[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids podcast. Have you ever noticed a teenager who's suddenly full of beans, talking a mile a minute, bubbling with energy, pulled into new activities, maybe even taking risks, or hardly sleeping at all? Perhaps you've seen that same young person swing quickly to then irritability or frustration or sadness. These may be signs of a typical adolescent up and down. But what if for some they're the very early signs of something a little bit more complex? This episode is called "Energised or at Risk, Distinguishing Hypomania in Adolescence." I'm Mark Tebbs. I'm your host for today. I spent my whole career working in mental health, from frontline service delivery to director of mental health commissioning. I'm currently chief executive of a charity. I'm a trustee of a mental health organisation and a career coach, and I'm delighted to be hosting these podcasts and get to speak to clinicians and academics at the forefront of children and young people's mental health. Today, I'm joined by Dr. Georgina Hosang, reader at Queen Mary's University of London. Dr. Hosang shares how her curiosity about that kind of almost there symptoms led to a study that tracked thousands of twins searching for that connection between subtle hypomania traits and that diagnosis with ADHD or psychosis, or bipolar disorder, or drug misuse, or anorexia nervosa. We'll hear about the real-life impact. So what subclinical hypomania looks like at home and in the classroom, why it can cause distress even if it doesn't meet that kind of threshold for formal diagnosis, and how understanding these patterns can help teachers, clinicians, and families offer support earlier before difficulties arise. Let's get started. Georgina, lovely to meet you. Nice to meet you too. Great stuff. So we're here to talk about your paper, "Subclinical hypomania, psychiatric and neurodevelopmental diagnoses, phenotypic and etiological overlap." So I'm looking forward to getting into the detail of that. But it'd be great if we could just-- if you could introduce yourself and maybe some opportunity to do a little name-check of any people that you worked with on the paper. Sure. So I'm Dr. Georgina Hosang, and I am a reader or associate professor at the Wolfson Institute of Population Health at Queen Mary University of London. Most of my work focuses actually on bipolar disorder, and this really has led me to think about the early presentation of the condition. And I've undertaken a series of studies focused on subclinical hypomania, particularly in young people. So we're really excited, actually, for the publication of this paper. It's the amalgamation of a lot of thinking and working. And I would like to give a special shout-out to Miriam Martini and Mark Taylor, who worked with me tirelessly to undertake all of the analyses really to think about what do the findings mean and to write up the paper. Great stuff. Before we get into the detail, it'd be really helpful just to give a little bit of an overview of the paper and maybe particularly focus on why it's such an important area of research. Sure. So the paper's focused on subclinical hypomania. And this is the milder symptoms of hypomania which characterise bipolar disorder. So this is really where we see unusually high levels of mood, activity, and energy, but they don't quite meet the threshold or the diagnostic criteria for a hypomanic episode. And why this is important is that subclinical hypomania is experienced quite commonly in young people, but we don't really understand what happens in the long run. Is this associated with poorer outcomes, for example? So in this paper, what we wanted to do was to understand how subclinical hypomanic symptoms are linked to psychiatric and neurodevelopmental diagnoses. And we were really fortunate to have access to a very large data set in Sweden. And what we found in this study is that subclinical hypomanic symptoms were significantly linked to 14 different psychiatric and neurodevelopmental diagnoses, which to me is astonishing. And the fact that there is very little research on subclinical hypomania is of great concern, considering its link with these psychiatric and neurodevelopmental diagnoses. What we were also able to do in this study was to dig a bit deeper and try and understand what are the origins of the overlap between subclinical hypomania and these diagnoses. And what I mean by origins are the shared genetic and environmental factors that may explain the co-occurrence of subclinical hypomania and psychiatric conditions. So why are these things happening in individuals? So in our particular study, we had a number of surprising findings. So when we think about the psychiatric conditions which were most strongly related to subclinical hypomania, the top three were psychotic disorders, ADHD, and bipolar disorder. And I would have thought bipolar disorder would have been number one, but it wasn't. It was psychotic disorders. And then when we looked at the genetic correlations, the strongest genetic correlations, very