February 23, 2024

The primary aims of BD treatment are to reduce acute symptomology, improve psychosocial functioning, and diminish the likelihood of relapse/recurrence through pharmacotherapy coupled with psychological interventions [e.g., 9]. Further, the efficacy of psychological therapies may be advanced as contemporary perspectives adopt a more holistic conceptualization of BD impact and management by exploring psychosocial factors such as social support [10,11,12,13]. Social support may be generally characterized by feelings of being loved and cared for, relying on others when in need [e.g., 14], and a sense of belonging to groups and/or communities [e.g., 15–17].

Within the context of BD, research tends to report better psychological health for those with more social support [e.g., 18, 19], perhaps by mitigating the severity of the disorder’s symptoms [e.g., 18, 20, 21], helping individuals better cope with life circumstances through the provision of empathy and understanding [e.g., 18], and/or challenging negative rumination thereby averting major mood episodes [e.g., 18]. On the contrary, unhealthy social relationships and interactions may serve to undermine the mental health of those with BD, particularly in situations where social others maintain and/or exhibit a highly stigmatize perspective of BD [e.g., 18], and have little sympathy or understanding of symptoms [e.g., 22]. Consequently, negative social contexts may serve to exacerbate already precarious mental health, potentially acting as a trigger for mania or depression [e.g., 18]. For this reason, it is feasible to explore the distinct impact that negative social interactions (NSIs) might have on wellness and functioning beyond social support factors.

Although investigations consistently indicate that those with BD tend to report less social support compared with non-clinical samples, [e.g., 8, 20], of particular importance are factors that may not only compromise the extent of social networks, but also quality and influence. For instance, studies into SMIs such as BD note the potentially harmful impact of internalized stigma [e.g., 23] which may directly diminish self-esteem and self-efficacy, leading to social withdrawal and a sense of alienation [e.g., 24]. Moreover, comprehensive assessments of the impact of stigma further suggest the potential for a paradoxical response whereby sufferers may be energized by prejudice which may be expressed as righteous anger [23]. This, combined with BD’s defining symptomology such as erratic mood changes, impulsivity [e.g., 25], and engagement in unhealthy coping behaviours [e.g., 26] may collectively serve to affect the extent and quality of social support [e.g., 18, 27]. Such complex social dynamics implicates a bi-directionality which has also been considered in the assessment of social factors in other SMIs such as posttraumatic stress disorder (PTSD), a diagnosis highly comorbid with BD [e.g., 26].

Indeed, social support is one of the most constant and primary covariates in PTSD research [28] with its influence typically interpreted as protective or salutary [e.g., 29], whereby deficiencies may result in poorer mental health such as psychological distress [e.g., 30]. Further, supportive social relations, particularly with family and close friends, have been observed to predict better functioning, and more effective symptom management following a traumatic event [31, 32]. However, since PTSD often presents with sufferers being easily alarmed and irritated, often resorting to problematic drug use, or alcohol consumption [e.g., 33], interpersonal difficulties with family and friends are quite likely [e.g., 34]. Accordingly, research investigating the relationship between social support and PTSD (particularly longitudinal studies) has suggested a causal association that operates the opposite way (i.e., the ‘social erosion hypothesis’) [e.g., 29, 30] whereby irritability, anger, and detachment behaviours serve to erode relationship quality and social support resources/availability [29, 30].

Similar to PTSD/social support investigations, relationship erosion as a consequence of stigma and/or intrusive symptomology is a challenging reality of BD, particularly given that the support of family members and caregivers dedicated to the welfare of sufferers is vital for optimal wellness outcomes [27]. Moreover, research suggests that familial support is especially precarious since those intimately involved also tend to report notable caregiver distress as a function of recurring BD symptoms of loved ones [e.g., 35]. Given the potentially detrimental social costs of BD, it has been proposed that a more complete appreciation of the bi-directional nature of relationship scope and quality, and health status/functioning are essential to both understand and ultimately improve BD interventions involving a psychosocial perspective [e.g., 18].

BD, resilience, positive mental health and social support

Although adverse mental health consequences of BD have been well documented in the literature, such as higher psychological distress [e.g., 19] and poorer quality of life, [e.g., 25] it has been proposed that SMIs such as BD may also produce circumstances resulting in constructive outcomes [e.g., 22]. For instance, some studies into BD report that hypomanic symptoms (e.g., reduced social inhibitions) may serve to enrich social networks by enabling new connections [18], while a sense of amplified confidence during times of positive affect may facilitate the pursuit of aspiring goals [36]. Moreover, the experience of living with BD could provide opportunities for growth as valued and beneficial psychosocial characteristics may foster a sense of resilience, particularly during negative social circumstances [22]. Indeed, it has been proposed that BD treatment plans may be vastly improved with efforts to explore and enhance the resilience of BD patients [e.g., 37].

Accordingly, studies into BD have explored the concept of resilience as both a dependent variable, as well as an explanatory variable of various mental health outcomes. For example, Choi et al. (2015) explored resilience as a dependent variable in BD patients [37] using the Connor–Davidson Resilience Scale (CD-RISC), an instrument designed to assess four distinct factors including (1) personal competence, (2) confidence and effectiveness, (3) positive coping and secure relationships, and (4) spirituality [38]. Compared with a matched control group, it was observed that BD patients had significantly lower CD-RISC scores, with higher impulsivity and more frequent depressive episodes specifically predictive of lower resilience levels [37].

