From Movements to Momentum: A Qualitative Exploration of What Global Mental Health Movements Teach Us About Building Collaboration for Early Intervention in Bipolar Disorder

From Movements to Momentum: A Qualitative Exploration of What Global Mental Health Movements Teach Us About Building Collaboration for Early Intervention in Bipolar Disorder | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 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Cotton Authors Info & Affiliations https://doi.org/10.22541/au.175593964.41552538/v1 Published Early Intervention in Psychiatry Version of record Peer review timeline 210 views 167 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Introduction A global movement focused on early intervention in bipolar disorder is long overdue. Given a dearth of work towards establishing coordinated efforts in this field, we aimed to explore what can be learned from successful global mental health movements. Methods We interviewed nine experts involved in the development of global mental health movements. Reflexive thematic analysis was used. Results Seven themes were generated: (1) “What do You Want to Be and for Whom?”, (2) There are Pros and Cons with Consensus in Ideas and Approaches, (3) The Catalytic Role of Early Action, (4) People are the Heart of a Movement, (5) Make it Matter, (6) Size and Structure Can Impact Effectiveness, and (7) Challenges of Scaling Up and Maintaining a Movement. Conclusions These learnings provide a framework for building a Global Alliance for early intervention in bipolar disorder, centring early action, nurturing passionate leadership, and inclusive collaboration. From Movements to Momentum: A Qualitative Exploration of What Global Mental Health Movements Teach Us About Building Collaboration for Early Intervention in Bipolar Disorder Melissa Hasty a,b , Craig Macneil a , Olivia Bruce a , Cadelle Stewart a , Emma E Morton a , Vani Jain c , Lori Smith c , Andre Rebeiz c , Sue M. Cotton a,b a School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia b Centre of Research Excellence in Bipolar Disorder (CORE-BD), Monash University, Clayton, Australia c Daymark Foundation, Toronto, Canada Corresponding author: Melissa Hasty ( [email protected] ) Funding statement: This work was supported by the Daymark Foundation. The funders did not have any involvement in the conception of the study or analysis. Conflict of interest disclosure: The authors declare no conflicts of interest. Ethics Statement: This qualitative study was granted ethical approval by the Monash University Human Research Ethics Committee (Approval number: 2024-43975-112874) Data availability statement: The data analysed in this study are not publicly available to protect participant confidentiality and due to the sensitive nature of the data. Acknowledgements: We would like to express gratitude to the participants for their generosity in sharing their time and expertise. Introduction A global movement focused on early intervention in bipolar disorder is long overdue. Given a dearth of work towards establishing coordinated efforts in this field, we aimed to explore what can be learned from successful global mental health movements. Methods We interviewed nine experts involved in the development of global mental health movements. Reflexive thematic analysis was used. Results Seven themes were generated: (1) “What do You Want to Be and for Whom?”, (2) There are Pros and Cons with Consensus in Ideas and Approaches, (3) The Catalytic Role of Early Action, (4) People are the Heart of a Movement, (5) Make it Matter, (6) Size and Structure Can Impact Effectiveness, and (7) Challenges of Scaling Up and Maintaining a Movement. Conclusions These learnings provide a framework for building a Global Alliance for early intervention in bipolar disorder, centring early action, nurturing passionate leadership, and inclusive collaboration. Keywords: Bipolar Disorder, Early Intervention, Mental Health, Global Movement, Global Collaboration, International Collaboration, Qualitative Research Introduction The onset of bipolar disorder (BD) typically occurs during late adolescence to early adulthood (Baldessarini et al., 2010; Baldessarini et al., 2012; Dagani et al., 2019). Because of disorder complexity and high rates of comorbidities, timely diagnosis and appropriate treatment are delayed by approximately a decade (Buoli et al., 2021; Fritz et al., 2017; Lublóy et al., 2020; Scott et al., 2022). Delayed diagnosis and untreated BD can be associated with deleterious outcomes including severe role impairment, disruption to relationships, burden to families, poor quality of life, increased rates of suicide and self-harm, and high health care costs (Birnbaum et al., 2003; Gonzales-Pinto et al., 2007; Hirschfeld, 2001; Keramatian & Morton, 2023; Keramatian et al., 2022; Post et al., 2010; Scott & Leboyer, 2011; Stang et al., 2006). Despite the burden of BD, prevention and early intervention (EI) efforts for BD are still in their infancy (McAulay et al., 