interestingly, were for drug misuse, alcohol misuse, and ADHD. So we're not seeing bipolar disorder there, which again, I think is really interesting. But when we focused on environmental influences, the top three were psychotic disorders; anorexia nervosa, which was very surprising to me, and then bipolar disorder. So I think for me, the real take-home message from our paper is that the origins of subclinical hypomania are complex. They are associated with a range of different psychiatric and neurodevelopmental conditions, and they are-- subclinical hypomanic symptoms are really important for clinicians as well as professionals working with young people. Great overview and so much to unpack there. I'm going to take us back to the start, I think, and just make sure that we take all the listeners with us and start to unpack some of those terms. So could you start by just explaining what subclinical hypomania is, how prevalent it is. Is it more common in boys than girls? Just get us really maybe some examples of what it would look like if you were a parent or a teacher. So maybe if I start off with what mania and hypomania is, that might be a good starting point. So mania and hypomania characterise bipolar disorder. And this is periods of unusual. So we're talking about changes in an individual's mood, energy levels, and activities. So this is usually where it's increased. So we might see elation, racing thoughts, increased energy, decreased need for sleep, increased engagement in risk-taking behaviours. So that might be being sexually promiscuous. It might be using drugs and alcohol. It might be spending money irresponsibly, for example. Mania is the most severe form. Hypomania is the milder form. And when we talk about subclinical levels of hypomania, essentially, what we're saying is that there are symptoms that are present, but they do not meet the threshold for being considered a clinical episode of mania or a hypomania. And that may be due to the degree of impact, stress, or dysfunction on the individual. It might be due to the duration of the symptoms. They're not lasting for long enough. And it might be that the number of symptoms that need to co-occur and happen at the same time in an individual, they're not quite meeting that threshold. So that's what we mean by subclinical levels of hypomania. But what this doesn't mean is that these symptoms do not cause distress or impact negatively on young people. So we conducted a study in 2017, and we looked at a community sample of young people. And we found that 10% of this cohort would meet the threshold of being at high risk for bipolar disorder based on the hypomanic symptoms, and that experiencing hypomanic symptoms were linked to decreased life satisfaction. And other studies have also shown that it can be linked to suicidal behaviours. So although when you think about hypomania, you're like, oh, there, have elated mood, and it seems all positive, actually, there can be negative consequences. OK, so hypomania doesn't quite reach the clinical threshold, but still clearly distressing and linked to things that are suicidal thoughts. So how would it be like observable if it was in the classroom or at home? What would teachers or parents see? So you may see that a child is more distractible. They're more talkative than normal. And when we talk about talkative, you can't get a word in edgeways. There is this pressured speech. They might be engaging in more of goal-directed behaviour, but in a way where it's not achievable. So they might be engaging in a lot of after-school clubs or trying to work towards a goal that doesn't quite meet their level of expertise or experience. So it's not a realistic goal. We may see that individual's dress more brightly, wear more makeup and more bright makeup, and just generally feeling high high energy. But the key thing I would say to note is that it's a change. And I think that's where when we were measuring hypomania in young people, we saw really high rates. And for me, it's really about us distinguishing there are young people. Like, adolescents can be a time where we do have more energy, we are more vibrant. But what we're talking about is a change from how a person is usually. And I think that's when we need to be thinking about what's going on here. Does this person need additional support? Do we need to investigate other symptoms? And I think the decreased need for sleep is quite an interesting symptom. So what we mean by that is that an individual may sleep for three hours, but for them, that is enough sleep to go about their day, which is quite unusual. So yes, I think for me the key thing is that this change in behaviour, energy levels, and activity. Brilliant. That's so clear. We've done some recent podcasts about irritability. Is there an association with hypomania and irritability? Yes, there is. And thank you for highlighting that. So often we do talk about the positive side of hypomania, where it's this racing thoughts and high energy. But for some individuals, it may also present as irritability. And I think one of