Psychosocial predictors of major affective recurrences in bipolar disorder: a 4-year longitudinal study of patients on prophylactic treatment

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.

Examination of Gender Differences in the Influence of Social Support on Psychological Distress in Canadian Adults with Bipolar Disorder

The objectives of this study were to determine whether gender differences exist in how social support, and different types of support, impact psychological distress among Canadian adults with bipolar I and bipolar II disorder (BD), to examine whether females and males with BD differ in their perceived levels of support and distress compared to females and males without BD, and to investigate whether females and males with BD perceive different levels of support and distress. Using a cross-sectional, national datafile, 281 females and 282 males (20-64 years) who reported being diagnosed with BD were investigated using the Social Provisions Scale (SPS) and the Kessler Psychological Distress Scale (K10). It was found that females and males with BD had significantly lower SPS scores and significantly higher K10 scores than females and males without BD, females with BD perceive significantly higher overall support, as well as higher attachment and guidance compared to males with BD, and support in the form of social integration and was associated with decreased psychological distress for both males and females with BD. Furthermore, reassurance of worth was an additional predictor of decreased distress for males, while guidance was an additional predictor of decreased distress for females. Despite the limitations, which include self-reported diagnosis of BD and potential exclusion of those who are not diagnosed but have BD, these findings suggest that different types of social support may serve as protective factors for psychological distress among females and males with BD.

Socio-demographic and clinical predictors of outcome to long-term treatment with lithium in bipolar disorders: a systematic review of the contemporary literature and recommendations from the ISBD/IGSLI Task Force on treatment with lithium

Objective

To identify possible socio-demographic and clinical factors associated with Good Outcome (GO) as compared with Poor Outcome (PO) in adult patients diagnosed with Bipolar Disorder (BD) who received long-term treatment with lithium.

Methods

A comprehensive search of major electronic databases was performed to identify relevant studies that included adults patients (18 years or older) with a diagnosis of BD and reported sociodemographic and/or clinical variables associated with treatment response and/or with illness outcome during long-term treatment to lithium (> = 6 months). The quality of the studies was scored using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Institute of Health.

Results

Following review, 34 publications (from 31 independent datasets) were eligible for inclusion in this review. Most of them (n = 25) used a retrospective design. Only 11 studies were graded as good or borderline good quality. Forty-three potential predictors of outcome to lithium were identified. Four factors were associated with PO to lithium: alcohol use disorder; personality disorders; higher lifetime number of hospital admissions and rapid cycling pattern. Two factors were associated with GO in patients treated with lithium: good social support and episodic evolution of BD. However, when the synthesis of findings was limited to the highest (good or borderline good) quality studies (11 studies), only higher lifetime number of hospitalization admissions remained associated with PO to lithium and no associations remained for GO to lithium.

Conclusion

Despite decades of research on lithium and its clinical use, besides lifetime number of hospital admissions, no factor being consistently associated with GO or PO to lithium was identified. Hence, there remains a substantial gap in our understanding of predictors of outcome of lithium treatment indicating there is a need of high quality research on large representative samples.

Examining the Influence of Social Support on Psychological Distress in a Canadian Population with Symptoms of Mania

Individuals who experience symptoms of mania in the form of a manic episode (ME) are at a greater risk of experiencing psychological distress. Given that a ME is a period during which one can become extremely socially dysfunctional, the potential influence of social support is especially important to explore. The primary objective of this study was to examine whether perceived social support predicts psychological distress in a sample of Canadian adults who have self-reported ME symptoms within the last 12-months. Using a cross-sectional, national datafile, 220 Canadians between 20 and 64 years who met the criteria for a ME within the last 12-months were investigated using the Social Provisions Scale (SPS), and the Kessler Psychological Distress Scale (K10). Results indicated that the ME sample experienced significantly higher distress and significantly lower perceived social support than the adult Canadian population. Further, social support in the form of reassurance of worth was associated with lower levels of psychological distress, but only for the male ME sample, and the overall (male and female combined) ME sample. Despite some limitations, this study adds to the research on mania as its own experience outside of comorbidities and indicates the important and specific role social support plays in terms of psychological well-being.

