Life events and relapse in bipolar affective disorder

Clinical, sociodemographic and environmental predicting factors for relapse in bipolar disorder: A systematic review

INTRODUCTION

Bipolar disorder (BD) is a chronic and recurrent illness characterized by manic, mixed or depressive episodes, alternated with periods of euthymia. Several prognostic factors are associated with higher rates of relapse, which is crucial for the identification of high-risk individuals. This study aimed at systematically reviewing the existing literature regarding the impact of sociodemographic, clinical and environmental factors, in clinical relapses, recurrences and hospitalizations due to mood episodes in BD.

METHODS

A systematic search of electronic databases (PubMed, Cochrane library and Web of Science) was conducted to integrate current evidence about the impact of specific risk factors in these outcomes.

RESULTS

Fifty-eight articles met the inclusion criteria. Studies were grouped by the type of factors assessed. Family and personal psychiatric history, more severe previous episodes, earlier age of onset, and history of rapid cycling are associated with clinical relapses, along with lower global functioning and cognitive impairments. Unemployment, low educational status, poorer social adjustment and life events are also associated with higher frequency of episodes, and cannabis with a higher likelihood for rehospitalization.

LIMITATIONS

Small sample sizes, absence of randomized clinical trials, diverse follow-up periods, lack of control for some confounding factors, heterogeneous study designs and diverse clinical outcomes.

CONCLUSIONS

Although current evidence remains controversial, several factors have been associated with an impaired prognosis, which might allow clinicians to identify patients at higher risk for adverse clinical outcomes and find modifiable factors. Further research is needed to elucidate the impact of each risk factor in the mentioned outcomes.

Triggers for acute mood episodes in bipolar disorder: A systematic review

OBJECTIVES

To identify triggers of acute mood episodes in bipolar disorder (BD).

METHODS

We performed a systematic review in the following databases: Pubmed, Embase, and PsycInfo following the preferred reporting items for systematic reviews and meta-analysis guidelines. The systematic search encompassed all relevant studies published until May 23rd, 2022.

RESULTS

A total of 108 studies (case reports/case series, interventional, prospective and retrospective studies) were included in the systematic review. While several decompensation triggers were identified, pharmacotherapy was the one with the largest body of evidence, particularly the use of antidepressants as triggers of manic/hypomanic episodes. Other identified triggers for mania were brain stimulation, energy drinks, acetyl-l-carnitine, St. John's wort, seasonal changes, hormonal changes and viral infections. There is a relative paucity of evidence concerning triggers for depressive relapses in BD, with possible triggers including fasting, decreased sleep and stressful life events.

CONCLUSIONS

This is the first systematic review about triggers/precipitants of relapse in BD. Despite the importance of identification and management of potential triggers for BD decompensation, there is a lack of large observational studies addressing this topic, with most of the included studies being case reports/case series. Notwithstanding these limitations, antidepressant use is the trigger with the strongest evidence for manic relapse. More studies are needed to identify and manage triggers for relapse in BD.

Dynamic interplay between life events and course of psychotic disorders: 10-year longitudinal study following first admission

BACKGROUND

Life events (LEs) are a risk factor for first onset and relapse of psychotic disorders. However, the impact of LEs on specific symptoms - namely reality distortion, disorganization, negative symptoms, depression, and mania - remains unclear. Moreover, the differential effects of negative v. positive LEs are poorly understood.

METHODS

The present study utilizes an epidemiologic cohort of patients (N = 428) ascertained at first-admission for psychosis and followed for a decade thereafter. Symptoms were assessed at 6-, 24-, 48-, and 120-month follow-ups.

RESULTS

We examined symptom change within-person and found that negative events in the previous 6 months predicted an increase in reality distortion (β = 0.07), disorganized (β = 0.07), manic (β = 0.08), and depressive symptoms (β = 0.06), and a decrease in negative symptoms (β = -0.08). Conversely, positive LEs predicted fewer reality distortion (β = -0.04), disorganized (β = -0.04), and negative (β = -0.13) symptoms, and were unrelated to mood symptoms. A between-person approach to the same hypotheses confirmed that negative LEs predicted change in all symptoms, while positive LEs predicted change only in negative symptoms. In contrast, symptoms rarely predicted future LEs.

CONCLUSIONS

These findings confirm that LEs have an effect on symptoms, and thus contribute to the burden of psychotic disorders. That LEs increase positive symptoms and decrease negative symptoms suggest at least two different mechanisms underlying the relationship between LEs and symptoms. Our findings underscore the need for increased symptom monitoring following negative LEs, as symptoms may worsen during that time.

Psychological factors in personal and clinical recovery in bipolar disorder

BACKGROUND

Research into bipolar disorder (BD) has primarily focused upon clinical recovery (CR), i.e. symptom reduction, and overlooked personally meaningful recovery outcomes emphasized by service users. Personal recovery (PR) has been a major focus in the formulation of mental health policies and guidelines, and yet, research into factors influencing PR in BD is in its infancy.

METHODS

This study compared psychological associates of concurrent PR and CR, and determined psychological factors in PR prospectively at 6 months.

RESULTS

107 participants completed baseline assessments, of whom 84% completed follow-up at 6 months. Controlling for potential confounders, multiple linear and ordinal regression models showed that some psychological factors underpinned both CR and PR at baseline: worse PR and CR outcomes were associated with higher negative self-dispositional appraisals and dysfunctional attitudes. Better PR, but worse CR ([hypo]mania related) were associated with higher adaptive coping. Additionally, better PR (but not CR) was associated with higher concurrent risk taking at baseline and predicted at follow-up by higher levels of baseline rumination. Better CR ([hypo]mania related), but not PR, was associated with lower impulsivity, but higher BAS processes.

LIMITATIONS

Psychological and clinical factors were not measured at follow up and may have changed over time. Participants were a convenience sample.

CONCLUSIONS

Understanding psychological factors driving recovery in BD is essential for refining the conceptual framework of PR, and informing psychological models and related interventions for BD. The identified differences in psychological factors highlight the importance of more individualised, PR focused therapeutic approaches.

Prolonged functional cerebral asymmetry as a consequence of dysfunctional parvocellular paraventricular hypothalamic nucleus signaling: An integrative model for the pathophysiology of bipolar disorder

Approximately 45 million people worldwide are diagnosed with bipolar disorder (BD). While there are many known risk factors and models of the pathologic processes influencing BD, the exact neurologic underpinnings of BD are unknown. We attempt to integrate the existing literature and create a unifying hypothesis regarding the pathophysiology of BD with the hope that a concrete model may potentially facilitate more specific diagnosis, prevention, and treatment of BD in the future. We hypothesize that dysfunctional signaling from the parvocellular neurons of the paraventricular hypothalamic nucleus (PVN) results in the clinical presentation of BD. Functional damage to this nucleus and its signaling pathways may be mediated by myriad factors (e.g. immune dysregulation and auto-immune processes, polygenetic variation, dysfunctional interhemispheric connections, and impaired or overactivated hypothalamic axes) which could help explain the wide variety of clinical presentations along the BD spectrum. The neurons of the PVN regulate ultradian rhythms, which are observed in cyclic variations in healthy individuals, and mediate changes in functional hemispheric lateralization. Theoretically, dysfunctional PVN signaling results in prolonged functional hemispheric dominance. In this model, prolonged right hemispheric dominance leads to depressive symptoms, whereas left hemispheric dominance correlated to the clinical picture of mania. Subsequently, physiologic processes that increase signaling through the PVN (hypothalamic-pituitaryadrenal axis, hypothalamic- pituitary-gonadal axis, and hypothalamic-pituitary-thyroid axis activity, suprachiasmatic nucleus pathways) as well as, neuro-endocrine induced excito-toxicity, auto-immune and inflammatory flairs may induce mood episodes in susceptible individuals. Potentially, ultradian rhythms slowing with age, in combination with changes in hypothalamic axes and maturation of neural circuitry, accounts for BD clinically presenting more frequently in young adulthood than later in life.