2018; Vieta et al., 2018), especially compared to the successes of EI for psychotic disorders (Vieta et al., 2018). Global mental health movements have been established focusing on other disorders and early intervention. Such organised collective efforts involve engagement and collaboration between researchers, clinicians, policymakers, and advocates/service users to increase awareness and access to care, reduce stigma, and improve outcomes in mental health. These movements have significantly advanced research and examples of achievements include reduced diagnostic delay, evidence-based treatment models, global service expansion, system reform, economic savings, and better clinical and functional outcomes. Although there is recognition of the need to advance EI for BD, the field lacks coordinated and collaborative approaches to improve outcomes and reduce burden (Cotton et al., 2023; Cotton et al., 2025; Ratheesh et al., 2023). The National Health and Medical Research Council funded Centre of Research Excellence in Bipolar Disorder (CORE-BD) based at Monash University (Australia) and the Daymark Foundation (a Canadian family foundation) have been working together to advance the field of EI for BD. Notably we have identified barriers, facilitators and opportunities to enhance global collaboration (Cotton et al., 2023; Cotton et al., 2025). This study aimed to address the following question: What can we learn from successful global mental health movements to build a Global Alliance for EI in BD? Methods We invited 22 international mental health experts who had significant leadership roles in the development of a global mental health movement to participate in a semi-structured interview. A pragmatic approach based on reflexive thematic analysis was used to identify relevant themes (Braun & and Clarke, 2019; Braun & Clarke, 2021). Results Nine mental health experts with leadership roles in the development of one or more global mental health movements were interviewed, with five different movements represented. Here, we describe the seven themes that were identified, with additional quotes/insights illustrating each theme presented in Table 1 . “What do You Want to be and for Whom?” Participants emphasised the importance of developing a clear vision, well-defined goals and objectives, and acknowledging the limits of a movement. Agreement on all aspects was recognised as potentially difficult to achieve and may not occur early. However, a united front was seen as important for positioning of a movement within the broader mental health landscape and attracting recognition and funding. Clarifying target audiences and stakeholders was viewed essential for tailoring the movement and helping it to resonate. One participant identified “you need a short and clear rationale for why you’re doing what you’re doing. It needs to outline the limits of what you think you can do, and it also needs to frame the unanswered questions, and acknowledge that you don’t have all the answers and that you don’t want to go too far out ahead of the evidence.” There are Pros and Cons with Consensus in Ideas and Approaches Consensus processes, or “reaching common ground” were recognised as facilitators of shared definitions and approaches, evidence-base development, and clinical practice guidelines. Participants noted that reaching full consensus is challenging, particularly in movements with larger membership. While three of the five movements had developed international consensus statements, some participants questioned their utility due to lack of uptake. An alternative view was that there should be flexibility in ideas and approaches to help accommodate cultural, governmental, and healthcare system diversity across regions. One participant noted “we’re not McDonalds”. Another participant reflected, “I think that alignment is important, but I don’t think it has to be a strong alignment. And then test the evidence around the alignment.” The Catalytic Role of Early Action Most movements emerged when early career clinician-researchers identified an existing problem or recognised unmet needs in their sector and swiftly implemented changes or trialled potential solutions. One participant described this as “people that had a passion to do something different… and had the vision to see that there needed to be some research to support the change in practice” . These challenges to the status quo acted as “ real-world examples of what was possible” and “beacons of best practice” that demonstrated real impacts as well as incited others to follow suit and helped build momentum, consistent approaches, and evidence bases. People are the Heart of a Movement Strong and effective leadership was considered crucial. Leaders should be “ effective storytellers” who can clearly communicate key messages and inspire others to see the movement as a worthwhile cause. “ Powerful or devoted and powerful people” who were “really passionate” and “fully committed to the mission” were identified as vital for momentum and