The team used a descriptive phenomenological approach, a method designed to capture the essence of lived experience as participants themselves describe it. Between October 2024 and May 2025, the researchers conducted in-depth, semi-structured interviews with twelve adults, six women and six men aged 22 to 41, recruited from six specialized mental health clinics in Kerman. Every participant met DSM-5 criteria for bipolar disorder, had experienced at least two mood episodes requiring treatment, and was in remission at the time of the study. The interviews were analyzed using Colaizzi’s seven-step method, a rigorous qualitative framework that moves from reading raw transcripts to extracting significant statements, formulating meanings, clustering themes, and finally describing the fundamental structure of the phenomenon. Saturation, the point at which no new information emerges, was assessed through team discussions based on code repetition across consecutive interviews.

Four major themes emerged from the analysis. The first describes the psychosocial process of adaptation, a trajectory that begins with denial of the diagnosis, passes through a difficult period of acceptance, and can end in what the authors call legitimation, the point at which a person comes to see their condition as a legitimate part of their identity rather than a shameful secret. This progression is not automatic or linear. Participants described oscillating between acknowledging their illness and pushing it out of awareness, a dynamic that directly affected whether they sought care, stayed on medication, and disclosed their diagnosis to others.

The second theme concerns the individual meaning-making structures through which participants explained why they had become ill. The researchers identified three distinct types of attribution: moral, supernatural, and contextual. Some participants framed their disorder in moral terms, as the consequence of personal failings or wrongdoing, a framing that carried heavy self-blame. Others reached for supernatural explanations, reflecting cultural and religious frameworks in which affliction can be understood as spiritual in origin. Still others offered contextual accounts, locating the cause of their illness in life circumstances, stress, and social conditions. These explanatory models matter clinically, because what a person believes caused their disorder shapes what they think will cure it, and whether a mood stabilizer seems like a rational answer at all.

The third theme, conflict with the treatment system and society, captures the ambivalence many participants felt toward psychiatric medication and the pressure they experienced toward what the authors describe as forced normalization. Ambivalence toward medication is a well-documented phenomenon in bipolar disorder research, but here it acquired a distinctive cultural texture. Participants weighed the benefits of pharmacological stability against concerns about dependency, side effects, and the social meaning of taking psychiatric drugs in a community where mental illness is heavily stigmatized. Forced normalization refers to the societal expectation that patients should appear normal, conceal their condition, and conform to social norms, regardless of their actual wellbeing. The pressure to perform normality, the study suggests, can itself become a barrier to honest engagement with treatment.

The fourth theme maps the context of interpersonal and social relationships, and it is here that the study delivers some of its most striking findings. Family emerged as a double-edged institution, simultaneously the most important source of support and a significant source of restriction. In collectivistic settings such as southeastern Iran, the family is the primary safety net for people with chronic illness, monitoring medication, accompanying patients to clinics, and providing economic and emotional backing. Yet the same closeness enables surveillance and control. Participants described family members who restricted their autonomy, made decisions on their behalf, and treated the diagnosis as a family secret to be guarded rather than an illness to be managed openly. The paradox of support and control, the authors argue, is a defining feature of the lived experience of bipolar disorder in this context.

Gendered pressures added another layer of complexity. Women and men encountered different expectations about how their illness should be expressed, concealed, and accommodated, and these expectations shaped their social functioning and their willingness to disclose. The study also found that participants’ support networks were fragile, often limited to immediate family and vulnerable to rupture. Because stigma operates at the level of the family as well as the individual, a diagnosis could affect marriage prospects, family reputation, and social standing, giving relatives strong incentives to enforce concealment. The result is a support system that is indispensable and constraining at the same time.

Running through all four themes, the researchers identified a single fundamental structure that unifies the lived experience of their participants: a continuous dialectical tension between acceptance and concealment, the paradox of support and control, and the interplay between individual agency and social structure. Patients are constantly negotiating how much of themselves to reveal, to whom, and under what conditions. Social stigma, the authors conclude, is the central and pervasive force that binds these tensions together, shaping participants’ identities, their relationships, and their engagement with treatment. Stigma is not an external add-on to the illness experience in this setting; it is woven into every decision about medication, disclosure, marriage, work, and friendship.