Are adult stressful life events associated with psychotic relapse? A systematic review of 23 studies

Relapse rates among individuals with psychotic disorders are high. In addition to the financial burden placed on clinical services, relapse is associated with worse long-term prognosis and poorer quality of life. Robust evidence indicates that stressful life events commonly precede the onset of the first psychotic episode; however, the extent to which they are associated with relapse remains unclear. The aim of this systematic review is to summarize available research investigating the association between recent stressful life events and psychotic relapse or relapse of bipolar disorder if the diagnosis included psychotic symptoms. PsycINFO, Medline and EMBASE were searched for cross-sectional, retrospective and prospective studies published between 01/01/1970 and 08/01/2020 that investigated the association between adult stressful life events and relapse of psychosis. Study quality was assessed using the Effective Public Health Practice Project guidelines. Twenty-three studies met eligibility criteria (prospective studies: 14; retrospective studies: 6; cross-sectional: 3) providing data on 2046 participants in total (sample size range: 14-240 participants). Relapse was defined as a return of psychotic symptoms (n = 20), a return of symptoms requiring hospitalization (n = 2) and a return of symptoms or hospitalization (n = 1). Adult stressful life events were defined as life events occurring after the onset of psychosis. Stressful life events included but were not limited to adult trauma, bereavement, financial problems and conflict. Eighteen studies found a significant positive association between adult stressful life events and psychotic relapse and five studies found a non-significant association. We conclude that adult stressful life events, occurring after psychosis onset, appear to be associated with psychotic relapse.

Mania Following Bereavement: State of the Art and Clinical Evidence

Bereavement is the state of loss, determined in most of the cases by the death of a close person. It is probably the greatest sorrow that can occur in an individual life. Grief is a normal, healthy response to loss, evolving through stages in the process of mourning. In some cases, bereavement may lead to the outburst of manic episode: despite literature data being scarce, reports have explored this important clinical entity, variously called as "funeral mania" or "bereavement mania". We systematically reviewed the literature exploring the possible relationships between bereavement and the onset of a manic episode, both first or recurrent pre-existing episode, besides describing a case report on a manic episode in the aftermath of a loss event, with an accurate evaluation of prior mild mood spectrum instability, supporting the role of loss-events as potential risk factor for bipolar illness progression. This article tries summarizing existing evidence on the debate whether clinicians should consider mania as a possible bereavement reaction.

Similarities and Differences of Strategies between Bipolar and Depressive Disorders on Stress Coping

OBJECTIVE

As coping strategies can influence the illness course of mood disorder, they could be potential targets for psychological intervention. The current study investigated the similarities and differences in stress coping styles between bipolar disorder (BD) and depressive disorder (DD).

METHODS

Subjects with BD (n=135) and DD (n=100) who met the DSM-IV diagnostic criteria were included in this analysis. Coping strategies were assessed using the coping inventory for stressful situations and depressive symptoms were assessed by Beck depression inventory.

RESULTS

The BD group showed significantly more avoidant and task-oriented coping than the DD group (t=2.714, p=0.007; t=2.193, p=0.039). After excluding the effect of the depressive symptoms themselves (by comparing two groups in non-depressive state), the BD group still showed significantly more avoidant and task-oriented coping than the DD group (t=2.040, p=0.045; t=2.556, p=0.013), but when the symptoms of depression get greater, the difference between BD and DD coping strategies were reduced.

CONCLUSION

Subjects with BD tend to use more task and avoidant coping than DD subjects. But when the symptoms of depression get greater, the difference in coping strategies between BD and DD were reduced.

Stressful Life Events and Relapse in Bipolar Affective Disorder: A Cross-Sectional Study from a Tertiary Care Center of Southern India

BACKGROUND

Bipolar affective disorder (BAD) is a severe mental illness which results in serious lifelong struggles and challenges. The full impact of stressful life events (SLEs) on the course of BAD is poorly understood.

MATERIALS AND METHODS

A cross-sectional study was conducted on 128 consecutive patients with BAD currently admitted with a relapse. Our objectives were (1) to estimate the proportion, type, and timing of preonset SLEs in relapsed BAD patients and (2) to study the association between SLEs and selected clinical variables in this group. Semi-structured proforma, Young Mania Rating Scale, Hamilton Rating Scale for Depression, Presumptive Stressful Life Events Scale, and Brief Psychiatric Rating Scale were used. Statistical analysis was done using R software for Windows.

RESULTS

About 69.5% (89/128) of patients reported preonset SLEs - among which 50 (56.2%) had mania and 39 (43.8%) had depression. Conflict with in-laws and financial problems were the commonly reported SLEs. The mean duration between SLEs and the relapse was 19.73 ± 4.8 days. BPRS score was significantly high in subjects with preonset SLEs (P = 0.022). No significant association was detected between SLEs and the type of episode during relapse (P = 0.402).

CONCLUSION

This study emphasizes the significance of SLEs in the relapse and longitudinal course of BAD. Understanding the association of SLEs and relapse in BAD will help in predicting further relapses and developing newer pharmacological and nonpharmacological measures targeting this aspect, thereby maximizing both symptom reduction and quality of life in patients with BAD.

Does stress play a significant role in bipolar disorder? A meta-analysis

BACKGROUND

There is evidence that stressful life events (LE) play a crucial role in the etiology of bipolar affective disorder (BD). However, primary studies, as well as narrative reviews, have provided mixed results. The present meta-analysis combined and analyzed previous data in order to address these inconsistencies.

METHOD

Forty-two studies published in 53 records were identified by systematically searching MEDLINE, PsychINFO, and PSYCHINDEX using the terms "bipolar disorder" OR "manic-depressive" OR "bipolar affective disorder" OR "mania" AND "stress" OR "life event" OR "daily hassles" OR "goal attainment". Then, meta-analyses were conducted.

RESULTS

Individuals diagnosed with BD reported more LE before relapse when compared to euthymic phases. They also experienced more LE relative to healthy individuals and to physically ill patients. No significant difference in the number of LE was found when BD was compared to unipolar depression and schizophrenia.

LIMITATIONS

When interpreting the present meta-analytic findings one should keep in mind that most included studies were retrospective and often did not specify relevant information, e.g., if the LE were chronic or acute or if the individuals were diagnosed with BD I or II. We could not entirely rule out a publication bias.