The influence of social support on psychological distress in Canadian adults with bipolar disorder

INTRODUCTION

Individuals with bipolar I disorder (BD-I) and bipolar II disorder (BD-II) are at higher risk for experiencing high levels of psychological distress and low levels of social support.

OBJECTIVES

The primary objectives of this study were to examine perceived social support and psychological distress among Canadian adults with self-reported BD-I or BD-II as diagnosed by a health professional and explore the relationship between types of social support and psychological distress within this sample.

METHODS

Using a cross-sectional, national datafile, 563 Canadian male and female adults (20-64 years) who reported being diagnosed with BD-I or BD-II were investigated using the Social Provisions Scale (SPS), and the Kessler Psychological Distress Scale (K10).

RESULTS

It was observed that while the BD-I or BD-II sample had significantly lower SPS scores and significantly higher K10 scores than the overall Canadian sample, age and support in the form of reassurance of worth and social integration were associated with decreased psychological distress. Further, a diagnosis of BD-I and BD-II was found to moderate the effect of social support on psychological distress.

CONCLUSIONS

Despite the limitations, which include self-reported diagnosis of BD-I and BD-II and potential exclusion of those who are not diagnosed but have BD-I or BD-II, these findings suggest that reassurance of worth and social integration may act as protective factors for psychological distress among individuals with BD-I or BD-II.

Comparison of Efficiency GEE and QIF Methods for Predicting Factors Affecting on Bipolar I Disorder Under Complete-case in a Longitudinal Studies

BACKGROUND

Mood variation in manic and depression phases during time is common in type I of Bipolar disorder. Analyzing recurrence require to the related statistical methods. In this paper, we compare the two methods of estimating the GEE and the QIF in recurrence data.

METHODS

In this study, data of 255 patients with Bipolar I disorder hospitalized during years of 2007-2011. Recurrence in Bipolar I disorder was as outcome. Patients' characteristics were gender, age of onset, recurrence history in first degree family, and economic status. Under simulation, percentage of missing were generated to vary and handled by complete-case(cc) strategy. Data were analyzed using GEE and QIF methods. Performance of the methods was assessed using Relative Efficiency.

RESULTS

QIF method had more efficiency than GEE method in the data with missing /without missing. Odds of recurrence in a first-degree family history was 30% more than those without a family history (p=0.009). Also, odds of recurrence in high/moderate level of economic status was 23% more than low level status (p=0.014).

CONCLUSION

QIF method was more appropriated for modeling recurrence during time with the structure of more correlation and low dropout rate in data. Family history and economic status were more affected recurrence in type I of Bipolar disorder.

Research Recommendations for Improving Measurement of Treatment Effectiveness in Depression

Background: Despite the steadily escalating psychological and economic burden of depression, there is a lack of evidence for the effectiveness of available interventions on functioning areas beyond symptomatology. Therefore, the main objective of this study was to give an insight into the current measurement of treatment effectiveness in depression and to provide recommendations for its improvement.

Materials and Methods: The study was based on a multi-informant approach, comparing data from a systematic literature review, an expert survey with representatives from clinical practice (130), and qualitative interviews with patients (11) experiencing depression.

Results: Current literature places emphasis on symptomatic outcomes and neglects other domains of functioning, whereas clinicians and depressed patients highlight the importance of both. Interpersonal relationships, recreation and daily activities, communication, social participation, work difficulties were identified as being crucial for recovery. Personal factors, neglected by the literature, such as self-efficacy were introduced by experts and patients. Furthermore, clinicians and patients identified a number of differences regarding the areas improved by psychotherapeutic or pharmacological interventions that were not addressed by the pertinent literature.

Conclusion: Creation of a new cross-nationally applicable measure of psychosocial functioning, broader remission criteria, report of domain-specific information, and a personalized approach in treatment decision-making are the first crucial steps needed for the improvement of the measurement of treatment effectiveness in depression. A better measurement will facilitate the clinical decision making and answer the escalating burden of depression.