The clinical implications are significant. The authors argue that interventions in this context must be culturally sensitive, targeting stigma reduction, family education, and structured support systems rather than the individual patient alone. Because families function as both caregivers and gatekeepers, educating relatives about the nature of bipolar disorder could transform them from instruments of concealment into partners in care. Because explanatory models are moral and supernatural as well as biomedical, effective treatment engagement requires clinicians to understand and work with patients’ own causal beliefs rather than dismissing them. The study’s authors call for future models of care that integrate biomedical approaches with community-based mechanisms tailored to the cultural realities of southeastern Iran, a region where specialized mental health resources are concentrated in urban clinics and where the social costs of a psychiatric label remain high.

For the international research community, the study is a reminder that bipolar disorder is never experienced in a cultural vacuum. Most of what psychiatry knows about illness perceptions and treatment adherence comes from Western, individualistic societies, where the dominant model assumes an autonomous patient making independent decisions about care. This research from Kerman shows what happens when that assumption fails: the patient is embedded in a family and community whose interests, fears, and reputations are entangled with the illness itself. Understanding recovery in such settings means understanding the dialectic the researchers describe, in which every step toward acceptance is shadowed by the pull of concealment, and every offer of support carries the possibility of control. The twelve voices captured in this study suggest that improving outcomes for people with bipolar disorder in collectivistic cultures will depend less on new medications than on changing the social conditions under which the illness is lived.

Subject of Research: Illness perceptions, treatment attitudes, and social relationships among adults with bipolar disorder in southeastern Iran

Article Title: Illness perceptions, treatment attitudes, and social relationships among clinic-attending adults with bipolar disorder in Kerman, Iran: a qualitative study

Article References: Garrusi, B., Garousi, S., & Raaii, F. (2026). Illness perceptions, treatment attitudes, and social relationships among clinic-attending adults with bipolar disorder in Kerman, Iran: a qualitative study. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08722-6

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08722-6

Keywords: bipolar disorder, qualitative research, illness perceptions, social stigma, cultural psychiatry, Iran, family relationships, treatment attitudes, phenomenology, mental health, collectivism, medication adherence

The study was led by Majed M. Aljabri, Alya Alghamdi, and Bandar S. Alharbi, researchers in the Community and Psychiatric Mental Health Nursing Department at the College of Nursing, King Saud University in Riyadh. The team recruited 413 adults with diabetes who were attending primary healthcare centers in the Saudi capital. Roughly one-third of the participants — 31.0 percent — had lived with diabetes for more than a decade, and just over a quarter, 26.9 percent, reported experiencing diabetes-related complications, a reminder that the cohort included many people for whom the stakes of good self-care were already painfully concrete. Ethical approval was obtained from the Research Ethics Committee of King Saud University, and the study was conducted in accordance with the principles of the Declaration of Helsinki, with informed consent from all participants.

To capture the psychological dimensions of the problem, the researchers deployed three well-established instruments. The 18-item Multidimensional Health Locus of Control Scale, or MHLC, breaks health-related beliefs into distinct components: Internal Health Locus of Control, reflecting confidence in one’s own agency; Powerful Others Health Locus of Control, reflecting reliance on healthcare professionals and other authority figures; and Chance or Fate Health Locus of Control, reflecting the sense that health outcomes are determined by luck or destiny. Illness perceptions were measured with the Brief Illness Perception Questionnaire, which probes how patients understand their condition — its consequences, its timeline, its controllability, and the emotional weight it carries. Self-care behavior was assessed with the Summary of Diabetes Self-Care Activities, a validated measure covering domains such as diet, exercise, blood glucose testing, foot care, and medication adherence.