CONCLUSION

The present meta-analyses found that individuals with BD were sensitive to LE, which corroborates recent theoretical models and psychosocial treatment approaches of BD. Childbirth, as a specific LE, affected individuals with BD more than individuals with unipolar depression. Future studies that investigate specific LE are warranted.

Comparison of precipitating factors for mania and partial seizures: Indicative of shared pathophysiology?

OBJECTIVES

Mania in bipolar disorder (BD) and partial (focal) seizures (PS) arising from the temporal lobes, have a number of similarities. Typically, a chronic course of the disorders is punctuated by acute illness episodes. Common features of episodes may include sensory, perceptual, cognitive and affective changes. Both respond to anticonvulsant treatment. Common mechanisms imputed include neurotransmitters and kindling processes. Further investigation may improve understanding of the occurrence of both mania and PS, casting light on the relevance of temporal lobe mediated processes and pathology. One avenue of investigation is to compare aetiological factors and determine the extent of overlap which may indicate shared brain localization or pathophysiology. Aetiology includes predisposing, precipitating or perpetuating factors. This paper examines the literature on precipitating factors of mania, first or subsequent episode, and of PS in diagnosed epilepsy, which is the second or subsequent seizure, to identify the extent and nature of their overlap.

METHOD

Narrative review based on a literature search of PubMed and Google Scholar.

RESULTS

Precipitating factors for both mania and PS were stress, sleep deprivation, antidepressant medication and, tentatively, emotion. For mania alone, goal-attainment events, spring and summer season, postpartum, and drugs include steroids and stimulants. For PS alone, winter season, menstruation and specific triggers in complex reflex epilepsies. Those not substantiated include lunar phase and menopause. A wide range of chemicals may provoke isolated seizures but by definition epilepsy requires at least two seizures.

CONCLUSIONS

The overlap of precipitating factors in mania and PS imply that common brain processes may contribute to both, consistent with findings from neuroscience research.

Measuring Life Events and Their Association With Clinical Disorder: A Protocol for Development of an Online Approach

Background

Severe life events are acknowledged as important etiological factors in the development of clinical disorders, including major depression. Interview methods capable of assessing context and meaning of events have demonstrated superior validity compared with checklist questionnaire methods and arguments for interview approaches have resurfaced because choosing the appropriate assessment tool provides clarity of information about gene-environment interactions in depression. Such approaches also have greater potential for understanding and treating clinical cases or for use in interventions.

Objective

(1) To argue that life events need sophisticated measurement not satisfactorily captured in checklist approaches. (2) To review life-events measures and key findings related to disorder, exemplifying depression. (3) To describe an ongoing study with a new online measure and to assess its psychometric properties and the association of life events in relation to disorder and educational outcomes.

Methods

The Computerised Life Events Assessment Record (CLEAR) is under development as a tool for online assessment of adult life events. Based on the Life Events and Difficulties Schedule interview, CLEAR seeks to assess life events to self and close others, link these to other events and difficulties, and utilize calendar-based timing, to improve upon checklist approaches.

Results

The CLEAR study is in the preliminary stages and its results are expected to be made available by the end of 2015.

Conclusions

There is currently no sophisticated technological application of social risk factor assessment, such as life events and difficulties. CLEAR is designed to gather reliable and valid life-event data while combating the limitations of interviews (eg, time consuming and costly) and life-event checklists (eg, inability to accurately measure severity and independence of life events). The advantages of using such innovative methodology for research, clinical practice, and interventions are discussed.

Contributions of the social environment to first-onset and recurrent mania

In treated cohorts, individuals with bipolar disorder are more likely to report childhood adversities and recent stressors than individuals without bipolar disorder; similarly, in registry-based studies, childhood adversities are more common among individuals who later become hospitalized for bipolar disorder. Because these types of studies rely on treatment-seeking samples or hospital diagnoses, they leave unresolved the question of whether or not social experiences are involved in the etiology of bipolar disorder. We investigated the role of childhood adversities and adulthood stressors in liability for bipolar disorder using data from the National Epidemiologic Survey on Alcohol and Related Conditions (n=33 375). We analyzed risk for initial-onset and recurrent DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) manic episodes during the study's 3-year follow-up period. Childhood physical abuse and sexual maltreatment were associated with significantly higher risks of both first-onset mania (odds ratio (OR) for abuse: 2.23; 95% confidence interval (CI)=1.71, 2.91; OR for maltreatment: 2.10; CI=1.55, 2.83) and recurrent mania (OR for abuse: 1.55; CI=1.00, 2.40; OR for maltreatment: 1.60; CI=1.00, 2.55). In addition, past-year stressors in the domains of interpersonal instability and financial hardship were associated with a significantly higher risk of incident and recurrent mania. Exposure to childhood adversity potentiated the effects of recent stressors on adult mania. Our findings demonstrate a role of social experiences in the initial onset of bipolar disorder, as well as in its prospective course, and are consistent with etiologic models of bipolar disorder that implicate deficits in developmentally established stress-response pathways.

The influence of life events on first and recurrent admissions in bipolar disorder

Background

Life events play an important role in the onset and course of bipolar disorder. We will test the influence of life events on first and recurrent admissions in bipolar disorder and their interaction to test the kindling hypothesis.

Methods

We collected information about life events and admissions across the life span in 51 bipolar patients. We constructed four models to explore the decay of life event effects on admissions. To test their interaction, we used the Andersen-Gill model.

Results

The relationship between life events and admissions was best described with a model in which the effects of life events gradually decayed by 25% per year. Both life event load and recurrent admissions significantly increased the risk of both first and subsequent admissions. No significant interaction between life event load and number of admissions was found.

Conclusions

Life events increase the risk of both first and recurrent admissions in bipolar disorder. We found no significant interaction between life events and admissions, but the effect of life events on admissions decreases after the first admission which is in line with the kindling hypothesis.

Characteristics of stress-coping behaviors in patients with bipolar disorders

Appropriate stress-coping strategies are needed to improve the outcome in the treatment of bipolar disorders, as stressful life events may aggravate the course of the illness. The aim of this study was to compare stress-coping behaviors between bipolar patients and healthy controls. A total of 206 participants comprising 103 bipolar patients fulfilling the Diagnostic and Statistical Manual for Axis I disorder fourth edition (DSM-IV) diagnostic criteria for bipolar I and II disorders and controls matched by age and sex were included in this study. Stress-coping behaviors were assessed using a 53-item survey on a newly-designed behavioral checklist. The characteristics of stress-coping behaviors between the two groups were compared by using t-test and factor analysis. Social stress-coping behaviors such as 'journey', 'socializing with friends', and 'talking something over' were significantly less frequent in bipolar patients than controls. On the other hand, pleasurable-seeking behaviors such as 'smoking', 'masturbation', and 'stealing' were significantly more frequent in bipolar patients than controls. These results suggest that bipolar patients may have more maladaptive stress-coping strategies than normal controls. It is recommended to develop and apply psychosocial programs to reduce maladaptive stress-coping behaviors of bipolar patients.

Stressful life events in bipolar I and II disorder: cause or consequence of mood symptoms?

BACKGROUND

Life events are assumed to be triggers for new mood episodes in bipolar disorder (BD). However whether life events may also be a result of previous mood episodes is rather unclear.