The Influence of Trauma, Life Events, and Social Relationships on Bipolar Depression

A growing body of research suggests that the social environment exerts a powerful influence on the course of bipolar depression. This article reviews longitudinal research to suggest that trauma, negative life events, social support deficits, and family difficulties are common and predict a more severe course of depression when present among those diagnosed with bipolar disorder. The triggers of bipolar depression overlap with those documented for unipolar depression, suggesting that many of the treatment targets for unipolar depression may be applicable for bipolar depression.

How much do we know about the functional effectiveness of interventions for depression? A systematic review

BACKGROUND

Functional difficulties are determined as one of the reasons for the public health priority given to depression. However, previous literature shows that the evidence on treatment effectiveness in depression does not reflect all relevant functional areas affected. This paper aimed to review recent literature and identify which areas are addressed and what are the gaps in the measurement of treatment effectiveness in depression.

METHODS

Electronic search was performed in PsycINFO, PubMed, Web of science, and the Cochrane Central Register of Controlled Trials. A content item analysis of outcome measures was performed.

RESULTS

Two hundred and fourty-seven studies were included. The functional areas addressed in the measurement process did not vary across studies assessing psychotherapeutic, pharmacological or alternative interventions. The content analysis revealed that 80% of the areas covered by instruments represented symptomatology. Many functional areas were insufficiently covered, whereas others like handling stress, solving problems, maintaining daily routine, problems in education, or participation in community, political or religious life were not addressed at all.

LIMITATIONS

Only articles in English were included and the time frame was limited.

CONCLUSIONS

More than 10 years after the first global burden of disease studies have been published evidence on the treatment effectiveness in depression is still based primarily on symptoms. Many important functional areas remain unexplored. Consequently the effectiveness of well recognized interventions might be overestimated. Future steps should include use of comprehensive tools, provision of detailed information on functional areas instead of global scores of instruments, and design of functional impairment oriented therapies.

The role of social relationships in bipolar disorder: a review

Social relationships and attachment are core developmental elements of human existence and survival that evolve over the lifetime of an individual. The internal and external factors that influence them include the presence of illness in the individual or in their immediate environment. The developmental aspects of attachment and social relationships have become increasingly of interest and relevance in light of early developmental epigenetic modification of gene expression patterns that may influence subsequent behavioral patterns and outcomes. This review examines extant literature on attachment and social relationships in bipolar cohorts. Despite many methodological challenges, the findings indicate that social relationships and capacity for attachment are significantly compromised in individuals with bipolar disorder compared to other mood disorders and normal controls. Though extant research is limited, research clearly points toward the importance of social relationships on the etiology, course, and consequences of bipolar disorder. We highlight a number of key considerations for future research.

Concordance between patient and family reports of family functioning in bipolar I disorder and major depressive disorder

Despite the extensive literature on family functioning and mood disorders, less is known about concordance between patient- and family-reported family functioning. To address this question, adults with bipolar I disorder (BD; n = 92) or major depressive disorder (MDD; n = 121) and their family members (n = 135 and 201, respectively) were recruited from hospital sources. All patients and their family members completed the Family Assessment Device (Epstein, Baldwin, Bishop. J Marital Fam Ther. 9:171-180, 1983). Intraclass correlation coefficients revealed that, in contrast to the moderate degree of concordance in the MDD sample, degree of concordance between patient- and family-reported family functioning was significantly weaker in BD. Subsequent analysis revealed that this discordance was driven by the reports of the child and young adolescent family members of the patients with BD. Results highlight the importance of collateral reports in the assessment of family functioning, especially among families of patients with BD, in research and treatment.

Poor adherence to treatment associated with a high recurrence in a bipolar disorder outpatient sample

BACKGROUND

We analyzed the association of previous course-of-illness and other variables of clinical interest with a high frequency of both depressive or (hypo)manic episodes controlling for the effect of socio-demographic characteristics.