the challenges that we have with irritability is that it's linked to a number of different conditions and groups of symptoms. So it can be indicative of depression and anxiety. But for hypomania, it's really where you see the irritability and agitation and sometimes anger. But it's alongside the other symptoms that I spoke about. So maybe increased engagement in risk-taking behaviour. So taking drugs and alcohol and high energy, distractibility, pressured speech. So it's where it's linked to those other symptoms. Yeah, brilliant. So I think you've explained some of this already, but is there any more to say in terms of why you wanted to do this study? What was your motivation? Was there a particular gap in the research you were trying to address? Yes. So although I have covered this already, I think I can expand on it slightly. So I think first and foremost, I'm really interested in the early manifestations and presentations of bipolar disorder. And an obvious set of symptoms would be hypomania. And when I first entered this space, I was really surprised how little research there is on subclinical hypomania compared to there are a number of studies looking at subclinical levels of depression and anxiety. We hear about it all the time. But there are very few studies on subclinical hypomania. So with this study, I think the main gap was trying to understand how subclinical hypomanic symptoms are linked to psychiatric diagnoses. So these are actually official diagnoses of these conditions, which demonstrates its importance in relation to the developmental pathway from these first presentations, first symptoms, psychopathological symptoms, and how they can then progress to clinical levels where they require clinical attention. But the other and secondary aspects of my interest is I want to understand the causes and developmental pathways and risk pathways for bipolar disorder. But bipolar disorder, the prevalence is around 1% to 2%, so it's not particularly prevalent in the population. And that restricts the types of research designs and studies that we can use to uncover the origins of the condition. So, for example, we can't really use community-based longitudinal prospective studies because the prevalence is so small. But by looking at subclinical hypomania, this provides us with a really neat opportunity to try and explore using these approaches what the risk factors and risk pathways are for bipolar disorder. And this type of research is done for depression, where you look at depressive symptoms and then apply it and extrapolate it for major depressive disorder. But there's less work doing this on bipolar disorder. So although we're at the beginning of the journey for this where we talk about a phenotypic continuum to bipolar disorder, I think we're making some headway in understanding the importance of subclinical hypomania. OK, brilliant. You're going to have to explain that for me. So-- Yeah. So there's a-- Tell us more about-- [AUDIO OUT] Sure. So this is the idea. And I think this is true for many psychiatric conditions, that their symptoms are common as part of human experience. So if we think about depression and some of the symptoms I described for hypomania-- so increased energy, increased goal-directed behaviour-- they're part of all human experience. So all of us will experience some of these symptoms at some point in our lives. With a phenotypic continuum, it's the idea that acknowledges that, that these symptoms will be experienced by the general population. But there are a group of individuals where these symptoms occur, co-occur more frequently. So we're having a number of hypomanic symptoms occurring in an individual. They're causing distress, and they're lasting a significant amount of time. And that's the more extreme end, where the symptoms are more severe. And those individuals, we would classify as being at high risk for developing bipolar disorder. So if we're looking at hypomanic symptoms in the general population, understanding how it relates to different behaviours, different traits, trying to understand the genetics, for example, we haven't been able to apply those learnings to bipolar disorder. So that's the phenotypic continuum. I hope that makes sense. Yeah, no that does. That was a good explanation. OK. So let's turn to your study a little bit more detail. So it'd be great for you to explain your methodology. So there's a twin study, wasn't it? So could you tell us how you went about trying to unpack this area? Sure. So I think one of the first things that I want to highlight, actually, is how we measured subclinical hypomania. So in our study, we're really fortunate to have parent-rated hypomanic symptoms using the mood disorder questionnaire, which is a well-respected questionnaire to study these types of symptoms. But there has been much debate in the literature about the best respondents for when you're measuring and trying to capture the experience of hypomanic symptoms. And what the literature indicates and what we've found is that particularly in young people, parent reports of