Barriers to and facilitators of success for early and Mid‐Career professionals focused on bipolar disorder: A global needs survey by the International Society for Bipolar Disorders

The International Society for Bipolar Disorders created the Early Mid‐Career Committee (EMCC) to support career development of the next generation of researchers and clinicians specializing in bipolar disorder (BD). To develop new infrastructure and initiatives, the EMCC completed a Needs Survey of the current limitations and gaps that restrict recruitment and retention of researchers and clinicians focused on BD.


| INTRODUC TI ON
Bipolar disorder (BD) is a serious mental illness that affects more than 40 million people worldwide. 1 In 2013 and 2017, the Global Burden of Disease Study reported that BD contributed to approximately 9 million disability adjusted life years, ranking it as the 19th leading cause of years lost to disability worldwide. 2, 3 The total economic burden of BD is estimated to be more than $195 billion in the United States (US) alone. 4 Despite its prevalence and impact, there is a lack of funding dedicated to researching BD. In the United Kingdom (UK), BD accounts for 17% of the total burden of disease for mental illness, 5 but only receives 1.5% of research funding that is allocated to mental health. 6 In the United States, approximately 5% of research funding allocated to mental health goes to BD. 7 In addition to lack of funding, few clinical services are specific to BD and there is an absence of BD-dedicated care pathways. This contrasts with other serious mental illnesses, such as schizophrenia, that have dedicated care pathways for early intervention in first-episode psychosis. Lack of specialized care leads to a delay in proper diagnosis and treatment. It takes an average of nine years from the onset of symptoms to obtain an accurate diagnosis of BD, even in countries with well-established tertiary health services. 8,9 Diagnostic and care-pathway problems are further exacerbated by the increase in mental health needs worldwide and the shortage of mental health providers. 10 Shortages of psychiatrists reflect increased demand for services, a lack of residency positions for training, and retirement-more than 60% of psychiatrists are 55 years or older. 11 In the past 10 years, there has been a 7% decrease in the number of psychologists entering academic research. 12 At the same time, growing funding constraints in some countries and inequality in academia are increasing the difficulty of maintaining a career in the field, and contributing to the mass exodus of talent. 13,14 There is a critical need for researchers and clinicians to advance the prevention and treatment of BD especially given recent findings that there is a pronounced lack of funding for clinical research and treatment development for BD. 7 Investing in the career development of early and mid-career (EMC) researchers and clinicians to offset these issues will ensure enhanced understanding of BD and progress toward new or refined treatment strategies to improve the lives of those living with it. EMC researchers and clinicians in the field of BD face increasing challenges and need to be properly supported during critical transitions in their career stages.
The International Society for Bipolar Disorders (ISBD) is committed to supporting the development of early-career (including students and trainees) and midcareer professionals who are pursuing research and clinical work focused on BD and have created the Early-to Mid-Career Committee (EMCC) with the remit of supporting the next generation of professionals in the field. 15 Specifically, the EMCC comprised individuals at the early-and midcareer stage working with BD from different geographic locations and specific interests. 15 The group includes clinicians and investigators with different expertise mentored by senior investigators in the field of BD, with the goal of nurturing and supporting the career development of the next generation of clinicians and researchers specializing in BD and related conditions. It was acknowledged that the creation of new infrastructure and initiatives to support EMC researchers and clinicians interested in BD must be based on an assessment of the current limitations and gaps that restrict their recruitment and deployed from May to August 2022 and was available in English, Spanish, Portuguese, Italian, and Chinese.
Results: Three hundred participants across six continents completed the Needs Survey. Half of the participants self-identified as belonging to an underrepresented group in health-related sciences (i.e., from certain gender, racial, ethnic, cultural, or disadvantaged backgrounds including individuals with disabilities). Quantitative results and qualitative content analysis revealed key barriers to pursuing a research career focused on BD with unique challenges specific to scientific writing and grant funding. Participants highlighted mentorship as a key facilitator of success in research and clinical work.

Conclusion:
The results of the Needs Survey are a call to action to support early-and midcareer professionals pursuing a career in BD. Interventions required to address the identified barriers will take coordination, creativity, and resources to develop, implement, and encourage uptake but will have long-lasting benefits for research, clinical practice, and ultimately those affected by BD.