METHODS

A total of 108 outpatients with a DSM-IV diagnosis of bipolar disorder (BD) were recruited. A retrospective and naturalistic study was conducted to examine the number of affective episodes and their relationship with socio-demographic, clinical and course-of-illness variables, including adherence to medication, type of medication used and the use of addictive substances. The episode frequency was estimated as the number of "major instances" of depression, hypomania and mania during the illness. To classify the patients into two groups (higher and lower-episode frequency), we used the statistical criterion of median split. Results were analyzed with logistic regression models to control for the effects of potential confounders.

RESULTS

A high episode frequency (nine or more episodes) was associated with age (36-55years), delay in diagnosis, poor adherence to medication and current use of antipsychotic medication. In addition, a high frequency of manic episodes (four or more) was associated with female sex, age (>36years) and a manic onset of the illness, whereas a high frequency of depressive episodes (five or more) was associated with delay in diagnosis and poor adherence to medication.

LIMITATIONS

Cross-sectional study design.

CONCLUSIONS

Avoiding delay in diagnosis and enhancing treatment adherence might be important targets for reducing recurrences in BD.

Improvement of social adaptation in depression with serotonin and norepinephrine reuptake inhibitors

Depression is a disabling condition resulting in significant impairment in social functioning, involving the patient's family, friends, work colleagues, and society at large. Although both psychologic and pharmacologic treatments generally improve many depressive symptoms, they do not always result in significant improvement in social functioning. The importance of recovery of social functioning in depressed patients is now widely appreciated, and studies are beginning to include it in evaluations of therapeutic efficacy. Among the various social adjustment evaluation rating scales, the Social Adaptation Self-Evaluation Scale, a social motivation and behavior scale, has been found to be simple to use and sensitive to change. Using this scale, the selective norepinephrine reuptake inhibitor, reboxetine, has been shown to be significantly more effective in improving social functioning than the selective serotonin reuptake inhibitor, fluoxetine. These findings are consistent with the notion that improvement in social adaptation involves functions depending primarily on noradrenergic neurotransmission. This hypothesis suggests that the serotonin and norepinephrine reuptake inhibitors, venlafaxine, duloxetine, and milnacipran, could be particularly helpful in improving social functioning. Preliminary studies with the serotonin and norepinephrine reuptake inhibitors suggest that they significantly improve social functioning. Comparative studies with selective serotonin reuptake inhibitors on the effects on social functioning should be encouraged.

Bipolar affective disorder in the postnatal period: investigating the role of sleep

OBJECTIVES

Psychotic disorders have a high rate of relapse in the postpartum period for reasons that are unclear, but may be related to changes in sleep patterns that occur during pregnancy and after birth. Understanding of the influence of sleep on postpartum psychosis presentation is limited. The aim of the current study was to investigate changes in sleep/wake activity during pregnancy and the postpartum period in women with a history of psychosis.

METHODS

Women with a history of bipolar disorder and/or postpartum psychosis (HxW) were recruited (n = 23) together with a control population (CtW) (n = 15). Data on demographic and psychosocial factors, mental health status, and sleep/wake activity were collected at seven timepoints-the last week of each trimester of pregnancy and four times during the postpartum (weeks 1, 4, and 8, and at month 6). Longitudinal data were analysed using an HLM version 6 repeated-measures multilevel model.

RESULTS

No significant differences were noted in sleep/wake activity between HxW and CtW. None of the HxW who were taking a mood stabilizer during their pregnancy, including at delivery, relapsed during the study. Of those taking an antidepressant or antipsychotic, or no medication, 3 relapsed within the first six months and 2 within the first two months. HxW were more likely to report a poor partner relationship than CtW.

CONCLUSION

Results suggest that during the perinatal period, there is no difference in sleep/wake activity in women with a history of a psychotic disorder. Use of mood stabilizer during pregnancy and at delivery appears important in preventing psychotic relapse in the postpartum.

