Please help me answer these questions. I do not need a specific word count. Even just helping me locate the answers within the article. I have no desire to copy and paste the tutors answers. The article of review will be after the questions.

1. Describe the theory/framework that supported the study. List the important concepts in the theory framework as described by the authors.

1. List the major study variables [NOT demographic variables]. Categorize them as research, independent, or dependent variables.
2. List the demographic variables measured in the study, and any extraneous variables identified by the authors. Evaluate whether there are missing demographic variables, in your opinion.

Research Design

1. Identify the specific study design. Explain how the design was appropriate to answer the study's research questions or hypotheses.

1. Briefly describe the study procedures, including recruitment, screening for eligibility, consent, timing & method of measurement of all variables, and intervention if applicable.

1. Discuss the clarity of description of study procedures. In other words, could another researcher replicate the study using the procedure described in the article?

1. If more than one group was included in the study, explain how participants were assigned to groups.

1. Describe any threats to design validity mentioned by the authors, usually in the limitations section.

1. Describe the generalizability of the study, or to what populations the findings could be applied.

Population, Sample, & Setting

1. What was the population for the study?

1. Identify the specific sampling method used for the study (i.e. bringing subjects into the study). Discuss how well this sampling method produces a sample representative of the population.

1. Identify and evaluate the inclusion and exclusion criteria used in the study. Describe any missing criteria that you believe should be there.

1. Discuss how the planned sample size was determined (including power analysis & consideration of potential attrition if included).

1. Discuss actual sample size attained for the study, including acceptance rate or refusal rate, and attrition rate if provided, or if you calculated them.

1. Describe the study setting [hospital, clinic, home, or other] and its appropriateness for the study.

Here is the article.

Efficacy of acceptance and commitment therapy on impulsivity and suicidality among clients with bipolar disorders: a randomized control trial

Abstract

Background: Among people with bipolar disorders, there are high rates of impulsivity and suicide attempts. Efforts to reduce suicide are hindered by the lack of conclusive evidence on interventional programs for those at risk. Thus, this work evaluated the efficacy of acceptance and commitment therapy on impulsivity and suicidality among bipolar clients. Methods In a randomized controlled trial, 30 eligible clients with bipolar disorders were given Acceptance and Commitment Therapy, and 30 eligible clients for the control group were chosen randomly at a 1:1 ratio using Research Randomizer version 4.0. Clients completed the Acceptance and Action Questionnaire II, the Short Arabic Version of the Impulsivity Behavior Scale, and the Arabic Version of the Beck Scale for Suicide Ideation. Results It can be observed that there was a statistically significant decrement in the mean scores of psychological inflexibility among the study group between baseline value (T0), posttest measurement (T1), and post-two-month follow-up (T2), from 32.91 SD (6.03) to 23.06 SD (6.22) post and 26.83 SD (3.49) post-two months, with an effect size of 0.846 (P<0.001), compared to the control group, which revealed an increase in the mean score. The overall impulsivity among the study group between T0, T1, and T2 was 61.27 SD (4.57) to 46.83 SD (4.47) post- and 43.0 SD (5.30) posttwo months, with an effect size of 0.906 (P<0.001). Compared to the control group, which revealed a relative increase in the mean impulsivity score at the post- and post-two-month intervals, the Arabic Versions of the Beck Scale for Suicide Ideation Scale mean score before the intervention was 16.33 SD (6.08), then the post was 7.23 SD (4.72), and the post-two-month mean was 10.13 SD (5.49) with an effect size of 0.878 (P<0.001) among the study group. On the other hand, mean scores of "suicide ideation" among clients in the control group increased posttest and nearly returned to the same value after two months. Conclusion For bipolar clients suffering from suicidal thoughts and impulsive behaviors, acceptance and commitment therapy, an emerging third-wave behavior therapy, is an effective intervention.