METHOD

173 bipolar outpatients (BD I and II) were assessed every three months for two years. Life events were assessed by Paykel׳s self-report questionnaire. Both monthly functional impairment due to manic or depressive symptomatology and mood symptoms were assessed.

RESULTS

Negative life events were significantly associated with both subsequent severity of mania and depressive symptoms and functional impairment, whereas positive life events only preceded functional impairment due to manic symptoms and mania severity. These associations were significantly stronger in BD I patients compared to BD II patients. For the opposite temporal direction (life events as a result of mood/functional impairment), we found that mania symptoms preceded the occurrence of positive life events and depressive symptoms preceded negative life events.

LIMITATIONS

The use of a self-report questionnaire for the assessment of life events makes it difficult to determine whether life events are cause or consequence of mood symptoms. Second, the results can only be generalized to relatively stable bipolar outpatients, as the number of severely depressed as well as severely manic patients was low.

CONCLUSIONS

Life events appear to precede the occurrence of mood symptoms and functional impairment, and this association is stronger in BD I patients. Mood symptoms also precede the occurrence of life event, but no differences were found between BD I and II patients.

Aggression and impulsivity as predictors of stress generation in bipolar spectrum disorders

BACKGROUND

Some evidence suggests that individuals with bipolar spectrum disorders (BSD) generate stressful life events, contributing to a more severe course of disorder. A recent update to the Behavioral Approach System (BAS) dysregulation theory of BSD highlights the need to investigate anger as approach motivation. Although research has shown that individuals with BSD generate stress, it is unclear whether personality traits characteristic of BSD, such as aggression and impulsivity, are related to this stress generation.

METHODS

The current longitudinal study employed multilevel modeling to examine stress generation in a sample of 104 individuals with BSD and 96 healthy controls. We examined rates of BAS-deactivating, BAS-activating, and Anger-evoking life events over a period of up to 4.5 years as a function of levels of aggression and impulsivity.

RESULTS

Individuals with BSD reported significantly higher numbers of dependent Anger-evoking events and BAS-deactivating events, but not dependent BAS-activating events, than controls. Trait levels of hostility and impulsivity predicted all types of events, although bipolar diagnosis remained a significant predictor of BAS-deactivating and Anger-evoking events.

LIMITATIONS

The life events measures were not designed to assess Anger-evoking events; further research should replicate these findings and develop more finely tuned assessments of stressful anger events. In addition, the sample was not a clinical sample.

CONCLUSIONS

This study adds to the literature on stress generation in BSD; trait level personality differences predict stress generation, beyond bipolar diagnosis. This also further establishes the importance of including anger-evoking events in the BAS model of BSDs and stress generation.

Life-event specificity: bipolar disorder compared with unipolar depression

BACKGROUND

Little is known about the impact of different types of stressful events (for example divorce v. bereavement) on unipolar depression compared with bipolar disorder. Inconsistencies exist concerning the association between independent events (beyond an individual's control, such as bereavement) and bipolar disorder.

AIMS

To examine the role of specific, independent and dependent events in mood disorders.

METHOD

Life-event information was collected from 512 people with bipolar disorder, 1448 people with unipolar depression and over 600 controls.

RESULTS

Various events were associated with unipolar depression and bipolar disorder, but some event specificity was detected. For example, financial crisis was more strongly related to bipolar disorder rather than unipolar depression. Independent events were only related to unipolar depression and not bipolar disorder.

CONCLUSIONS

The events that were linked to bipolar disorder and unipolar depression were similar. Independent events were not associated with bipolar episodes, suggesting that life stress may be a consequence of, rather than a trigger for, bipolar episodes.

Life events and social rhythms in bipolar spectrum disorders: an examination of social rhythm sensitivity

OBJECTIVES

To examine the presence of an underlying social rhythm sensitivity in individuals with bipolar spectrum disorders.

METHODS

The present study examined the impact of life events on sleep loss and social rhythm disruption in 184 individuals with bipolar spectrum disorders (BSD) compared to 197 demographically similar normal controls (NC) drawn from the Longitudinal Investigation of Bipolar Spectrum Disorders (LIBS) project. Life events data were obtained at three time points, each spaced four months apart, and included information on the intensity of the event (high or low), valence (negative or positive), and levels of sleep loss and social rhythm disruption brought about the event. We hypothesized that BSD participants would exhibit higher levels of social rhythm disruption and sleep loss than normal controls as a consequence of the same life events.

RESULTS

BSD participants experienced significantly more social rhythm disruption and sleep loss following all classes of life events.

LIMITATIONS

The cross-sectional design of this study limits the strength of the conclusions that can be drawn, primarily cause and effect relationships between social rhythms and symptoms.

CONCLUSIONS

Findings support the presence of an underlying social rhythm sensitivity in individuals with bipolar spectrum disorders. An additive effect of sleep loss and social rhythm disruption may contribute to subsequent mood symptomatology. Results from this study may inform early psychosocial interventions for at-risk individuals.

The precipitants of manic/hypomanic episodes in the context of bipolar disorder: a review

BACKGROUND

Mania/hypomania is the hallmark feature of bipolar disorder. This paper aims to review the current evidence in relation to factors hypothesised to precipitate bipolar mania/hypomania, and suggest areas for future research.

METHODS

A selective review of original and review papers was conducted. The electronic databases 'PsycINFO' and 'PubMed' were searched using the following search strings: "bipolar disorder" or "mania" or "hypomania" or "manic-depression" with "triggers" or "precipitants" or "precedents" or "predictors".

RESULTS

There is evidence that goal attainment events, antidepressant medication, disrupted circadian rhythms, spring/summer seasonal conditions, and more tentatively, stressful life events and high emotional expression, may precipitate bipolar mania/hypomania in susceptible individuals. Evidence from case reports and clinical observations are also reported.

DISCUSSION

The pathways to bipolar mania/hypomania may be many and varied, and many of these pathways may be outside the awareness of individuals with bipolar disorder. Greater awareness of the broad number of precipitating factors is needed to inform self-management and psycho-educational programs to build resilience to further episodes. Future research is needed to explore what other factors may precipitate bipolar mania/hypomania, and to determine why some factors may precipitate mania/hypomania in some individuals with bipolar I or II disorder but not in others.

Increased rates of events that activate or deactivate the behavioral approach system, but not events related to goal attainment, in bipolar spectrum disorders

Research indicates that life events involving goal attainment and goal striving trigger hypomania/mania and that negative life events trigger bipolar depression. These findings are consistent with the behavioral approach system (BAS) dysregulation model of bipolar disorders, which suggests that individuals with bipolar disorders are hypersensitive to cues signaling opportunity for reward and cues signaling failure and loss of rewards. However, no studies to date have investigated whether individuals with bipolar spectrum disorders experience increased rates of these BAS-relevant life events, which would place them at double risk for developing bipolar episodes. The present study found that individuals with bipolar II disorder and cyclothymia experience increased rates of BAS-activating and BAS-deactivating, but not goal-attainment, life events. Finally, for bipolar spectrum individuals only, BAS-activating events predicted BAS-deactivating events' rates.

A comparison of life events in patients with unipolar disorder or bipolar disorder and controls

OBJECTIVE

The present study aimed to explore the association between stressful life events (LEs) and the development of affective psychopathology.