The analytical strategy unfolded in two stages, each answering a different question. First, the team used multivariable linear regression to ask whether each locus-of-control dimension was associated with diabetes self-care after statistically adjusting for sociodemographic and clinical characteristics — a crucial step, because raw correlations between beliefs and behavior can easily be distorted by age, education, disease duration, or the presence of complications. Second, the researchers turned to structural equation modeling, a statistical framework that allows investigators to test hypothesized pathways linking variables simultaneously, including indirect effects that pass through an intermediate variable. Here, the intermediate variable was positive illness perception, and the question was whether locus of control influences self-care directly, or whether it works by first shaping how patients mentally frame their disease.

The regression results were striking in their asymmetry. Internal Health Locus of Control showed a positive association with diabetes self-care, with a standardized coefficient of 0.29 and a 95 percent confidence interval running from 0.11 to 0.47. Powerful Others Health Locus of Control was nearly identical in magnitude, with a coefficient of 0.28 and a confidence interval of 0.09 to 0.47. In plain terms, people who believed they controlled their own health, and people who trusted the power of their healthcare providers, both tended to report better self-care. The Chance and Fate dimension, by contrast, showed no significant direct association with self-care at all — a finding that might seem to suggest fatalism is irrelevant to diabetes management, until the structural equation modeling revealed otherwise.

That second stage of analysis is where the study becomes genuinely illuminating. Internal Health Locus of Control was strongly and positively associated with positive illness perceptions, with a coefficient of 0.620 and a p-value below 0.001. Positive illness perceptions, in turn, were strongly associated with better diabetes self-care, with a coefficient of 0.506, again at p below 0.001. When the researchers traced the indirect pathway — from internal control beliefs, through more constructive perceptions of the illness, to self-care behavior — the indirect effect was 0.314, with a confidence interval of 0.126 to 0.502 that excluded zero. In other words, a substantial share of the relationship between believing in one’s own agency and actually practicing good self-care appears to run through the way patients conceptualize their disease: how controllable they judge it to be, how serious they consider its consequences, and how coherent their understanding of it feels.

Perhaps the most unexpected result concerned the Chance and Fate dimension. Although fatalistic beliefs showed no direct link to self-care in the regression models, the structural equation model detected a significant indirect association: the pathway from Chance Health Locus of Control through positive illness perceptions to self-care carried a coefficient of 0.113, with a confidence interval of 0.025 to 0.201. This suggests that the relationship between fatalism and diabetes behavior is more nuanced than a simple negative correlation. The authors concluded that Internal and Chance dimensions of health locus of control are associated with self-care primarily through their relationships with illness perceptions, whereas the Powerful Others dimension showed a direct association with self-care behavior — implying that trust in clinicians may motivate action more immediately, without needing to first reshape how the patient views the disease.

The clinical implications of this pathway analysis are considerable. Diabetes self-care is the foundation of glycemic control and the primary defense against the long-term complications that make diabetes one of the world’s most burdensome chronic diseases — retinopathy, nephropathy, neuropathy, and cardiovascular disease among them. Yet self-care is notoriously difficult to change through education alone. If the Saudi findings generalize, interventions that target illness perceptions — for example, helping patients develop a more coherent and controllable mental model of their diabetes — could unlock self-care improvements that information-only programs fail to achieve. The results also hint that different patients may need different psychological levers: those with strong internal control beliefs might benefit most from perception-focused work, while those who defer heavily to their doctors may respond well to structured clinical support and clear, actionable guidance from trusted providers.

The study’s context matters as well. Saudi Arabia faces a substantial and growing diabetes burden, and primary healthcare centers in Riyadh serve a diverse population in which cultural and religious framings of health and destiny can shape how illness is understood. The cross-sectional design, however, imposes an important limitation: because beliefs, perceptions, and behaviors were all measured at a single point in time, the analysis cannot prove that locus of control causes illness perceptions, or that illness perceptions cause self-care. Reverse pathways — in which successful self-management fosters a stronger sense of control, for instance — remain plausible, and longitudinal or interventional studies will be needed to establish directionality. The authors also relied on self-report instruments, which are vulnerable to social desirability and recall bias, although all three scales are widely validated in diabetes research.