hypomanic symptoms seem to be the most valid and the most robust in identifying those young people who are at risk. And I think one of the main reasons for that is what we call a lack of insight. So a lack of insight can be present in individuals with these symptoms. And that just means that they don't have good self-awareness or understanding that their symptoms may be problematic or impacting on their lives negatively. So having that parent rating really helps to capture that. So that's the first thing that I think is a real strength of our study. The data comes from the CATSS study, which is the Child and Adolescent Twin Study in Sweden. And this is a longitudinal study of thousands of twins in Sweden. But the real advantage is that we're able to link this cohort to population registers. So these are official records of people living in Sweden which records their medical care. But what we were interested in is their diagnoses. And the diagnoses were up to age 24. And hypomanic symptoms were measured at age 18. So we are able to capture a period in time where we know that mental health and mental illnesses start to manifest in young people. Many disorders are present in adolescence and early adulthood. So we were able to leverage and take advantage of the twin study, the twin method. And with the twin method, what you're able to do is, first and foremost, we're able to look at what we call phenotypic correlation. So the degree to which hypomanic symptoms correlate. So if they increase, are they also associated with higher rates of the psychiatric condition? But we're also able to disentangle the degree of genetic and environmental overlap that explains the relationship between hypomania, for example, and bipolar disorder. So we looked at genetic correlation. So the degree of shared genetic influences between subclinical hypomania and each of the 14 psychiatric diagnoses. And we were also able to do the same for environmental factors. And this is really helpful when we're trying to pinpoint what are the underlying factors or origins of the phenotypic correlations that we're interested in. It must have been a big sample size? Yes. So the sample consisted of several thousand young people. And as I said, I'm really lucky to have access to this data. So it's from the CATSS study. And you really need these large sample sizes in twin studies to be able to have confidence in your findings. But I also think that this speaks to the robustness of our findings, particularly in terms of the phenotypic correlations where we're saying subclinical hypomania is associated with all of these psychiatric conditions. We have a good amount of confidence because of the sample size, but also how we're measuring subclinical hypomania, and the fact that we have confirmed official diagnoses of these conditions. Yes, that feels very reliable, doesn't it? So before we go into those results in a little bit more detail, are there any limitations in terms of the methodology that you'd like to share? So I have been saying how wonderful it is to use official records, which it is. And we're really lucky to have that because we know that there are several potential biases with self-reported diagnoses. But when we're using official records, we have to be cautious with our estimates and our results because receiving diagnoses, there are a number of different barriers and challenges in actually accessing care and obtaining the psychiatric diagnoses. So there may be some individuals that have not yet sought health, health care, or want to have yet received a diagnosis. So we would have missed those individuals. So this may be an underestimation. And there may be some groups of society that don't have access or struggle to have access to mental health care or have been misdiagnosed. So I think there are some limitations with using official records and for some of the conditions. So for example, with sleep disorders, we included the prescription of certain medications which are used for sleep disorders as well as the official diagnoses to really try and capture a group of individuals. But there may be challenges in using prescription of medication. So I think there are definitely strengths, but then I don't think that necessarily we're capturing everyone who has meets the threshold for diagnosis of the conditions that we're interested in. Yeah, because I was thinking that kind of-- 24 is still quite young, isn't it, I imagine. Well, yes. Yeah. And I think there are definitely future studies, although thank you for highlighting that. So although age 24 was-- we are capturing the period generally where mental health conditions start to manifest. That doesn't necessarily mean that individuals have yet had diagnosis. So we know, for example, with bipolar disorder globally that there is a diagnostic delay of 9 and 1/2 years. So you might have the first presentation of the symptoms, but it takes you 9 and 1/2 years to actually get the correct diagnosis of bipolar disorder. And I'm sure that's true for a number of different conditions. So it would be helpful