K E Y W O R D S
barriers, bipolar disorder, early career, facilitators, midcareer, needs assessment retention. Thus, one of the first charges of the EMCC was to initiate a Needs Survey to evaluate the landscape of facilitators and barriers to successfully pursuing a career focused on BD.
A needs assessment is a formal process whereby investigators determine the critical gaps between the current state of affairs and desired outcomes in order to develop appropriate training, response, and initiatives that address these gaps. 16 In contrast to other types of evaluation, needs assessment emphasize gaps at societal, organizational, and individual levels as well as diverse needs with varying levels of importance, and allow for planning and strategy development that can be prioritized based on the gaps identified. 17 Importantly, needs assessments increasingly emphasize the identification of assets in addition to gaps, which can further shape the development of solutions and reform.
A working group of the ISBDD EMCC, the EMCC Needs Survey Workgroup, was formed to develop and conduct an online Needs Survey. 15 The goal of this study was to disseminate the Needs Survey to EMC researchers, clinicians, and trainees working in the field of BD and to conduct a mixed methods analysis of responses to identify facilitators of and barriers to success for EMC's. This paper describes the results of the Needs Survey, highlighting key findings in terms of both assets and gaps in the interests of prioritizing strategies and planning for enhanced support to EMC individuals interested in a career focused on BD.

| Participants
The Needs Survey online deployment targeted EMC individuals working in the field of BD. Participants were informed about the purposes of the survey and that their responses would remain anonymous and be kept confidential. Following providing consent to participate in the study, a screening question was asked regarding inclusion/exclusion criteria as follows: "Do you currently work or are you interested working in research, education, or clinical work in the field of bipolar disorder?" Inclusion criteria required participants to select "yes." Participants who selected "no" were thanked for their interest in participating and ended the survey. No other inclusion/ exclusion criteria were included. The study was approved by the University of Utah Institutional Review Board #00160451 and undertaken by the ISBD EMCC.

| Survey development
The EMCC Needs Assessment Workgroup met to identify domains relevant for EMCs. Based on an initial literature review, [18][19][20][21][22][23][24][25]   Conference [13]. To maximize outreach, the survey was made available in English, Spanish, Portuguese, Italian, and Chinese. Multilingual ISBD EMCC members translated the survey and any qualitative responses. Responses were reviewed and efforts were made to target distribution and recruitment to underrepresented areas (through independent chapters of ISBD, e.g., ISBD Kenya). EMCC members made additional outreach efforts and invited individuals from underrepresented countries to participate in the survey. To encourage participation, participants were entered into a draw for one free registration to the ISBD annual conference.

| Data analysis
All analyses were completed in Rstudio (V.2022.02.0 + 443). Chisquare analysis and linear regression were used for categorical and continuous outcomes, respectively. Quantitative models included the following covariates: gender identity (female, male, other), country socioeconomic status (SES), ISBD membership (current, past, never), and underrepresented status (yes, no, prefer not to say).
"Underrepresented" status was defined using a self-reported question and defined as individuals from certain gender, racial, ethnic, cultural, or disadvantaged backgrounds including individuals with disabilities who have been shown to be underrepresented in healthrelated science fields. Accordingly, if an individual self-identified as "underrepresented" in this question, it is likely that they did so relative to their own demographic region, context, and definitions. SES was categorized as low-income, lower middle income, upper middle income, and high-income using World Bank Classifications, which are calculated using the World Bank Atlas Method and GNI per capita. 26 Reference groups were female, lower middle SES, not a ISBD member, and "not underrepresented." For questions limited to qualitative responses, we applied conventional content analysis. 27 For each response, the primary coder (SHS) identified the individual meaning units, wrote a condensed meaning unit, and created a code to capture the theme of the response. Each meaning unit was allowed one code. Next, 20% of responses were randomly selected using a random number generator for reliability coding. The second coder (RSH) was given the list of codes created by the primary coder. Intercoder reliability was assessed using percent agreement with values ≥75% viewed as acceptable and ≥ 90% as high. Note that all surveys completed in another language were reverse translated to be included in the content analysis.