METHOD

Thirty patients with unipolar disorder and 30 patients with bipolar disorder were compared to 60 matched healthy controls in regard to the rate of stressful LEs. Assessment measures included the Beck Depression Inventory, the Adult Life Events Questionnaire, and the Childhood Life Events List.

RESULTS

The entire sample of affective patients had more LEs in general, more negative LEs, and more loss-related LEs in the year preceding their first depressive episode as compared with normal controls. Subjects with unipolar disorder had more positive LEs and more achievement LEs, whereas subjects with bipolar disorder had more uncontrollable LEs in the year preceding the first depressive episode. The relationship between LEs and manic episodes was prominent in the year preceding the first manic episode, with subjects with bipolar disorder reporting more LEs in general and more ambiguous events in that year. Almost no significant differences on LE frequency were observed in the year before the last depressive and manic episodes in the patient groups with unipolar and bipolar disorder. A significant relationship was found between childhood LEs and the development of affective disorders in adulthood, with patients with unipolar disorder exhibiting less positive and achievement LEs.

CONCLUSIONS

In both the unipolar and the bipolar groups, the major impact of LEs on the onset of affective disorders was found in the year before the first depressive or manic episodes. This suggests that the accumulation of stressful LEs at this crucial period contributes to the precipitation of a pathological response mechanism. Once established, this mechanism would be reactivated in the future by even less numerous and less severe stressors, compatible with the kindling hypothesis.

Social and Familial Factors in the Course of Bipolar Disorder: Basic Processes and Relevant Interventions

This article reviews the role of social factors, notably life events and family relationships, in the course of bipolar illness in adults and youth. We also discuss psychological variables that help explain the vulnerability of bipolar patients to social environments, including personality factors (e.g., neuroticism), reward sensitivity, and difficulty with the accurate perception of facial emotions. Bipolar patients are highly sensitive to reward, and excessive goal pursuit after goal-attainment events may be one pathway to mania. Negative life events predict depressive symptoms, as do levels of familial expressed emotion. Psychosocial interventions can speed recoveries from episodes and delay recurrences over 1-2 year intervals. Future research should examine the nature of vulnerability/stress interactions at different phases of development, and the role of psychosocial interventions in altering these processes.

Longitudinal Predictors of Bipolar Spectrum Disorders: A Behavioral Approach System (BAS) Perspective

We review longitudinal predictors, primarily psychosocial, of the onset, course, and expression of bipolar spectrum disorders. We organize our review along a proximal - distal continuum, discussing the most proximal (i.e., prodromes) predictors of bipolar episodes first, then recent environmental (i.e., life events) predictors of bipolar symptoms and episodes next, followed by more distal psychological (i.e., cognitive styles) predictors, and ending with the most distal temperament (i.e., Behavioral Approach System sensitivity) predictors. We then present a theoretical model, the Behavioral Approach System (BAS) dysregulation model, for understanding and integrating the role of these predictors of bipolar spectrum disorders. Finally, we consider the implications of the reviewed longitudinal predictors for future research and psychosocial treatments of bipolar disorders.

Implementing clinical guidelines for bipolar disorder

PURPOSE

To critically review the evidence concerning the implementation of clinical guidelines for bipolar disorder.

METHODS

A Medline search was made of the literature on the implementation of guidelines in bipolar disorder and mental health. The implementation of non-pharmacological treatments from the 2006 NICE Guideline for Bipolar Disorder was then used as a case example. May's model of normalization of complex interventions was then applied to the NICE guideline recommendations for bipolar disorder.

RESULTS

The effective local implementation of guidelines requires a detailed understanding of local barriers to their implementation. Some recommendations in the NICE Guideline on advanced directives and management of anxiety disorder in bipolar disorder appear to follow the existing trends in practice and are more likely to be implemented. Interventions concerning the psychological management of bipolar depression and maintenance psychological treatments are going to be the most difficult to implement because of shortages of skilled staff, the absence of specific training and supervision, the requirements for staff to adopt practices that are quite different from what they are used to, and some uncertainty about whether these interventions are effective in the most severe patients.

CONCLUSIONS

Without a detailed local understanding of the barriers to implementation and the resources and will to overcome them, there is likely to be a considerable local variation in the implementation of guidelines for bipolar disorder. Recommendations that require little change to working practices and resources are most likely to be implemented.

Life events as predictors of mania and depression in bipolar I disorder

To date, few prospective studies of life events and bipolar disorder are available, and even fewer have separately examined the role of life events in depression and mania. The goal of this study was to prospectively examine the role of negative and goal-attainment life events as predictors of the course of bipolar disorder. One hundred twenty-five individuals with bipolar I disorder were interviewed monthly for an average of 27 months. Negative and goal-attainment life events were assessed with the Life Events and Difficulties Schedule. Changes in symptoms were evaluated using the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Scale. The clearest results were obtained for goal-attainment life events, which predicted increases in manic symptoms over time. Negative life events predicted increases in depressive symptoms within regression models but were not predictive within multilevel modeling of changes in depressive symptoms. Given different patterns for goal attainment and negative life events, it appears important to consider specific forms of life events in models of bipolar disorder.

Dysregulation of the behavioral approach system (BAS) in bipolar spectrum disorders: review of theory and evidence

In recent years, a call for increased research on bipolar disorder has been answered with methodologically diverse studies exploring goal striving, life events, cognitive style, decision-making, and neurobiological abnormalities in bipolar disorder. In order to further this spurt of research and to systematize our understanding of bipolar disorder, an integrative perspective is warranted. The behavioral approach system (BAS) dysregulation theory, proposed by Richard Depue and colleagues, provides such an integrated model for understanding psychosocial and biological aspects of bipolar disorder. In this paper, we review studies on life events, cognitive style and other psychosocial and neurobiological factors to examine whether the BAS dysregulation theory is supported by existing data. Then, we draw on recent advances in the study of emotion and motivation, and propose an expansion of the BAS dysregulation model of bipolar spectrum disorders to foster further biopsychosocial investigations of bipolar disorder. This expanded model provides greater specificity in predictions, especially about the nature of BAS dysregulation, environmental factors and psychological processes (e.g., appraisal processes) featured in a causal chain culminating in bipolar symptoms. Finally, we discuss the implications of the expanded BAS model for the course of bipolar spectrum disorders.

Lamotrigine in bipolar disorder: efficacy during pregnancy

OBJECTIVE

Clinical management of bipolar disorder (BPD) patients during pregnancy is a major challenge. The high risk of bipolar depression during pregnancy encourages consideration of lamotrigine (LTG). We therefore compared recurrence risks among pregnant women with BPD treated with LTG to those discontinuing mood stabilizer therapies.

METHODS

We compared risks and weeks to new DSM-IV illness-episodes among 26 initially clinically stable pregnant women diagnosed with DSM-IV BPD who continued LTG treatment to those discontinuing all mood stabilizer treatment during pregnancy.

RESULTS

The risk of new illness-episodes with LTG was 30% versus 100% after discontinuing mood stabilizers, and survival-computed time-to-25%-recurrence was 28.0 versus 2.0 weeks (chi(2 )=17.3, p < 0.0001; hazard ratio = 12.1; 95% confidence interval = 1.6-91.7).