More recently, a 23-item resilience instrument specific to BD has been developed (i.e., the Resilience Questionnaire for Bipolar Disorder (RBD)) to assess five particular domains including ‘self-management’ (i.e., personal capacity to manage BD), ‘turning point’ (i.e., resolve and commitment to change), ‘self-care’ (i.e., disciplined management one’s own health), ‘self-confidence’ (i.e., self-reliance and self-respectful attitudes and actions), and formal and informal ‘interpersonal support’ (i.e., feeling loved, supported, as well as being informed by others when BD symptoms become active/apparent) [39]. Using the RBD to explore whether, and degree to which domains predicted mental health outcomes of 125 BD patients, it was observed that ‘self-management’, ‘turning point’, ‘self-care’, and ‘self-confidence’ were associated with personal recovery, symptomology, psychosocial functioning, and quality of life measures at baseline, with ‘self-confidence’ predictive of personal recovery at follow-up [1]. Interestingly, it was also observed that the improvement of the ‘self-confidence’ domain mediated the link between ‘interpersonal support’ and ‘self-care’, and subsequent personal recovery at follow-up, suggesting that resilience domains are significantly associated with positive mental health outcomes in BD, with some (including ‘interpersonal support’) predictive of personal recovery at follow-up.

As measures of resilience, both the CD-RISC and RBD feature comparable domains with general themes reflecting a sense of personal competence, self-efficacy, and positive coping as well as distinct social support domains (i.e., ‘secure relationships’ and ‘interpersonal support’ respectively). It is also evident that both instruments reflect the significant conceptual evolution of ‘mental health’ which has advanced beyond a rudimentary notion of the mere presence/absence of mental illness, to involve the degree to which individuals may thrive and adapt in response to various mental health experiences. For example, the World Health Organization’s definition of mental health reflects a state of wellness defined by positive coping with life stressors, efficacious involvement in work and society, and an acute appreciation of one’s potential [40]. As a very comparable construct, positive mental health (PMH) also represents a sense of resilience or flourishing whereby people maintain a sense of control, self-esteem, constructive coping, and self-acceptance [41]. PMH has also been conceived of as a means by which resilient responses are realized [42], as well as a type of defense mechanism as indicated by a person’s perseverance through continued negative occurrences [e.g., 43–45]. In fact, according to Srivastava (2011) in an editorial considering the connection between PMH and resilience, “It will be incomplete to talk about positive mental health without making a mention of resilience” [46].

In terms of specific PMH measures, a 14-item instrument called the Mental Health Continuum – Short Form (MHC-SF) [41] has been used in several national population health surveys (e.g., the CCHS-MH) to capture the degree to which respondents might languish or flourish [e.g., 47]. Similar to resilience measures such as the CD-RISC and RBD, the MHC-SF contains psychological, emotional and social well-being subscales assessing such characteristics as one’s sense of confidence and competence, life satisfaction and wellness, and belongingness to a community (See Methods for more detailed description). Overall, it would appear that conceptualizations of resilience and PMH are quite similar, particularly since they contain distinct social support domains which appear especially prognostic of personal recovery for BD patients [e.g., 1]. Taken together, while establishing the PMH and capacity to flourish may prove valuable to understand degree of resilience in adults with BD, specifically examining whether, and degree to which subtypes of social support, and NSIs predict PMH may further elucidate, and hence help influence one’s propensity toward adaptive responses to facilitate the management and treatment of BD, and self-recovery [e.g., 1].

Exploring PMH in adults with BD as a function of social support subtypes and NSIs: objectives of the current study

Based upon the preceding, the present study aimed to examine how adults with BD compare with those without in terms of social support, NSIs, and PMH. Additionally, for those with BD, determine whether male and female respondents differ in terms of social support, NSIs, ands PMH, and whether, and extent to which particular social support subtypes, and NSIs predict PMH. Currently, there is limited research assessing the association between psychosocial factors and PMH for individuals diagnosed with BD [10,11,12,13], so elucidating the connection may allow for more effective prevention, intervention, and treatment options for those seeking mental health support [48]. Moreover, while research does investigate a probable link between social support and mental health for those with BD, studies directly assessing resilience within the context of social support are scarce [e.g., 18–21].

It is also important to note a literature gap in the potential influence of NSIs on the resilience of those diagnosed with BD. To our knowledge, since BD studies have not considered the NSI/PMH link, the current research aims to advance the groundwork. In line with previous research [e.g., 19], it is hypothesized that levels of social support will positively predict PMH levels in those with BD. Furthermore, while specific literature considering the potential relationship between NSIs and PMH among those with BD does not apparently exist, it is feasible to posit that these variables will be inversely associated.

As a specific note about the BD sample utilized in this research, although studies into BD are widespread, many are likely to have recruited participants from clinical treatment programs whereby patients will have received a substantiated diagnosis by a mental health professional [e.g., 1, 8, 37, 49]. However, the sample featured in the present study involves population health survey respondents which (among many variables) captures adult Canadians reporting BD diagnosed by a health care professional. Since this is a population-based sample, a proportion of respondents, despite reporting the diagnosis, may not have actually received treatment (and hence, excluded from potential sampling frames for BD research), or have opted not to participate in studies promoted through clinical programs. Therefore, by utilizing a large, nationally representative Canadian adult health survey, the current study findings may be more representative of adults managing BD in Canada.


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