to replicate this study when these individuals are older. I think late 30s would be an ideal time to undertake this to replicate the study. Brilliant. OK. So you've mentioned the correlation with the 14 psychiatric disorders. Do you want to just sort of say where the association was strongest? You've mentioned a little bit about the surprises, but I'd like to hear a little bit more about that too. So when we looked at just the correlations-- what disorders are most strongly related to bipolar-- with subclinical hypomania-- I was reassured by the findings. So it was psychotic disorders, ADHD, and bipolar disorder. And this is what I would have expected. And I would have also expected depression to be up there as well. So people with bipolar disorder. Although mania and hypomania characterise the condition, they also experience lifetime episodes of depression and of psychosis. So I would have thought depression would have been in all top five, which it wasn't. But we are seeing this association with psychotic disorders and bipolar disorder. We've previously looked at the interface between ADHD and hypomanic symptoms in young people. So I think that's probably important to touch on. Within the last 20 years or so, there has been increased interest in looking at bipolar disorder in young people, particularly in adolescents. And one of the things that we noted was extremely high rates of ADHD in these individuals. And this raised questions about, are we really looking at bipolar disorder in young people, or are we looking at ADHD? And maybe a slight variation of ADHD in these individuals. So one of the first studies that I did looking at subclinical hypomania in young people was to look at the overlap between ADHD and subclinical hypomania. And we found a significant correlation, but the correlation was not one, which suggests that we're not looking at the same construct. We also looked at the shared genetic and environmental influences on those two conditions. Although again, there was a significant substantial shared genetic and environmental overlap between them, it was not one. So there were some genetic and environmental factors that were specific to hypomania and not shared with ADHD. So I think it's important to explain to the audience that there's evidence to show that subclinical hypomania in young people is not just a slightly different presentation of ADHD, that it is a symptom domain in itself that needs to be recognised, explored, inquired about in our youth. So they were the main findings in terms of the correlations. And then as I mentioned earlier on, we were able to dig deeper and look at the genetic correlations between subclinical hypomania in each of the psychiatric and neurodevelopmental conditions. And I think these were the findings that were most surprising to me and took us quite a lot of discussion to try and unpick what do we think is going on. So the top three genetic correlations were drug misuse, alcohol misuse, and ADHD. And considering what I'm saying-- what I've said earlier on about what we know clinically, I would have thought bipolar disorder would have been up there. I would have thought that psychotic disorders would have been up there. And those two conditions were in our top five, but they just weren't the top hitters. But on reflection, these findings make sense. So we know that there are high rates of drug and alcohol misuse in people with bipolar disorder and with subclinical hypomanic symptoms. And there is some suggestion that it might be down to increased impulsivity, which is characteristic of bipolar disorder and subclinical hypomania, that might be driving that association. But I think it definitely has highlighted areas of further investigation for me to really think about the drug and alcohol misuse and this risk-taking behaviour in young people. And I think that's really important for clinicians and parents and health professionals to be thinking about when we do see young people maybe using drugs and alcohol. Yeah, I'm wondering whether that's-- there's a form of self-medicating through alcohol and drug use to manage the distress of that hypomania. Absolutely. And I think there is definitely opportunities where we have longitudinal data for us to try and unpick that association and relationship a bit more to try and understand what's happening first, do we see an increase in symptoms or distress prior to drug and alcohol use, and then what happens to the hypomanic symptoms. So I know there was a paper published this year in JAMA Psychiatry looking at the relationship between cannabis use and psychotic symptoms. And what they found was actually the relationship was best explained through self-medication. So that may be what's happening here. But yeah, definitely would like to investigate that further. So I'm just-- I think it would be really useful for us to move on to a little bit of the implications. I'm just wondering whether your research challenges the traditional ways that we categorise and understand mental health problems. I'm just wondering whether your