sustainability, with some movements sustained by a small group or even just one or two tireless, committed, and energetic individuals. Participants highlighted the value of “just collaborating wherever you can” and suggested “ international collaboration is key” to increase the likelihood of support. The value of bringing people from around the world together in person, rather than just virtually, was described as essential for fostering relationships. One participant stressed how “it kind of legitimises the work as well, if you start to see that people are coming together to talk about it”. While barriers to collaboration were mentioned by participants, they universally agreed “ the benefits of having global reach and global connection definitely outweigh the challenges” . Four participants encouraged leveraging other international meetings and conferences of other organisations for networking. Diverse multidisciplinary stakeholder involvement also contributed to movement success. It was striking that the development of three of the five movements had significant early contributions from people outside of the usual mental health disciplines. Seven participants highlighted the value of learning from “people with lived experience”, especially in advocating for change when a movement is faced with criticism. Four participants stressed the utility of researchers, academics, and university linkages. Make it Matter A compelling, targeted brand which is “ clear, concise, and without jargon” was considered essential. Six of the participants viewed dissemination of evidence and publishing journal articles and policy documents as integral. One participant reflected “you can’t just run off emotion, evidence ‘future proofs’ it”. However, relying solely on facts and figures was considered insufficient to win people over, motivate personal or financial investment, or drive change. Engaging ways to communicate (e.g., through media, including social media and testimonials/human interest stories) were viewed as key to frame the rationale and make a movement “an easy sell” to governments. Size and Structure Can Impact Effectiveness Participants viewed small, focused movements as agile and more able to avoid legal and financial complexity, reach agreement, and maintain control over direction. However, the absence of larger structures and resources was recognised as having potential to “threaten sustainability” and momentum. Larger structures provide capacity for smaller, targeted interest groups or specialised teams to support different areas of the movement (e.g., policy, advocacy, or training teams) which in turn can facilitate growth and effectiveness. Affiliation with a larger existing movement (suggested to “ piggyback off some other kind of big existing things” ) was endorsed as beneficial for increased recognition and resources, thereby enhancing the credibility of the cause, facilitating communication to a larger audience, and reducing administrative load. One participant reflected “we’re not going to get anywhere if we just try and work in isolation…”. Challenges of Scaling Up and Maintaining a Movement Nearly all participants identified funding as a “massive issue” to the development and sustainability of a movement, with one participant reflecting “you need some serious cash” . Chronic underfunding in the global mental health field fosters competition for funds rather than collaboration or coordinated action. Most movements were developed with modest funding and were buoyed by dedicated clinicians, researchers, advocates, and allies that often gave their time and effort on an unpaid basis. They relied heavily on stakeholders to lobby governments and to secure funding. Participants acknowledged that establishing and maintaining a movement can be exhausting, particularly in the mental health sector which is resistant to change. They emphasised the need for realistic expectations regarding people’s time, resources, competing demands, skills, and enthusiasm. Succession planning and “nurturing” early-career individuals to be the ones “carrying the torch” were seen as crucial for ensuring the long-term sustainability of a movement. Participants also reflected on how a movement’s priorities may evolve over time, moving beyond the pursuit of innovation and evidence. Participants spoke about consolidation of what is already known, training, fidelity, advocacy, implementation, and closing the research-practice gap as areas needing to be better prioritised. One participant reflected “I find medicine embarrassing. In the sense that it takes so many years to introduce new research findings into clinical practice, not just in psychiatry, but in medicine in general. You know, it takes more than a decade to go from the research data to the actual clinical practice. And it’s like, what the hell’s going on?” Discussion This study lays the groundwork to inform the development of a Global Alliance for EI in BD. Global movements in other areas of mental health have led to major advances in