CONCLUSIONS

Discontinuing mood stabilizer treatment presents high risks of illness-recurrence among pregnant women diagnosed with BPD. LTG may afford protective effects in pregnancy, and its reported fetal safety compares favorably to other agents used to manage BPD.

Daily hassles, uplifts, and time use in individuals with bipolar disorder in remission

Although life stress has been shown to trigger relapse in bipolar disorder, little is known about how bipolar patients perceive daily hassles or their positive counterparts, uplifts. We used the experience sampling method to investigate the daily experience of hassles and uplifts in 38 patients with remitted bipolar disorder and 38 healthy controls. Largely because of current unemployment, patients were more often alone and at home and spent less time working and more time in passive leisure activities. Contrary to expectations, the groups did not differ in total frequencies or appraisals of events. Within the patient group, however, those patients with current depressive symptoms and more previous depressive episodes experienced negative events as more stressful. These findings are consistent with hypothesized processes linking depressive symptoms to the generation of stressful conditions or to the reactivation of negative cognitive schemas.

A cognitive vulnerability-stress perspective on bipolar spectrum disorders in a normative adolescent brain, cognitive, and emotional development context

Why is adolescence an "age of risk" for onset of bipolar spectrum disorders? We discuss three clinical phenomena of bipolar disorder associated with adolescence (adolescent age of onset, gender differences, and specific symptom presentation) that provide the point of departure for this article. We present the cognitive vulnerability-transactional stress model of unipolar depression, evidence for this model, and its extension to bipolar spectrum disorders. Next, we review evidence that life events, cognitive vulnerability, the cognitive vulnerability-stress combination, and certain developmental experiences (poor parenting and maltreatment) featured in the cognitive vulnerability-stress model play a role in the onset and course of bipolar disorders. We then discuss how an application of the cognitive vulnerability-stress model can explain the adolescent age of onset, gender differences, and adolescent phenomenology of bipolar disorder. Finally, we further elaborate the cognitive vulnerability-stress model by embedding it in the contexts of normative adolescent cognitive (executive functioning) and brain development, normative adolescent development of the stress-emotion system, and genetic vulnerability. We suggest that increased brain maturation and accompanying increases in executive functioning along with augmented neural and behavioral stress-sensitivity during adolescence combine with the cognitive vulnerability-stress model to explain the high-risk period for onset of bipolar disorder, gender differences, and unique features of symptom presentation during adolescence.

The social zeitgeber theory, circadian rhythms, and mood disorders: review and evaluation

The social zeitgeber theory [Ehlers, C. L., Frank, E., & Kupfer, D. J. (1988). Social zeitgebers and biological rhythms. Archives of General Psychiatry, 45, 948-952] offers an explanation of how life events trigger depressive episodes. According to this theory, life stress leads to mood episodes by causing disruptions in individuals' social routines and, in turn, their biological circadian rhythms. In this article, we review the literature pertaining to the social zeitgeber theory, as well as evidence that this theory may be applied to (hypo)manic episodes. Given the limited data supporting the social zeitgeber theory to date, we also evaluate whether circadian rhythm disruptions are triggered by an internal mechanism, such as an abnormality in one's pacemaker (the suprachiasmatic nucleus; SCN). We review these two theories in an attempt to understand the potential causes of circadian rhythm disruptions and affective episodes in individuals with unipolar and bipolar disorders. We also propose several areas of future research.

The nature and treatment of depression in bipolar disorder: A review and implications for future psychological investigation

Bipolar depression is poorly understood and researched, yet it is has a huge impact on functioning in bipolar disorder. This review explores the current status of research regarding the phenomenology, natural history, neuropsychology, psychosocial predictors and cognitive style of bipolar depression. The current status of pharmacotherapy and psychological treatment of bipolar depression is also described. In particular, the manner in which cognitive behaviour therapy for bipolar depression has been adapted from CBT for unipolar depression is critically evaluated. It is concluded that there appears to be a considerable overlap between the features of unipolar and bipolar depression, yet there is also emerging evidence for specific elements. The ability of current psychological theories of bipolar disorder to account for the findings are compared, and as a consequence, a new preliminary integrative model is proposed to direct future hypothesis-led research, which will need to incorporate more suitable populations and utilise more objective methods of assessment.

The psychosocial context of bipolar disorder: environmental, cognitive, and developmental risk factors

In this article, we review empirical research on the role of individuals' current environmental contexts, cognitive styles, and developmental histories as risk factors for the onset, course, and expression of bipolar spectrum disorders. Our review is focused on the following over arching question: Do psychosocial factors truly contribute risk to the onset, course, or expression of bipolar disorders? As a secondary issue, we also address whether the psychosocial risks for bipolar disorders are similar to those for unipolar depression. We begin by discussing the methodological requirements for demonstrating a psychosocial risk factor and the challenges posed by bipolar spectrum disorders for psychosocial risk research. Next, we review the extant studies on the role of recent life events and supportive and non-supportive social interactions (current environment) in bipolar disorders, as well as psychosocial treatments designed to remediate these current environmental factors. We then review the role of cognitive styles featured as vulnerabilities in theories of unipolar depression as risk factors for bipolar disorder alone and in combination with life events, including studies of cognitive-behavioral therapies for bipolar disorder. Finally, we review studies of parenting and maltreatment histories in bipolar disorders. We conclude with an assessment of the state of the psychosocial risk factors literature in bipolar disorder with regard to our guiding questions.

Life events in bipolar disorder: towards more specific models

This article reviews the evidence concerning life events as a predictor of symptoms within bipolar disorder. First, key methodological issues in this area are described, and criteria used for including studies in this review are defined. Then findings that negative life events predict worse outcomes within bipolar disorder are reviewed. Beyond general studies on relapse, it is important to differentiate predictors of depression from predictors of mania. When severe negative life events occur, they appear to trigger increases in bipolar depression. Nonetheless, many depressions are unrelated to negative life events and appear to be triggered by other variables. The strongest evidence suggests that negative life events do not trigger mania, except perhaps in certain contexts. Retrospective findings for schedule-disrupting life events as a trigger for manic symptoms await further assessment within a longitudinal study. Life events involving goal attainment do appear to trigger manic symptoms. Overall, it is time to differentiate among specific types of life events, as these different forms of events point towards mechanisms linking stressors with symptom expression. These mechanisms provide clues into ways to integrate the social environment with biological vulnerability (see [Monroe, S.M., & Johnson, S.L. (1990)). the dimensions of life stress and the specificity of disorder. Journal of Applied Social Psychology, 20, 167-1694; Harris, T.O. (1991). Life stress and illness: the question of specificity. Annals of Behavioral Medicine, 13, 211-219]).

Distinctions between bipolar and unipolar depression

This is a review of the studies comparing unipolar and bipolar depression, with focus on the course, symptomatology, neurobiology, and psychosocial literatures. These are reviewed with one question in mind: does the evidence support diagnosing bipolar and unipolar depressions as the same disorder or different? The current nomenclature of bipolar and unipolar disorders has resulted in research that compares these disorders as a whole, without considering depression separately from mania within bipolar disorder. Future research should investigate two broad categories of depression and mania as separate disease processes that are highly comorbid.