discussion around the continuum of subclinical hypomania through to mania. So is there a sense that your findings are starting to challenge the way that we categorise mental health problems? So I think our study provides further support for a movement of the conceptualization of mental illnesses, where we have this-- I think there's HiTOP and there's the p factor model, where we understand that mental illnesses, actually, they commonly co-occur. That's the first thing. So if you have one disorder or diagnosis, you're very likely to have another psychiatric diagnoses. And that actually when we look at the origins of all psychiatric conditions, they overlap greatly. So it demonstrates the importance of us thinking about moving away from a single disease model where we're just looking at disease-specific symptoms-- sorry, risk factors and aetiology, et cetera, and think about mental health problems more broadly. And I think our study demonstrates really clearly, actually, that there's a huge amount of overlap between subclinical hypomanic symptoms and a range of conditions. So I mentioned that we found a substantial environmental overlap for subclinical hypomanic symptoms and anorexia nervosa. That was also a really interesting finding. And we again, isn't necessarily what we would have expected. So there is a movement away from thinking about single diseases and thinking about shared risk factors for psychiatric conditions. But I think we need to be thinking about young people in particular who are in front of us holistically. And although they may be complaining about one set of symptoms, we need to be thinking broadly about maybe other experiences that they're having to provide a comprehensive package of support and intervention for them. Yeah, that's just so interesting. And I'm wondering how young people experience that, whether they experience that as reassuring, that they're not being labelled and pigeonholed into very tight kind of diagnostic criteria or whether they experience it as uncertainty around what it is and how to treat it. Yeah, I mean, I was thinking about that prior to meeting with you today. And I think my perspective is that we all have mental health. I think often we talk about, oh yes, it's my mental health. Yeah, we all have physical health, and we all have mental health. And that fluctuates throughout our lives, where some individuals, they might benefit from having a diagnosis and having very specific interventions. I think all of us have times where maybe our mental health needs more support. And if we're thinking about specific symptoms, it might be a set of symptoms. It might be a particular symptom that's causing us distress. Actually, being aware of our mental health and the types of symptoms that are impacting on us and our daily lives, and having more tailored support for that, I think, is helpful for individuals and, I think, reduces this kind of stigmatising belief about pathologizing like all of the symptoms. I've been talking about subclinical hypomanic symptoms. And I can tell you often when I teach my students, I show the symptoms. And I say, think about just before you submitted your assignment, did you experience any of these symptoms? And a lot of them put their hands up, because it is part of human experience, and we just need to think about how we can support young people holistically in managing their lives. I'm a psychologist by background, and I have an interest in how stress impacts on our mental health. And I think if we can upskill our young people to manage life and regulate our emotions and negative thinking and impulsivity that that will have a positive impact on their mental health broadly, because these are the underlying challenges that are relevant to mental health. Yeah, I think that focus holistically is incredibly helpful. And I'm guessing this study's focus on that kind of developmental pathway also provides opportunity for earlier intervention. Is that what part of your aims of what you're trying to achieve through the work? Yes, I think in the long term, I definitely have an eye on thinking about interventions for young people who maybe are presenting with subclinical hypomanic symptoms. And I think there is a robust suite of bipolar disorder-specific interventions that might be relevant. Or we can draw on in developing interventions for young people. So there's a particular therapy called social rhythm and interpersonal therapy. And the thing I like about this particular intervention is that there's a focus on social interactions and managing those, which can often be challenging if you are experiencing mania or depression, but also on your social rhythms. So we know that sleep disturbances are a hallmark of bipolar disorder, whether that be depression or mania, and there is an emphasis on having really clear routines. So waking up at the same time, going to sleep at the same time, trying to eat at particular times of the day to have very clear daily routines and to strengthen our sleep hygiene, to reduce the potentially triggering effects that sleep