their fields, providing evidence, increased awareness and funding, and enhanced detection, treatments, and services. The findings of this study support the work CORE-BD has been doing in partnership with the Daymark Foundation, bringing diverse stakeholders from around the globe together to meet in person (Cotton et al., 2023; Cotton et al., 2025). At one meeting, held in Reykjavik, Iceland in September 2024, the learnings from these interviews with leaders of other global movements were used to inform the selection of priorities and actionable steps towards developing a Global Alliance for EI in BD. Formalising an affiliation to leverage off other international meetings makes financial sense in a field where funds are particularly limited. Cultivating emerging leadership is an urgent priority to build collaboration, drive action, and to rally support for meaningful change in the field of EI for BD. References Baldessarini, R. J., Bolzani, L., Cruz, N., Jones, P. B., Lai, M., Lepri, B., Perez, J., Salvatore, P., Tohen, M., Tondo, L., & Vieta, E. (2010). 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Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., Birmaher, B., Tohen, M., & Suppes, T. (2018). Early Intervention in Bipolar Disorder. American Journal of Psychiatry , 175 (5), 411-426. https://doi.org/10.1176/appi.ajp.2017.17090972 Tables Table 1 Additional quotes from experts identifying important underpinnings for the development of global mental health movements Theme 1: “What do You Want to be and for Whom?” “Start with the end in mind, like, where are you wanting to get to? What’s your time horizon? In - how far? How realistic is it? And then, obviously, you want to kind of try and build to things that are a bit more realistic. But then work backwards from there.” “To define what it is you’re going to do, and then that is helpful in so many ways, because it helps you to lobby for what you want and point out where it isn’t happening. And so I think that’s an important thing to do. But bite off the right amount. So try don’t open the floodgates and have services that can’t cope. At the same time, you can’t be too niche, otherwise you’ll be told that you’re not doing enough as well, so you need to try and find that happy balance.” “Come up with the core components. To define what it is you’re going to do, and then that is helpful in so many ways, because it helps you to lobby for what you want and point out where it isn’t happening.” Theme 2: There are Pros and Cons with Consensus in Ideas and Approaches. “Creating some clinical guidelines is really important - probably the most important thing in trying to get a standardised approach.” “We managed to get consensus on that and essentially, we kept it short as well, and I used to joke at the time… that it needed to fit on one page, you know, double sided, so that you could then wrap it around a brick and beat people over the head with it.” “…they have often talked about you know, writing consensus statements or declarations, or those kinds of things. They’re pretty powerless. They don’t really get implemented or used.” “It is a bit like herding cats. But you have to have alignment. Just think you have to make sure that the really extreme elements aren’t aren’t um doing anything under your name. but you can’t- I don’t think you can get full alignment.” “It was a consensus. You know, it was getting together a lot of experts, having lots of meetings talking about you know what’s the best way to go, and you know there wasn’t universal agreement on everything. But I think we came to a reasonable consensus…. But one of the first steps is to get, you know, together the experts and come up with a consensus as to okay, so how do we do this?” “I think we still struggle with [common definitions]… and I think there’s a lot of confusion in the field…. One issue is to come to some resolution about what are we actually talking about?… that has to come into play somehow, and there has to be some agreement as to what are we actually talking about?” “So I don’t think you have to control everything… you can have some um ah plurality, and I certainly think you know you let a thousand flowers bloom and see what happens.” “Get together an international group of experts and come up with some common ground. You know and then it can be tailored to the needs of each particular geography. But at least have some basic framework of okay this is what we’re all going to do. This is what we’re all going to try to do.” Theme 3: The Catalytic Role of Early Action. “The setting and the one size fits all approach, was not only not appropriate or well attuned to their needs, but was actually iatrogenic…. And so the first step in in the whole venture was to do no harm, you know, to actually to stop the harmful practices and to start building an evidence base for how to treat.” “Came from that experience of the early days of seeing these patients and looking with fresh eyes at their needs.” “It proved a real beacon for other like-minded people