Introduction Suicide is a severe health problem, with a global mortality rate of 1.4% of all deaths. Annually, more than 700,000 people commit suicide [1]. One-half to two-thirds of all successfully completed suicides are caused by mood disorders. According to a meta-analysis, around 90% of suicide cases involved a mental illness, of which about 43.2% had some affective disorders, and 25.7% had problems with substance use [2]. About 30-40% and 50% of patients with affective disorders had major depressive disorder (MDD) and bipolar disorder (BD), respectively [3]. Bipolar disorder (BD), marked by recurrent manic/ hypomanic and depressive episodes, has several subtypes, including bipolar I (BD-I), bipolar II (BD-II), and BD Not Otherwise Specified (BD-NOS) [4]. Bipolar disorder's rapid cyclical nature, mixed episodes of agitated depression, early onset, comorbidity with anxiety disorders, and substance use disorders have all been identified as risk factors for suicide [5]. Suicidal behavior has a wide variety of complex causes. Although bipolar disorder (BD) is a significant trigger for suicide, suicidal behaviors cannot be fully explained by BD without the interaction of other factors, such as the severity of the illness, impulsivity, hopelessness, hostility, and aggression [6]. The research looked at impulsivity as either a trait characteristic of BD that remained constant throughout the disorder's progression or as a statedependent characteristic that fluctuated with the severity of the symptoms [7]. Impulsiveness is more likely to be observed in people with remitted BD. A general population study has shown that impulsivity predicts suicide attempts. The high rates of impulsivity in bipolar disorders are also linked to suicide attempts within that illness. However, a recent comprehensive meta-analysis of 70 trials revealed only minor impacts [8]. Nonetheless, in the scientific literature, the connection between impulsivity and suicidal behavior is well-established. It has been presumed that impulsivity facilitates the transition from suicidal ideation to a suicide attempt, and it has even been suggested that impulsivity is a more significant indicator of a suicide attempt than the presence of a specific suicide plan [9]. The absence of conclusive evidence on interventional programs targeted at the at-risk population is a critical limitation for reducing suicide and suicide attempts (e.g., clients with a suicide attempt history). In addition, the lack of randomized clinical studies limits our understanding of current therapy's (RCTs) effectiveness. Although some therapies have been demonstrated to be effective, it has been challenging to implement and spread these programs in routine clinical practice [10]. Several studies have examined using cognitive behavior therapy (CBT) as a suicidality intervention; some findings indicate it is successful. Borderline personality disorder clients who report self-harm respond well to dialectical behavioral therapy (DBT) [11]. Additionally, acceptance and commitment therapy (ACT), known as the "third wave" of behavioral therapy, had positive effects on reducing suicidal ideation [12]. On the other hand, Morrison et al. (2020) [13] investigated the different diagnostic effects of ACT on impulsive decision-making and found that it can be utilized as a meta-diagnostic treatment for impulsive behaviors. ACT may be helpful in the management of psychiatric diseases such as depressive episodes, eating disorders, borderline personality disorder, and psychosis, which are connected to an increased risk of suicide [14]. The foundation of ACT is the premise that people seeking treatment are encouraged to embrace painful feelings rather than try to suppress or modify them [15]. Moreover, ACT encourages psychological flexibility, acceptance of one's own experiences, and dedication to behaviors consistent with one's ideals. ACT therapies focus on six key processes to improve psychological flexibility: engagement with the present moment, acceptance, defusion, self as context, value clarification, and committed action [16, 17]. Therefore, we are dealing with a complicated, multifaceted, and multifactorial primarily psychological phenomenon marked by suffering and intolerable psychological pain, in which a person decides to end their life in a specific situation (insufferable, insoluble, interminable, inescapable, without a future or hope) [18]. Psychiatrists face a massive challenge in predicting and preventing suicidal behavior in their clients, but it may also be one of the most accurate measures of how well their clinical care works. In addition, high impulsivity scores are associated with increased overall functional impairment, a higher number of episodes with early onset, and a higher number of past suicide attempts, as well as increased substance intake [19]. Thus, this study evaluated the efficacy of acceptance and commitment therapy on psychological inflexibility, impulsivity, and suicidality among bipolar clients. Trial registration The study