disturbance can have on our mental health. So I think there are definitely opportunities to draw from those types of interventions for our young people. Yeah, easier to suggest than maybe to--[AUDIO OUT] [CHUCKLES] Yes. If listeners want to find out more about that kind of social rhythms, or maybe some of the work you've done, is there websites or places they need to look to find out a little bit more? Sure. So I'm based at Queen Mary, and I'm also on social media. So on Bluesky and X. And you can find me @DrHosang. And I'm also on LinkedIn. There are two Georgina Hosangs, just two of us in the world, so hopefully, you can find out which one's me if you google it. And I would also alert people to a network that I'm part of called CREST.BD. So C-R-E-S-T. B-D. And this is an international network of researchers who are focused on psychosocial factors related to bipolar disorder. But they have excellent resources for people with lived experience. And they have a number of podcasts as well as blogs that highlight factors which are relevant to self-management. And then on World Bipolar Day, which is the 30th of March, every year, we have an event called Ask Me Anything. So you can post any of your questions that are related to bipolar disorder. And then a panel of us who are researchers, clinicians, people with lived experience can ask your-- answer your burning questions. Amazing, amazing. That's really, really helpful. We're coming to the end of the podcast. I'm just thinking, are there any-- I think those resources would be really helpful, but are there any-- or is there any advice to parents or young people that you would like to share? I think I would like to reiterate that we all have mental health. I think that's really important to think about, and that this may fluctuate during our lifespan, and that even at this kind of subclinical level, experiencing those symptoms can cause distress and can impact on our lives. So don't ignore them. Health professional says you don't have a diagnosis. You may still want to seek or provide support to young people. And I think I would encourage clinicians in particular and teachers to be thinking about subclinical hypomanic symptoms when they are engaging with young people that may present with challenging behaviour or are expressing distress, and not to forget about these symptoms when they're building a clinical picture for them and interventions as well. Yeah, brilliant. And what research have you got in the pipeline? Have you got any things that you'd be able to share with us? Sure. So following on from this study, actually, we are currently working on identifying and looking at specific genetic factors which are associated with both subclinical hypomanic symptoms and the 14 different psychiatric diagnoses to see whether we can actually pinpoint specific genetic factors doing this using polygenic risk scores. So these are common genetic factors that are linked to a particular disorder or trait. So we're looking at each of the 14 diagnoses and their polygenic risk scores to see how strongly they're linked to subclinical hypomanic symptoms. And I think this will bring us one step closer to understanding the genetic architecture, if you like, of subclinical hypomania. And I think alongside that, we're interested in trying to identify subclinical hypomanic-specific genetic factors and to understand how they're related to other symptoms and behaviours and outcomes. So that's where we're at at the moment. And I'm sure following those studies, we'll also look at environmental factors too. Amazing. Brilliant. So is there a final message for our listeners, ones of like take-home, that you'd like to focus us on? Yes, I think subclinical hypomanic symptoms, although they may present as positive-- having increased energy or feeling elated-- may seem positive, I think that taking a further look at the experiences of young people and looking at the full range of symptoms is important. And for us to provide sufficient support and intervention for those young people are likely to have really positive impacts on them in the long term and may indicate early warning signs of mental distress, but also being on a pathway to risk for psychiatric conditions. Brilliant. Georgina, it's been lovely speaking to you. I've really enjoyed it. Me too. Thank you so much for your time. And thank you. Such a privilege to be speaking to Georgina. I hope you enjoyed that as much as I did. Don't forget, it'd be really helpful if you could leave a comment or review a suggestion. It really helps us. If you share this with your colleagues, it gets the message out about these really important research areas. So if you have an ACAMH Learn account, which is free-- and you can get this from www.acamhlearn.org-- you'll be able to get a free CPD, CME certificate for listening to any of the podcasts. Next week, we'll be going to Finland via Canada, as I speak to Marie-Pier Larose of the University of Turku, as we discuss the associations between genetic predisposition to mental health problems and academic achievements.