Even with those caveats, the research adds a compelling piece to the psychology of chronic disease management. It suggests that the mind’s model of an illness is not merely a passive reflection of medical facts but an active mechanism that converts belief into behavior. For the 413 adults in Riyadh who participated, and for the hundreds of millions of people worldwide living with diabetes, the message is that how you think about your disease — whether you see it as manageable, coherent, and within your influence — may matter almost as much as the medications in your cabinet. And for the clinicians treating them, the study argues that listening to how patients perceive their illness could be as clinically productive as prescribing the next dose.

Subject of Research: Health locus of control, illness perceptions, and diabetes self-care among adults with diabetes in Saudi Arabia

Article Title: Associations of health locus of control with diabetes self-care: the role of illness perceptions among adults with diabetes in Saudi Arabia

Article References: Aljabri, M. M., Alghamdi, A., & Alharbi, B. S. (2026). Associations of health locus of control with diabetes self-care: the role of illness perceptions among adults with diabetes in Saudi Arabia. BMC Endocrine Disorders. https://doi.org/10.1186/s12902-026-02567-6

Image Credits: AI Generated

DOI: 10.1186/s12902-026-02567-6

Keywords: diabetes, health locus of control, illness perceptions, diabetes self-care, self-management, health psychology, structural equation modeling, Saudi Arabia, primary health care, chronic disease, patient behavior, endocrinology

The trial, known as GAIN 2.0, evaluated an interdisciplinary intervention called Get going After concussIoN (GAIN) against enhanced usual care in adults aged 18 to 60 who were still suffering severe symptoms two to four months after their injury. The work, conducted across 16 of the 19 municipalities in the Central Denmark Region, was published in eClinicalMedicine. The researchers hypothesized that GAIN, delivered by therapists working in community settings rather than specialized hospital staff, would produce larger reductions in post-concussion symptoms three months after treatment compared with enhanced usual care alone.

The scientific rationale behind GAIN reflects a major shift in how researchers understand persistent post-concussion symptoms. While neurometabolic dysfunction and microstructural injury to the brain are real consequences of concussion, they cannot fully explain why some people recover and others do not. Instead, PPCS is increasingly understood through a biopsychosocial lens, in which biological, psychological, social, and environmental factors all shape the trajectory of recovery. Central to this model is the concept of illness perceptions—each patient’s subjective understanding of their symptoms and what they mean for the future.

Maladaptive illness perceptions can be remarkably destructive. A patient who catastrophizes about their symptoms, or who holds pessimistic expectations about recovery, may adopt behaviors that inadvertently perpetuate the problem. Some retreat into excessive rest and avoid any activity that provokes symptoms—a pattern known as fear-avoidance behavior. Others swing to the opposite extreme, engaging in so-called all-or-nothing behavior, pushing themselves hard when symptoms abate and then collapsing into prolonged recovery periods when symptoms inevitably return. These ideas align with the influential predictive coding model of symptom perception, which frames persistent physical symptoms as a potentially reversible disturbance in brain-body interaction and the experience of bodily signals.

GAIN was designed to interrupt this symptom-perpetuating cycle. Drawing on principles from third-wave cognitive behavioral therapy, the eight-week program supports patients in gradually returning to daily activities, with physical activity as a central treatment target. Participants are encouraged to be active every day with aerobic exercise of their choosing—walking, running, cycling, even gardening—beginning at an individualized starting level and increasing only gradually as tolerated. Importantly, a temporary worsening of symptoms is considered acceptable, provided it subsides by the next day. The original version of GAIN, tested in adolescents and young adults in a specialized hospital setting, had significantly reduced the risk of still suffering from PPCS three and twelve months after treatment ended.

The challenge for GAIN 2.0 was whether this success could survive the transition from a specialized hospital to ordinary municipal clinics staffed by physiotherapists and occupational therapists with limited prior experience. To answer this question, the researchers employed a stepped wedge cluster randomized design, one of the more elegant structures in clinical trial methodology. Five healthcare clusters in Central Denmark Region served as the units of randomization, and one cluster transitioned to delivering GAIN every three months in a randomly determined order. This design allowed therapists in each cluster to be trained shortly before their community began offering the intervention, while simultaneously reducing the risk that patients allocated to enhanced usual care would accidentally receive elements of GAIN.