| RE SULTS
A total of 444 participants opened the survey with 110 initially being excluded (n = 4 indicated they were not interested or did not have a career focused on BD; n = 106 opened the survey but did not complete demographics). Of the remaining 334, 300 were considered "completers" (i.e., completed at least one full section of the survey) and 34 "noncompleters" (i.e., only filled out demographics information). As designed, response rates differed for individual sections of the survey (Table 1) Table 1. Roughly half of completers (n = 153) selfidentified as belonging to an underrepresented group in healthrelated sciences, defined as individuals from certain gender, racial, ethnic, cultural, or disadvantaged backgrounds including individuals with disabilities. Thirty nine percent of respondents indicated they were a member of the ISBD (current = 77, past = 40).
Below, we highlight key findings from each of the eight domains.
Note that we provide all survey results in Supplemental Materials.
Distributions of work domains among EMC individuals (e.g., clinical, research, and supervision) are presented in Figure 2. Overall, participants indicated that they were least involved in community engagement, which is reflected in more unanswered data in this section ( Figure 2). In addition, work-life balance had the lowest number of responses, which could be due to survey fatigue-this was the last possible section of the survey. After each section, participants were asked to identify ways that ISBD could help facilitate success and reduce barriers. We outline the top three approaches that participants indicated ISBD could help with across each domain in Table 2.

| Navigating transitional career stages
Participants were asked about the current stage of their career or  Figure 3 and did not differ based on any covariates (see Supplemental Table S1). The majority of participants indicated that they had some confidence in transitioning to graduate school (72% agree; 22% disagree; 6% neutral) and faculty/academic positions (75% agree, 18% disagree, 7% neutral). In contrast, only 40% of participants indicated that they felt confident applying for and transitioning to postdoctoral fellowships (34% disagree, 26% neutral).
Of those participants (n = 159) who identified as being at a professional career stage (e.g., Research Fellow, Psychologist, Social Worker, Occupational Therapist, Lecturer, and Assistant Professor), 27.9% reported being an independent researcher with their own lab or program. Researchers reported the following challenges when transitioning to independence: obtaining funding necessary to establish their own lab or program (67.4%), having lack of time for their own research due to clinical/administrative/or other research tasks (58.1%), and needing additional mentoring support or training (39.5%). In contrast, facilitators to success included strong mentorship, funding, collaborations, publications, institutional support and resources, and personal qualities such as persistence.

| Creating and fostering mentorship
Participants were asked about their experiences as both a mentee and a mentor. The majority (68.9%) reported having either a formal or an informal mentor, of which 73.6% had mentors in the field of BD. Most were satisfied with the quality of the mentorship (78.2%).
Common benefits perceived from mentor relationships included research discussion and/or supervision (72.5%), career advice and support (65.3%), and clinical discussions and/or supervision (50.8%).
Of those who did not have a mentor, the majority desired a mentor (66.7%), 23.0% were not sure, and 10.3% would not like to have one. There were no differences in SES index, gender, or underrepresentation status in any questions relating to mentorship (see Supplemental Table S3).
Approximately half of the participants (51.1%) reported currently having a formal or informal role as a mentor to a student or staff member. Most common reported mentorship areas were education/ teaching (62.9%), clinical work (62.3%), and research (60.1%). Most participants (63.6%) did not receive any training in mentorship, but most (69.9%) were confident with their mentorship skills. There were no differences in gender, SES Index, ISBD membership, or underrepresentation in participants reporting having a mentor, being satisfied with the quality of the mentor, and receiving training in mentorship skills (Supplemental Table S2). Male participants were more likely to feel confident about their mentorship skills than female participants ( = 0.60, 95% CI [0.13-1.07], p = 0.013).   Table S2).

| Raising your academic profile
Seventy six percent (n = 203) of participants indicated that research was a part of their work, on average spending 47% of their time on research (SD = 31.38, Range = 5%-100%). Those in high income countries were more likely to report being engaged in research activities than those in low/middle income countries (X 2 (1) = 7.17, p = 0.007) (Supplemental Table S5). When asked whether participants were meeting their publication goals, 68% indicated that they were publishing fewer manuscripts than their goal with only 17% meeting their publishing goals. Participants were given the opportunity to qualitatively describe challenges or barriers that they have experienced in reaching their writing goals. Content analysis revealed 10 codes with excellent interrater reliability (93% agreement; see Table 3

