can have practical application in this context. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/68517.

The Future of Women in Psychological Science

UNC Libraries · 2025-06-27

There has been extensive discussion about gender gaps in representation and career advancement in the sciences. However, psychological science itself has yet to be the focus of discussion or systematic review, despite our field's investment in questions of equity, status, well-being, gender bias, and gender disparities. In the present article, we consider 10 topics relevant for women's career advancement in psychological science. We focus on issues that have been the subject of empirical study, discuss relevant evidence within and outside of psychological science, and draw on established psychological theory and social-science research to begin to chart a path forward. We hope that better understanding of these issues within the field will shed light on areas of existing gender gaps in the discipline and areas where positive change has happened, and spark conversation within our field about how to create lasting change to mitigate remaining gender differences in psychological science.

Baseline and Lifetime Suicidality and Risk Factors Among Pretrial Jail Detainees Enrolled in a Suicide Prevention Trial

Psychiatric Services · 2025-04-16 · 1 citations

OBJECTIVE: Jail detention may be a marker of suicide risk in the community. This article aimed to describe the phenomenology of suicide risk, including lifetime suicidal behaviors and comorbid conditions, observed among individuals recruited into a suicide prevention trial who passed through pretrial jail detention before returning to the community. METHODS: Data on baseline characteristics of 800 adult participants from the SPIRIT (Suicide Prevention Intervention for At-Risk Individuals in Transition) study were analyzed. RESULTS: Half the participants reported a suicide attempt in the 30 days prior to study enrollment, 85% reported at least one lifetime suicide attempt, and (93%, N=743) reported any suicidal behavior in their lifetime. Most (85%) suicide attempts in the past 30 days were made in the community, prior to arrest. Participants had a mean±SD of 14.1±53.6 lifetime suicide attempts. One-third (34%) reported that their first attempt occurred when they were ≤10 years old. Comorbid conditions were common, with high rates of problematic substance use as well as symptoms of depression, posttraumatic stress, psychosis, and mania. CONCLUSIONS: Individuals passing through pretrial jail detention have a complex suicide risk profile that often includes addiction, serious mental illness, and long histories of suicidal behaviors. Because most of these individuals return to the community within days, effective postdetention suicide prevention services in the community are needed.

Mental Health and Clinical Psychological Science in the Time of COVID-19: Challenges, Opportunities, and a Call to Action

UNC Libraries · 2025-05-13

COVID-19 presents significant social, economic, and medical challenges. Because COVID-19 has already begun to precipitate huge increases in mental health problems, clinical psychological science must assert a leadership role in guiding a national response to this secondary crisis. In this article, COVID-19 is conceptualized as a unique, compounding, multidimensional stressor that will create a vast need for intervention and necessitate new paradigms for mental health service delivery and training. Urgent challenge areas across developmental periods are discussed, followed by a review of psychological symptoms that likely will increase in prevalence and require innovative solutions in both science and practice. Implications for new research directions, clinical approaches, and policy issues are discussed to highlight the opportunities for clinical psychological science to emerge as an updated, contemporary field capable of addressing the burden of mental illness and distress in the wake of COVID-19 and beyond.

Suicide methods in the year following release from pretrial jail detention

International Journal of Prison Health · 2025-03-12 · 1 citations

PURPOSE: Despite an increasing body of knowledge on suicide methods, no previous studies have examined methods of past suicide attempts among individuals in pretrial jail detention and a follow-up after release from jail in the USA or in any other country. This study aims to describe suicide attempt methods considered and used in one's lifetime prior to pretrial jail detention and suicide attempt methods considered and used in the year following release from pretrial jail detention. DESIGN/METHODOLOGY/APPROACH: Participants (n = 800) were recruited as part of a randomized controlled trial. They provided information on methods considered or acted on in their lifetime prior to the current pretrial jail detention as well as in the first year of release from jail. FINDINGS: Participants most frequently reported having considered and attempted suicide by poisoning (82% and 72.8%), cutting/piercing (47.8% and 35.3%), suffocation (42.1% and 20.8%), transportation (39.9% and 25.3%), falls and jumping (27.4% and 8.0%) prior to jail detention. After jail detention, they mostly considered and attempted suicide by poisoning (73.6% and 73.4%), cutting/piercing (28.6% and 13.9%), suffocation (33.2% and 10.1%), transportation (23.6% and 18.6%), falls and jumping (20.9% and 2.5%). ORIGINALITY/VALUE: Given that poisoning, often with drugs or alcohol, was the commonest suicide attempt method, increasing access to effective substance use treatment may help to attenuate significant suicide risk. The study has laid the foundation for future research to explore potential moderators of suicide methods as well as to assess whether the findings are applicable to other parts of the world.