around the world who had similar ideas to kind of gather around and work with.” “One of the roles you might play is taking a stance against some of the harmful things.” “Those of us who were doing research many years ago, I think, were concerned that these patients were not necessarily getting state of the art care…. I think a lot of us were interested in you know, what kind of research is necessary to help bridge that gap.” “[Problem] became pretty obvious and the concern that that was contributing to poor outcomes. And it took a while, you know, to establish data to support that.” “You had to have good clinical practice…. establish good practices within the approach.” Theme 4: People are at the Heart of the Movement. “[The movement] has grown largely through people like [name of leader] advocating for it and creating the international networks.” “You have to have these people who are real drivers and are willing to basically get smashed a bit as well.” “We were trying to find like-minded people because we realised that it has to be a paradigm shift. And that means you need leadership everywhere to make that.” “There was the first meeting… some international people were brought over, and it gave some credence and importance to the movement. But then, starting to have meetings around the world every 2 years is a key thing to building the international recognition.” “And it’s perhaps a little bit easier these days with modern, with zooms and modern communication technologies. It’s a bit easier to stay on the same page and work together.” “People always listen to people from other countries more than people who are local.” “I could travel to places and meet people and get to know them, and they could get to know me. So there was trust.” “And there was just a lot of really goodwill from people like people wanted to see change happen.” “We bought a group of about 10 people, who were researchers and or experts, and from around all sorts of different countries…… But really what that did was it was the jumping off point for that group to kind of get to know one another. And hear more about what one another were doing from that perspective and that then led on to this desire to think about. Well, how might people kind of come together more, and we promote this idea of this new and emerging approach and share information and knowledge.” “But the actual day [of in person meeting], that half day we have itself has been really um pretty cool to maintain that connection across with all these people who are just basically really passionate about the space and have that privilege of being able to do something…” “Hearing what the families have gone through and learning from that… how do we avoid some of those pitfalls, is incredibly important.” “Families. Get the families involved. And you know, listen. We’re very focused on people with lived experience now… hearing what the families have gone through and learning from that. And how do we avoid some of those pitfalls, I think, is incredibly important.” Theme 5: Make it Matter “Get that branding and making it… an easy sell.” “Evidence… a pretty good sort of setup for an argument to go ‘you should try this’.” “As well as the scientific evidence and the logic and everything else, if you don’t actually try to persuade and you know, communicate and inspire, which can be written off as just you know evangelism, then then nothing’s going to change.” “As the as the movement grew, people got on board. You could see that it was a useful way of going. And then you needed to keep promoting it, I suppose, to make sure that it continued to grow…. the start of the journal, and the start of the international meetings. They were all important. “You’ve got to promote it to keep it building, keep the momentum.” “You gotta be media savvy.” “It’s important to continue the promotion, the education… the lived experience group of people to help promote the need for resources in the area and the development of services and treatments. I think’s important.” “I guess behind all of that there’s the willingness to go and talk and lobby as well.” Theme 6: Size and Structure can Impact Effectiveness. “[Lack of] organisational structure I think has been quite good, has kept [movement] flexible. But I think it does threaten sustainability.” “You need to have the structure and the supports to make that work… there is a need for formality, because otherwise things don’t happen.” “I don’t think [movements] would have grown the way they had if they couldn’t have piggybacked off [existing international association]” “We’re not going to get anywhere if we just try and work in isolation. We need to be part of the broader [movement], and we need to invite ourselves into the tent when we’re… either not wanted or maybe even liked when we get there.” “I look at how much better it is with a whole government relations team, a whole policy team, a whole training team…. I can sit there and go ‘Oh, I want to do this’. And then I can go speak to an expert in how you do that