was registered retrospectively with reference number NCT05693389 on 23/1/2023, available at: https://clinicaltrials.gov/ct2/show/NCT05693389. Keywords Acceptance and commitment therapy, Impulsivity, Suicidality, Bipolar disorders El-Sayed et al. BMC Nursing (2023) 22:271 Page 3 of 14 Research hypothesizes Clients who engaged in acceptance and commitment therapy had less psychological inflexibility than the control group. Clients who engaged in acceptance and commitment therapy had less impulsivity than the control group. Clients who engaged in acceptance and commitment therapy had less suicidality than the control group. Methods and materials Study design A randomized controlled trial was conducted between October 2022 and February 2023. Study setting The study was conducted at the Main University Hospital's psychiatric outpatient clinics affiliated with Alexandria University's Faculty of Medicine. The clinics offer free treatment to clients with mental diseases. These treatments include mental health evaluation and diagnosis, pharmaceutical prescriptions, and counseling. The intervention took place in the outpatient clinic, which was equipped with various rooms to accommodate the different needs of the patients. The researchers chose a rehabilitation room with a quiet, welcoming, comfortable environment and a private and confidential space to demonstrate client therapy sessions. The clinics are open three days a week (Sunday, Monday, and Tuesday) for clients with mental illnesses from 8 a.m. to 2 p.m. Participants: sample size calculation and sampling technique The number of clients with bipolar disorders who regularly visit psychiatric outpatient clinics ranges from one to four every day (216 to 864 clients/6 months), according to hospital statistics for 2021-2022. The sample size was determined using the G*Power Windows 3.1.9.7 program, with the following criteria: effect size=0.25, err prob=0.05, power (1-err prob)=0.85, number of groups examined=2, and the number of measurements=3, following Sim, and Lewis (2012) [20]. Thus, the study group contained 30 clients with a DSM-5 bipolar diagnosis, and the control group had a similar number. Inclusion criteria Specific eligibility criteria were established to ensure participants' suitability for the study. These criteria included the requirement that clients must be at least 18 years old, able to communicate coherently and meaningfully, possess reading and writing abilities, and not have an illness that has persisted for over 10 years. Their medical records were retrieved and reviewed to confirm the client's eligibility. Outpatients who met the criteria for type I or II bipolar disorder as outlined in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-V) were selected as subjects for the study through a random selection process [4]. Exclusion criteria To ensure that bipolar disorders were not influenced by comorbid conditions, clients who exhibited chronic psychotic symptoms, were diagnosed with psychotic comorbidity, or were found under the influence of drugs or alcohol were excluded from participation in this study. The eligibility of potential participants was confirmed through a combination of direct questioning and reviewing their medical records. Random allocation Using Research Randomizer version 4.0, eligible clients with BD were given ACT therapy at a 1:1 ratio chosen randomly. A software application generated random integers with a predefined group code. After getting written consent from eligible participants, a structured interview to investigate each client's mood symptoms was conducted; the enrolling investigators asked the clients to choose a number between 1 and 60 to determine their group assignment. The trained researcher who prepared the software program and the enrolling investigators were not involved in any other trial operations; therefore, the allocation was kept secret. Throughout the trial, trained outcome assessors were blinded to group assignments. The ACT intervention will consist of eight sessions delivered over eight weeks, with evaluations of outcomes at baseline, study completion, and two-month follow-up. The flow chart for BD (Fig.1) shows that participants (n=30) got acceptance and commitment therapy (ACT) face-to-face for 8 weeks. The immediate post-treatment assessments were performed with all BD clients in the intervention and control groups (n=60). All participants completed the two-month follow-up posttest (30 from the intervention group and 30 from the control group). Tools for data collection The data for the current study was gathered using the following tools: Tool I: sociodemographic and clinical data, structured interview schedule The researchers developed this tool to elicit data from clients' sociodemographic characteristics, such as age and marital status. It was also used to collect information about the person's level of education, the length of their first psychiatric visit, the length of their illness, the causes of previous episodes, and the medicines they were given.