Major stressful life events and other risk factors for first admission with mania

OBJECTIVES

To investigate whether first admission with mania is associated with the occurrence of death in the family or with major stressful life events and to explore whether the associations change with age.

METHODS

Case register study with linkage of the Danish Psychiatric Central Research Register, including data on all admissions at psychiatric wards in Denmark from 1981 to 1998, and the Civil Registration System, including data on death and on socio-demographic variables. All patients who got a diagnosis of mania/mixed episode at the first ever admission at a psychiatric ward and a random gender- and age-matched control group of subjects who had never been admitted to psychiatric ward were identified.

RESULTS

A total of 1565 patients and 31,300 control subjects were identified. Suicide of a mother or of a sibling was associated with a highly increased risk of being admitted for the first time ever at a psychiatric ward with a diagnosis of mania/mixed episode. Death of a relative by other causes than suicide was not associated with increased risk of getting hospitalized with mania. Recent unemployment, recent divorce, but also a recent marriage showed moderate effects. No interaction was found on the association between life events and the first admission with mania, totally, or for men or women, separately regarding ageing.

CONCLUSIONS

The occurrence of death in the family and the experience of major life events are associated with increased risk of first admission with bipolar disorder. The susceptibility to major life stressors of inducing mania does not seem to change throughout life.

Negative Cognitions Predict the Course of Bipolar Depression, Not Mania

Cognitive interventions for bipolar disorder have received increased attention, but very few prospective studies have focused on whether cognitive variables predict the course of bipolar disorder. Available studies have yielded conflicting results concerning the effects of negative cognitions on mania. In this study, 60 individuals with bipolar I disorder completed monthly symptom severity interviews. At a 6-month follow-up, they completed the Dysfunctional Attitudes Scale, the Negative Automatic Thoughts Questionnaire, and the Positive Automatic Thoughts Questionnaire. Participants then completed monthly symptom severity interviews for another 6 months. Cognitive scales were correlated with current depression and predicted increases in depression over time, but were not related to mania. Although results do not support negative cognitions as a predictor of mania, they do provide support for the increasingly common use of cognitive interventions to treat bipolar depression.

Targeted psychosocial interventions for bipolar disorder

Pharmacotherapy is the foundation of treatment for bipolar disorder, but research suggests that adjunctive psychosocial interventions that are manualized, reproducible, time-limited, empirically supported, and strategically target a number of critical domains, can efficiently provide additional benefits. Psychoeducation as an adjunct of pharmacotherapy may be beneficial, but questions remain about the utility of this treatment for patients who are already compliant with medication treatment. Family educational interventions have demonstrated encouraging results in relapse prevention, but follow-up data are limited and application to patients who have limited social networks may be problematic. Reports on interpersonal and social rhythm therapy in patients with bipolar disorder are scarce, and what is available shows no differential effect on time to remission or relapse, but a significant impact on subsyndromal symptoms. Follow-up data suggest that patients receiving cognitive behavior therapy have significantly fewer bipolar episodes, shorter episodes, fewer hospitalizations, and less subsyndromal mood symptoms. It is unclear, however, if cognitive behavior therapy is superior to other active psychosocial treatments and whether its mechanism in patients with bipolar disorder is through changing dysfunctional cognitions or simply enhancing early symptom detection. Psychotherapies should be considered early in the course of illness to improve medication compliance and to help patients identify prodromes of relapse in order to take steps for prevention. In addition, some strategies may have a beneficial effect on residual symptoms, particularly symptoms of depression, and thus help move patients toward a more comprehensive functional recovery.

Life events and affective disorders

OBJECTIVE

To summarize research in life events and affective disorders

METHOD

Review of the literature.

RESULTS AND CONCLUSION

Many studies have shown that episodes of unipolar depression are preceded by life events at higher rates than in control samples. A variety of stressful events are involved with only limited specificity but some relationship to social exit events. Life events also affect remission and relapse of depression. Effects of life events are less when the disorder has already been recurrent, particularly where illness is severe. Effects of life events are also weaker in bipolar disorder than unipolar, but major life events may be important in first onset. Recent evidence suggests a specific role of social rhythm disruption events in manic relapses. Causative chains are multifactorial and complex, and genetic factors can influence life event exposure.

Life events in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls

OBJECTIVE

To examine life events in subjects with a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) compared to those in subjects with attention-deficit hyperactivity disorder (ADHD) and normal controls (NC).

METHODS

To optimize generalizeability, subjects with PEA-BP (n = 93) and ADHD (n = 81) were consecutively ascertained from pediatric and psychiatric sites. Subjects in the NC group (n = 94) were obtained from a random survey. PEA-BP was defined by Diagnostic and Statistical Manual of Mental Disorders (fourth edition) mania with at least one of the cardinal symptoms of mania (i.e., elation and/or grandiosity) to avoid diagnosing mania only by criteria that overlapped with those for ADHD. All subjects received comprehensive, blind research assessments of mothers about their children and separately of children about themselves. Assessment instruments included the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) and the Life Events Checklist. Data from the Life Events Checklist were examined by total life events and by subcategories of dependent, independent, or uncertain relationships to the child.

RESULTS

Total, independent, dependent, and uncertain life events were all significantly more frequent in the PEA-BP subjects compared to both the ADHD and NC groups.

CONCLUSIONS

Because there was no a priori reason to expect significantly more independent life events in the PEA-BP compared to the ADHD and NC groups, these results warrant further research into the role of life events in the onset of PEA-BP.

Stress, social rhythms, and behavioral activation: psychosocial factors and the bipolar illness course

Current, more sophisticated models of bipolar disorder emphasize the interaction of psychosocial factors with biology as determinants of the long-term illness course. Recent research has documented the effects of psychosocial stress on the onset of new episodes, exacerbation of symptoms, and response to pharmacologic treatment in bipolar individuals. In this article, relevant theories and empiric findings regarding these relationships will be reviewed. In particular, two specific pathways relating psychosocial stressors to the onset of mania (eg, social rhythm disruption and behavioral activation) will be explicated.

Life events and onset of a new phase in bipolar affective disorder

BACKGROUND

There is an increasing focus on the impact of psychosocial factors and stressors on the course of bipolar affective disorder. The life event research has revealed many biases and the results are conflicting. In a prospective study we examined the relationship between life events and affective phases in a group of bipolar patients with a long duration of the disease.

METHODS

A group of patients with at least three admissions to hospital for bipolar disorder was followed every 3 months for up to 3 years. At each examination an evaluation of affective phase was made according to the Hamilton Depression Scale, the Newcastle Depression Rating Scale and the Bech-Rafaelsen Mania Rating Scale. Moreover, the patients were rated according to the Paykel Life Events Scale. Their current medical treatment was noted.

RESULTS

Fifty-six patients (19 men and 37 women) were included in the study. Women experienced a significantly higher number of life events than men. In 21% of the 353 examinations of women, a new phase was preceded by life events whereas this was the case only in 8% of the 152 examinations of men. In 13% of the male examinations the patients were in a manic phase and in 5% in a depressive phase. In 5% of the female examinations the patients were in a manic phase and in 15% in a depressive phase. Half of the women's depressive phases were preceded by life events, but none of the depressive phases of men. The categories of life events preceding the depressive phases presented a significant overweight of somatic ill health and conflicts in the family.