Functional impairment as a predictor of short-term symptom course in bipolar I disorder

OBJECTIVES

Most prior research has focused on functional impairment as a consequence, rather than a predictor, of mood symptoms in bipolar disorder (BD). Yet the majority of this research has been cross-sectional, thus limiting conclusions regarding directionality of effects. Indeed, just as functional impairment may represent an important outcome of BD, it may also serve as a risk factor for future affective symptoms or episodes. Thus, the primary aim of this study was to evaluate functional impairment as a predictor of mood symptoms in BD.

METHODS

Ninety-two patients with bipolar I disorder, recruited from hospital settings, were administered the Modified Hamilton Rating Scale for Depression, Bech-Rafaelson Mania Scale, and UCLA Social Attainment Survey (SAS) at baseline and at four-month follow-up.

RESULTS

Overall, patients evidenced a moderate level of functional impairment at both time points. Whereas baseline functional impairment was not associated with subsequent manic symptoms, baseline functional impairment was significantly predictive of depressive symptom levels at four-month follow-up. When individual SAS subscales were evaluated, impaired romantic relationship functioning and activity involvement were each significantly predictive of subsequent depressive symptoms, whereas baseline peer functioning was not.

CONCLUSIONS

The study results suggest that functional impairment may be predictive of subsequent depressive, but not manic, symptoms over a relatively short-term follow-up period. Future studies that evaluate illness course over longer follow-up periods would be useful to further clarify the potential bidirectional relationship between depression and functional impairment in BD.

Parental communication style and family relationships in children of bipolar parents

OBJECTIVES

To examine relationships between parental communication styles and family environment in parents with bipolar disorder (BD) and their children (CBP).

METHODS

On measures of parental communication styles and family environment, 20 BD parents and their 23 children (CBP) were compared to controls. Children completed a current mood measure.

RESULTS

BD parents endorsed more negative communication styles and were less expressive than controls. CBP presented with more current or lifetime mood disorder diagnoses than control children (CC). Current depressive mood was associated with different perceptions of family environment for both CBP and CC.

CONCLUSIONS

This familial high risk design indicated differences in family environment, parenting style, and in children of bipolar parents' perception of their family environment as it relates to their current mood.

Social adjustment based on reported behaviour in bipolar affective disorder

OBJECTIVES

To determine the effects of mood and additional clinical variables on different domains of current interviewer-rated social adjustment reflecting the reported behaviour of patients with bipolar disorder (BD).

METHOD

Multi-center cross-sectional study employing multiple linear regression to investigate whether mood and other clinical features, previously linked to self-rated social adjustment, were associated with eight domains of interviewer-rated social adjustment in 253 BD patients. Baseline variables were entered sequentially in blocks representing current mood, demographic, current other psychiatric, past psychiatric and current treatment variables.

RESULTS

Mood episode or symptoms together with five other variables (borderline/antisocial personality disorder, male gender, living alone, hypnotic drug and drugs for physical illness) were associated with impairment on two or more domains of interviewer-rated social adjustment. They explained up to 31% of the variance in social adjustment, although friction, dependence and overactivity were associated with a different pattern of variables. Hypomanic symptoms were associated with increased friction and worse social adjustment with the extended family in the whole sample but improved performance and social and leisure activities in patients who were not in acute bipolar episode.

CONCLUSION

Clinicians may determine up to about 30% of outcome in current social adjustment in BD patients from the patient's current mood episode or symptoms and a small number of other clinical or demographic variables. Hypomanic episodes and symptoms usually worsen friction and overall social adjustment, but in patients who are not in acute episode, hypomanic symptoms can increase performance and social and leisure activities.

