Title: Investigating anxiety as an early intervention target for bipolar disorder
Funder: Health Education England

Abstract: Background Bipolar disorder (BD) is a severe mental health problem characterised by extremes of high and low mood (depression and mania). It is the sixth leading cause of disability among people aged 15-44 worldwide and is associated with costs of up to 5.2billion annually in England alone. BD has a chronic and progressive course making early intervention a top priority in the field. However, the earliest stages of the illness are highly heterogeneous and often difficult to distinguish from other psychiatric disorders making early recognition and treatment difficult. Encouragingly, recent studies of youth at high familial risk of BD, have shown that there are reliable, clinical indicators present prior to the onset of major mood symptoms that could be viable targets for early intervention. One such target is childhood anxiety, which confers as much as a four-fold increase in risk. By learning how anxiety operates as a risk factor in high risk youth, my research will develop a novel intervention for BD targeting anxiety.Aims and Objectives My first aim is to investigate the characteristics of anxiety in youth at high-risk for BD. This will involve examining anxiety through self-report and clinical interviews, quantifying the relationship between real-world momentary anxiety and mood, and measuring the body's cortisol awakening response. My second aim is to identify psychological processes that generate and maintain this anxiety in high-risk youth by measuring key cognitive and affective processes, establishing whether these processes predict anxiety symptoms over time and using experimental tasks to test this relationship. My final aim is to translate these findings into a novel early intervention through co-design with a service user advisory group and to conduct an initial pilot study. Methods A sample of 60 high-risk youth aged 11-16 will invited to take part in a longitudinal study with follow up at 12 months. These young people will be recruited through initial contact with parents via psychiatric services in South London and Maudsley (SLaM) NHS Foundation trust and advertising initiatives. 60 matched controls will also be recruited through local schools. Self-report, experimental and biobehavioural methodology will be utilized to examine the characteristics of anxiety in high-risk youth and results will be translated into a novel intervention through co-design with a service user advisory group. A small pilot study using a single case experimental design will be conducted to provide an initial indication of effectiveness and to refine the intervention for further larger-scale study. Dissemination and Anticipated Impact The results of this fellowship will be disseminated through academic channels, to local psychiatric services and nationally through relevant charities and media. This research may have far-reaching implications for both prognostic research in BD and the development of preventative interventions. It will develop our understanding of a well-known risk factor for BD as well as delivering and testing a novel psychological intervention.

Lay abstract: Background Bipolar disorder is a severe mental illness that affects up to 4% of the population. People with bipolar disorder experience extreme changes in mood, from very high (mania) to very low (depression). These mood swings can cause problems in nearly every aspect of life. Bipolar disorder usually starts in adolescence, but it's very hard to recognise. This means that many people wait for over ten years to get the right diagnosis and treatment. Unfortunately, we know that the symptoms can get worse over time if left untreated. If we could intervene earlier, it might be possible to improve symptoms and even prevent some problems from starting at all. One way to improve early intervention is to work with people who are most likely to develop bipolar disorder. For example, we know that people who have a parent with bipolar disorder are at high risk of developing the illness. This is because bipolar disorder is a condition that runs in families. However, there are also other important risk factors to consider. We know that if people with this family risk also have anxiety problems when they are young, they are far more likely to develop bipolar disorder. I want to know more about how these risk factors work so we can try to prevent serious problems like bipolar disorder from developing. Aims My research will be focused on anxiety in young people who are at high risk of developing bipolar disorder. My first aim is to better understand their anxiety. I want to know more about the symptoms they experience and how their body copes with stress. My second aim is to measure important psychological process that might be causing this anxiety. To do this, I will look at the way participants think and respond when they become anxious. My third aim is to use these results to create a new psychological intervention and to test it in a small pilot study. Methods I will recruit 60 young people who have a parent with bipolar disorder. As part of the research, young people will complete several different tasks.First, I will assess their symptoms of anxiety using self-report measures and clinical interviews. Second, I will examine their anxiety from a biological perspective by measuring cortisol, the body's stress hormone. Third, I will track changes in their anxiety and mood using smartphone technology. Fourth, I will measure psychological processes using well-known scales and tasks. After twelve months, I will meet with the families again to see what has changed over time. Working alongside a service user advisory group, I will use these findings to co-design a new psychological intervention. I will run a small pilot study to see if the intervention is helpful. This will give me important information that I will need to plan larger studies testing our intervention.Anticipated Impact and Dissemination I will share the results of this research in scientific journals and conferences. I will also communicate the findings with mental health charities, local mental health services and the media. This work is important because it is the first important step towards a new early intervention for bipolar disorder. This approach has the potential to promote resilience and well-being in vulnerable young people.

Research activity codes: 2.1 BIOLOGICAL AND ENDOGENOUS FACTORS;2.3 PSYCHOLOGICAL, SOCIAL AND ECONOMIC FACTORS
Health categories: MENTAL HEALTH