CONCLUSION

We found a gender difference in the course of bipolar affective disorder, as women had a significantly higher number of depressive episodes than men and men had a higher number of manic episodes than women. In bipolar patients with long duration of disease a significant number of depressive episodes in women were preceded by negative life events. Somatic health problems and conflicts in the family were significant factors preceding new depressive phases.

Lithium in bipolar disorder: can drug concentrations predict therapeutic effect?

The evidence is reviewed for effective serum lithium concentrations for the acute and prophylactic treatment of mania and depression in patients with bipolar disorder. The efficacy of lithium in the treatment of acute manic episodes has been recognised for several decades, primarily using concentrations in the range of 0.8 to 2 mmol/L. The number of patients responding increases as the serum lithium concentration increases, although individual patients may respond at lower concentrations (<0.8 mmol/L). Lithium doses and serum concentrations similar to those used to treat acute mania have been studied in bipolar depression, with no evaluation of a relationship between concentration and clinical response. Several prospective controlled trials have evaluated this relationship in the prophylactic treatment of bipolar disorder. Maintaining higher serum lithium concentrations (0.8 to 1 mmol/L) improves the likelihood of good effect in prophylactic treatment, although individual patients may do well on lower concentrations. Despite the paucity of evidence to specifically support the efficacy of lithium at lower serum lithium concentrations in the elderly, lower target ranges (0.5 to 0.8 mmol/L) are commonly recommended due to an increased sensitivity to adverse effects, particularly neurotoxicity. The serum lithium concentrations recommended in adults have been applied to children; however, this has not been studied. Overall, the evidence suggests a relationship between serum lithium concentration and therapeutic effect, although the exact nature of this relationship is not clear. For example, it is not known why some people respond to lower concentrations and others do not. There are many factors that influence studies trying to elucidate this relationship. Many of these factors are related to the interpretation of the serum lithium concentration. In summary, patients have an increased chance of responding to lithium if 12-hour serum lithium concentrations at steady state are above 0.8 mmol/L. Many patients will respond to lower concentrations (0.4 to 0.7 mmol/L), but we are unable to identify these patients a priori. The relationship between serum lithium concentrations and adverse effects is also very important in determining appropriate target lithium concentrations. The current best advice is to individualise the target serum lithium concentrations based on efficacy and tolerability and to optimise the interpretation of these concentrations by ensuring within-patient consistency with respect to dosage schedule, lithium preparation and the timing of blood sampling.

Which depressions are related to life stress?

This paper examines the relationship of recent life events to specific kinds of depression using published studies and the author's own work. An overall effect of life events on depression has been found consistently and is moderate in degree. In suicide attempts there are stronger and more immediate effects than in depression. Life events precede both non-melancholic and melancholic depressions. It is only in recurrent depressions that life events are less common with melancholic pictures. Life events influence bipolar disorder as well as unipolar. Mania may be preceded by life events, particularly those involving social rhythm disruption, but it is harder to rule out events which are consequences of insidious development of illness. There are strong effects of life events and social support in postpartum depressions but in postpartum psychoses these effects are absent. Events precede depression comorbid with other disorders as well as pure depression. The course of depression is also influenced by life stress with less remission where negative events occur after onset and better outcome where earlier adverse events are neutralized. Relapse is related to immediately preceding life events. However, where depressions are both severe and recurrent life stress effects weaken and as the number of episodes increases preceding life events lessen. These findings suggest that some kinds of depression are more related to psychosocial causation and some are more biological in origin.

Increases in manic symptoms after life events involving goal attainment

Bipolar disorder has been conceptualized as an outcome of dysregulation in the behavioral activation system (BAS), a brain system that regulates goal-directed activity. On the basis of the BAS model, the authors hypothesized that life events involving goal attainment would promote manic symptoms in bipolar individuals. The authors followed 43 bipolar I individuals monthly with standardized symptom severity assessments (the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Rating Scale). Life events were assessed using the Goal Attainment and Positivity scales of the Life Events and Difficulties Schedule. As hypothesized, manic symptoms increased in the 2 months following goal-attainment events, but depressed symptoms were not changed following goal-attainment events. These results are congruent with a series of recent polarity-specific findings.

Increases in manic symptoms after life events involving goal attainment

Bipolar disorder has been conceptualized as an outcome of dysregulation in the behavioral activation system (BAS), a brain system that regulates goal-directed activity. On the basis of the BAS model, the authors hypothesized that life events involving goal attainment would promote manic symptoms in bipolar individuals. The authors followed 43 bipolar I individuals monthly with standardized symptom severity assessments (the Modified Hamilton Rating Scale for Depression and the Bech-Rafaelsen Mania Rating Scale). Life events were assessed using the Goal Attainment and Positivity scales of the Life Events and Difficulties Schedule. As hypothesized, manic symptoms increased in the 2 months following goal-attainment events, but depressed symptoms were not changed following goal-attainment events. These results are congruent with a series of recent polarity-specific findings.

Age of onset in affective disorder: its correlation with hereditary and psychosocial factors

BACKGROUND

Affective disorders probably have a multifactorial aetiology, both biological and psychosocial factors may be of importance at onset as well as at relapses. The aim of the study was to investigate how the age of onset of bipolar and unipolar disorder relates to family history of affective disorder, early parental separation and life events. A second purpose of this study was to analyze the importance of life events preceding the first and subsequent episodes of affective disorder.

METHODS

The case records of 282 patients (161 females/121 males; mean age 56) were investigated. They all had a DSM-IV based diagnosis of either bipolar I/II (67%) or unipolar (33%) disorder. Variables, such as family history, early parental loss and life events according to Paykel life events scale, were examined.

RESULTS

We found a significantly lower age of onset in bipolar patients with a family history of affective disorder (28.9 vs. 33.9 years). Bipolar patients with preceding life events had a higher age of onset (33.1 vs. 28.3 years). Moreover, bipolar patients with heredity, had less life events at onset. For the bipolar, as well as the unipolar group, life stressors more frequently preceded the first episode of affective disorder than the subsequent episodes.

LIMITATIONS

The major limitation of this study is the retrospective approach, with e.g. difficulties to decide whether a life event plays a role in aetiology of affective disorder or is its consequence.

CONCLUSIONS

Bipolar patients with high constitutional vulnerability have an earlier age of onset and need less stress factors to become ill. Better knowledge about the stress- and the vulnerability-factors in affective disorder might contribute to development of individually tailored therapeutic strategies in future.

Mood and anxiety syndromes in emergency psychiatry

Mood and anxiety disorders are common in the general population and in the emergency setting. As psychiatric emergency care moves from the realm of triage and referral to a more definitive initiation of treatment, clinicians must approach the assessment and initial management of patients with mood and anxiety disorder in a rational and safe way. In the ED, the next step in assessing patients with mood or anxiety symptoms, after any immediate safety concerns are addressed, is to rule out medical or substance-induced causes. Treatment of these patients is directed at the underlying condition. When a primary psychiatric diagnosis is made, initial management, including definitive pharmacologic or psychotherapeutic intervention, can be started in the ED.