Disability and its treatment in bipolar disorder patients

Bipolar disorders (BPD) are major, life-long psychiatric illnesses found in 2-5% of the population. Prognosis for BPD was once considered relatively favorable, but contemporary findings suggest that disability and poor outcomes are prevalent, despite major therapeutic advances. Syndromal recovery from acute episodes of mania or bipolar major depression is achieved in as many as 90% of patients given modern treatments, but full symptomatic recovery is achieved slowly, and residual symptoms of fluctuating severity and functional impact are the rule. Depressive-dysthymic-dysphoric morbidity continues in more than 30% of weeks in follow-up from initial episodes as well as later in the illness-course. As few as 1/3 of BPD patients achieve full social and occupational functional recovery to their own premorbid levels. Pharmacotherapy, though the accepted first-line treatment for BPD patients, is insufficient by itself, encouraging development of adjunctive psychological treatments and rehabilitative efforts to further limit morbidity and disability. Interpersonal, cognitive-behavioral, and psychoeducational therapies all show promise for improving symptomatic and functional outcomes. Much less is known about how these and more specific rehabilitative interventions might improve vocational functioning in BPD patients.

Role of treatment alliance in the clinical management of bipolar disorder: stronger alliances prospectively predict fewer manic symptoms

The strength of the treatment alliance between patients and their clinicians may play a unique role in the management of bipolar disorder. However, few empirical studies have examined the alliance in bipolar disorder or its effects on patient outcomes. This study investigates variables associated with a strong treatment alliance in bipolar disorder, and the prospective effects of treatment alliance on patients' mood symptoms and treatment attitudes. Participants were 58 longitudinally followed individuals with Bipolar I disorder. We found that alliance ratings covaried with depressive symptoms, such that alliance strength increased as depressive symptoms decreased, and stronger alliances were associated with more social support. Tests of temporal association indicated that stronger alliances predicted fewer manic symptoms 6 months later. Stronger alliances also predicted less negative attitudes about medication and less of a sense of stigma about bipolar disorder. Thus, a strong treatment alliance may help to reduce manic symptoms over time. It may be that a strong treatment alliance encourages patients' greater acceptance of bipolar disorder and psychopharmacological interventions, and thus contributes to improved medication adherence and clinical outcomes. Considered in sum, these findings suggest that the treatment alliance is an integral component of the long-term management of bipolar disorder.

Predictors of relapse in bipolar disorder: A review

INTRODUCTION

Bipolar disorder is the sixth leading cause of disability in the United States. Moreover, repeated episodes and non-responsiveness to treatment continue to present a significant problem, and little is known about the factors that may precipitate relapse. This article reviews the available literature on predictors of bipolar relapse.

METHODS

We conducted a literature search on Medline from 1996 to March 2006, using the keywords "relapse," "recurrence," "compliance," "adherence," "life events," "kindling," and "predictors" combined with the term "bipolar disorder(s)." References from the resulting articles also supplemented the initial search. Thirty-eight articles were included in the analysis.

RESULTS

Predictors of episodes include stressful life events, increased number of previous episodes, decreased interval between episodes, and persistence of affective symptoms and episodes. Factors associated with longer survival times include psychotherapy, social support, and medication adherence.

CONCLUSIONS

Our review suggests several reliable predictors of bipolar episodes. Knowledge of these factors has significant clinical implications and could aid in treatment and prevention strategies. However, further research is clearly needed to address the limitations of the existing research and to increase our understanding of predictors of relapse, with the intent of improving quality of life and preventing episodes in patients with bipolar disorder.

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.

Bipolar disorder in women: reproductive events and treatment considerations

OBJECTIVE

Bipolar disorders are prevalent in women. Women with bipolar disorder often present with different clinical features than men. Reproductive events and hormonal treatments may impact the course of bipolar disorder. Our main objectives are to i) assess the impact of reproductive events on the course of the disorder, and ii) to discuss the relationships between reproductive events and psychiatric treatments.

METHOD

A literature search was conducted of MEDLINE journals from 1965 to present. Manual literature searches were also conducted. We review the presentation, clinical course, and treatment considerations of bipolar disorder in women, with emphasis on treatment considerations in the context of reproductive events. Treatment-related issues such as teratogenicity, breastfeeding, polycystic ovarian syndrome, weight gain and obesity, and medication interactions with oral contraceptives are reviewed.