Between May 2021 and November 2022, 310 participants were enrolled, with 170 allocated to GAIN plus enhanced usual care and 140 to enhanced usual care alone. Most participants were women, and more than half had higher education—consistent with evidence that both groups face elevated risk of developing PPCS. Roughly half of all participants were on full-time sick leave at enrollment, underscoring how disabling the condition can be. On average, participants entered the study nearly five months after their injury, with mean scores on the Rivermead Post-Concussion Symptoms Questionnaire around 36 out of a possible 64, well above the threshold for treatment-demanding symptoms.

The primary outcome was the change in RPQ total score from baseline to three-month follow-up. Here the results were nuanced. The group receiving GAIN did show greater symptom reduction, but the difference—2.4 points in the fully adjusted analysis—failed to reach statistical significance, with a confidence interval that included the possibility of no difference. Yet at the end of the eight-week intervention itself, the effect was striking and robust: GAIN participants had improved by roughly 5.5 points more than controls, a highly significant difference that diminished over subsequent months. It appears the intervention accelerated recovery, but the advantage eroded as the control group caught up over time.

Where GAIN truly shone was in its predefined treatment targets. At three-month follow-up, the GAIN group showed substantially larger reductions in maladaptive illness perceptions, excessive rest, all-or-nothing behavior, and fear avoidance. Illness worry, measured by the Whiteley-6 questionnaire, also improved significantly more in the GAIN group. Participants reported high satisfaction with the intervention, and 69 percent described their general health as improved compared with before treatment. Only 5 percent reported minor adverse effects such as temporary fatigue or symptom flares, and no serious adverse events occurred. Post-hoc analysis also revealed that the treatment effect varied significantly depending on whether participants had a psychiatric diagnosis at some point before their concussion, suggesting that patient complexity matters.

Why did the effect on symptom severity itself fade? The researchers point to what trial scientists call the voltage drop—the tendency for a treatment’s efficacy to shrink when scaled up from ideal conditions to real-world delivery. The municipal therapists received only a two-day training course before delivering GAIN, and audio recordings revealed that strategies targeting maladaptive symptom-perpetuating perceptions—a core component of the therapy—were applied in only 57 percent of sessions. Participants in GAIN 2.0 were also more complex than those in the original trial, being older on average and more likely to carry prior psychiatric or functional somatic diagnoses. Moreover, an eight-week, low-dose intervention may simply be insufficient for highly symptomatic patients, many of whom still exceeded the treatment threshold when the program ended. The researchers suggest that extended treatment periods, booster sessions, and enhanced therapist training could strengthen long-term outcomes, and they call for future studies to examine whether GAIN improves participation in everyday life even when symptom scores alone do not dramatically change.

Subject of Research: A stepped wedge cluster randomised trial testing the GAIN interdisciplinary intervention against enhanced usual care for reducing persistent post-concussion symptoms in adults.

Article Title: Interdisciplinary intervention (GAIN) vs. enhanced usual care for reducing severe post-concussion symptoms in adults 2–4 months post-injury: A stepped wedge cluster randomised controlled trial

Article References: Hellemose, L. A., Thastum, M. M., Stabel, H. H., Odgaard, L., Rask, C. U., Silverberg, N. D., Skandsen, T., Rytter, H. M., Nygaard, C., Eggertsen, P. P., Pedersen, C. B., & Nielsen, J. F. (2026). Interdisciplinary intervention (GAIN) vs. enhanced usual care for reducing severe post-concussion symptoms in adults 2–4 months post-injury: A stepped wedge cluster randomised controlled trial. eClinicalMedicine, Article 104243. https://doi.org/10.1016/j.eclinm.2026.104243

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104243

Keywords: concussion, persistent post-concussion symptoms, GAIN intervention, cognitive behavioral therapy, stepped wedge trial, illness perceptions, fear avoidance, mild traumatic brain injury, municipal rehabilitation, Denmark, physical activity, randomised controlled trial