and how you translate that to government. I can get this other team over here to make it, train, make the training actually engaging, and build something off it.” Theme 7 : Challenges of Scaling Up and Maintaining a Movement. “It’s [mental health care] funded about less than half the level it should be, even in rich countries. And that means there’s competition for resources. So a lot of our colleagues, they weren’t sort of merchants of doubt. They were just people who were trying to look after people with more chronic illnesses, which were also neglected… they saw that as somehow competing for their funds” “We should be on the on the same page and collaborating… but in in a situation where the whole field is seriously underfunded, that’s kind of difficult to achieve at times or most of the time” “Everyone wants to be involved in it, and it sounds really cool. And then everyone’s just like, ‘Oh, I don’t have any money to pay for any research assistant time, or this or that, or the other’. And so you end up taking on a lot of work yourself and basically burning yourself out.” “You just have to try and forge good relationships and keep the communication open and try not to be too territorial and protective. Which is tricky in the environment where everyone - well most people are trying to forge a career and trying to get academic advancement.” “It’s very hard to change traditional systems of care and mental health. They’re full of inertia… the status-quo fights back very strongly.” “And I think it’s making sure there’s pathways for young guns to come through… who’s gonna take over and kind of lead this area effectively… it’s really hard to create that passion in someone else. Because this is kind of my special interest, right? And so how do you find someone who’s got the same sort of similar special interests as you who will, you know, dedicate, I guess, a big chunk of their career to focusing on this one area…” “Early on the focus was about ‘let’s develop the evidence’. But now a lot more of the focus is on the implementation like, how do we make this available?” “And then it became a question of training and implementation.” “There’s this whole field of research that didn’t exist before. I think there’s still a way to go on the implementation and how you leverage [movement] to engage with that next challenge? I’m not really sure. The whole of mental health is full of evidence-based interventions that we just don’t implement well. So how we do that, if we could solve that challenge, that’s the thing I’d like to do best.” “It seems like in order for things to grow you have to go a few million miles ahead, you need to move on to the next thing before you finish the current thing. That seems to be what’s successful…. I would have done much more consolidation.” “I think it’s a problem with mental health care generally that there isn’t a commitment to evidence-based care as soon as it’s available.” “And what we’ve seen is that you know the application of evidence-based practices is tremendously variable…. to an extent that is a little bit embarrassing. I think you know, we still have a long way to go in terms of implementing best practices.” “…we have to figure out what really motivates people. And what can we do to make sure that they’re achieving the fidelity that we need and consistently. Training is a big problem. You know, people are just not well enough trained, in my opinion… how do you get everybody to sort of achieve a certain standard?” Information & Authors Information Version history V1 Version 1 23 August 2025 Peer review timeline Published Early Intervention in Psychiatry Version of Record 10 Mar 2026 Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Early Intervention in Psychiatry Keywords bipolar disorder early intervention global movement international collaboration qualitative research Authors Affiliations Melissa Hasty 0009-0000-9040-7602 [email protected] Monash University View all articles by this author Craig Macneil Monash University View all articles by this author Olivia Bruce 0000-0002-7200-273X Monash University View all articles by this author Cadelle Stewart Monash University View all articles by this author Emma Morton Monash University View all articles by this author Vani Jain Daymark Foundation View all articles by this author Lori Smith Daymark Foundation View all articles by this author Andre Rebeiz Daymark Foundation View all articles by this author Sue M. Cotton Monash University View all articles by this author Metrics & Citations Metrics Article Usage 210 views 167 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Melissa Hasty, Craig Macneil, Olivia Bruce, et al. From Movements to Momentum: A Qualitative Exploration of What Global Mental Health Movements Teach Us About Building Collaboration for Early Intervention in Bipolar Disorder. Authorea . 23 August 2025. DOI: https://doi.org/10.22541/au.175593964.41552538/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . 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