F I G U R E 2
Percentage of participants involved in each type of work (n = 300).

| Research activities
Fifty percent (n = 132) of participants indicated that acquiring research funding was a part of their work with those from low/middle income countries answering yes less frequently than those in high income countries (X 2 (1) = 5.27, p = 0.02) (Supplemental Table S6). EMC individuals' confidence in writing a grant, knowledge of information sources related to grant announcements, and history of funding are presented in Figure 4. Participants identified several barriers and challenges that they have experienced when applying for funding to support BD research. Content analysis revealed 10 codes (see Table 4) with excellent interrater reliability (93% agreement). The three most common barriers included lack of opportunities for funding, grant writing skills, and grant reviewers. Responses that were coded as lack of opportunities for funding highlighted a lack of funding agencies focused on BD and not enough federal dollars spent on mental health funding in general.
Responses that were coded as grant writing skills highlighted a lack of experience in applying for grants and a need to improve grant writing skills. Responses that were coded as grant reviewers highlighted specific difficulties with grants focused on BD getting through review processes. Specifically, some participants highlighted that their grants were unsuccessful in review panels due to an overemphasis on biology over social/psychological studies of BD.

| Networking and collaborating
Seventy-seven percent of participants reported trying to network by attending conferences and presentations. The majority of participants had tried making a connection with someone in their department/institution (66.1%) or reaching out to colleagues outside of their department or institution (58.1%). There were no differences in gender, SES Index, or underrepresentation status in participants reporting feeling successful establishing and maintaining collaborations (Supplemental Table S7). EMC individuals identified several facilitators to developing collaborations. Content analysis revealed 10 codes (see Table 5

| Community engagement
Participants were asked about their community or public engage- Note: Participants were asked, "What challenges or barriers have you experienced in reaching your writing goals (e.g., making time to write, efficiency in writing and publishing)?" and given a free text response box to answer.

TA B L E 3 Content analysis of barriers
to writing goals.

F I G U R E 3
Confidence regarding applying to next stage of career path.
Participants were given the opportunity to qualitatively describe the types of community or public engagement opportunities that they would find valuable. Content analysis revealed two reliable codes (100% agreement): Community education (n = 53) and Advocacy and Patient Engagement (n = 17). Participants indicated that they would like opportunities to raise awareness about BD and reduce stigma through community education, including through public events (talks and discussion panels), social media (including Twitter outreach and YouTube), formal webinars, lay publication writing (e.g., The Conversation), traditional media (print, radio, or TV interviews), and online resources (e.g., fact sheets on ISBD website). Groups explicitly identified by participants as targets of this public education and community outreach included school groups and young people, workplaces, people with BD who are vulnerable to relapse, caregivers of people with BD, LGBTQIA+, as well as the academic and public service communities. Participants further indicated that they would like resources and assistance to improve advocacy and patient engagement including translating research into practice, engaging with people with lived experience as part of research co-design, and engaging with organizations involved in policy making.

| Work-life balance
The final section of the survey asked participants about work-life bal-

| DISCUSS ION
To our knowledge, this is the first study to explore the needs of

| CON CLUS ION
The results from this needs survey are a call to action to support the next generation of clinicians and researchers interested in pursuing a career in BD. Although many of key findings are comparable to those of other groups of early-and midcareer individuals, our survey also identified specific bottlenecks directly related to the field of BD. The retention and success of EMCs are essential in securing the future of the field. The benefits of this will be felt not only by the researchers and clinicians themselves but also by those who live with BD. The interventions required to address the identified barriers will take much coordination, creativity, and resources to develop, implement, and encourage uptake. Fortunately, at the ISBD, the EMCC has been tasked with such activities, which will be a lasting component of their remit and manifesto. In a forthcoming paper, the EMCC aims to detail specific strategic directions for the future that could be realistically implemented by the ISBD based on the findings of the Needs Survey.

ACK N O WLE D G E M ENTS
The authors would like to acknowledge the support and guidance of Professor Gin Malhi (President of ISBD) and Professor Erin Michalak

CO N FLI C T O F I NTER E S T S TATEM ENT
OMD has received grant support from the Brain and Behavior 19/082).

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

S U PP O RTI N G I N FO R M ATI O N
Additional supporting information can be found online in the Supporting Information section at the end of this article.