RESULTS

Women with bipolar disorder may be more vulnerable to mood episodes in the context of reproductive events, particularly postpartum. In women of reproductive age, mood stabilizers must be selected with teratogenic risks in mind, with the highest reported risks in pregnancy with valproate, and the greatest concern during breastfeeding with lithium use. In the areas of the perimenopause and polycycstic ovarian syndrome, more data are needed to advise treatment decisions.

CONCLUSION

We urgently need further study in these areas to deliver care that is appropriate to women with bipolar disorder.

Social support in bipolar disorder: its relevance to remission and relapse

OBJECTIVES

While an association between low-level social support and depression has been found in many studies, its relevance in bipolar illness has been rarely investigated. The aim of this study was to investigate the effects of social support in the remission and relapse of bipolar disorder.

METHODS

We obtained ratings from 94 stabilized bipolar patients using two different questionnaires that measure perceived social support: the Interview Schedule for Social Interaction and the Interpersonal Support Evaluation List.

RESULTS

Significantly lower social support was found in patients in partial recovery compared with those in full recovery (p = 0.003). Patients who relapsed during a 1-year prospective follow-up period perceived a significantly lower level of social support than patients with no relapse (p = 0.012).

CONCLUSIONS

Bipolar patients with full interepisode remission perceive more social support than those who do not achieve full remission. Poor social support may increase the risk of relapse in bipolar disorder.

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.

How does work work for people with bipolar affective disorder?

Despite modern treatments, bipolar disorder remains a chronic, relapsing disorder that leads to long-term psychosocial disability. A review of the literature suggests that while employment rates amongst individuals with bipolar disorder may improve over time, and are relatively better compared to some other chronic mental disorders, employment prospects do not match the high scholastic achievements seen amongst this group of people before the onset of their illness. For those with bipolar disorder, clinical recovery does not necessarily mean functional recovery, and the usual early age of onset may further reduce an individual's preparedness for employment. Two brief vignettes are used to discuss how occupational therapists can help their clients maintain their sense of hope in vocational recovery, gain better self-awareness and work with clients at various stages of recovery rather than waiting for full functional recovery. Further research is required to help identify specific factors that contribute to the success of employment integration amongst people with bipolar disorder.

The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients

BACKGROUND

Since recent NIMH Bipolar Disorder Workshops highlighted the dearth of longitudinal and controlled studies of bipolar illness, the Stanley Foundation Bipolar Network (SFBN) has recruited a large cohort of patients with bipolar disorder to begin to address these issues. This report describes the demographics and course of illness characteristics of this study population.

METHODS

The first 261 outpatients to be diagnosed by the Structured Clinical Interview for DSM-IV (SCID) and complete a detailed patient and a brief clinician questionnaire are described. All patients met DSM-IV criteria for bipolar I (n=211), bipolar II (n=42), or NOS (n=5) or schizoaffective (n=3), bipolar type. Chi-square and t-tests were used to examine statistically significant associations among important demographic and descriptive items.

RESULTS

The general demographic and illness characteristics were similar to those in many bipolar clinical samples and not dissimilar from those reported in epidemiological surveys. The majority of patients had been hospitalized, with almost half reporting a worsening of illness over time, and two-thirds were not asymptomatic between episodes. First treatment for patients had been delayed by an average of 10 years from illness onset (by SCID). Almost a third of patients had attempted suicide at least once, and 30% reported current suicidal ideation at study entry. A total of 62% reported moderate to severe impact of the illness on occupational functioning. Early onset bipolar illness (< or =17 years old) was associated with increased frequency of mood switches, worsening course of illness, and history of early abuse (physical, verbal, or sexual).

CONCLUSION

The SFBN represents a sample of predominantly BP I patients largely recruited from the community who will be followed in detail longitudinally, participate in clinical trials, and thus help advance our understanding and treatment of this life-threatening medical disorder. While there is a broad range of illness characteristics and severity, the majority of patients have been severely impacted by their illness despite the availability of multiple conventional treatment approaches in the community. These data further underscore the need for development of new and earlier treatment interventions.

LIMITATION

The SFBN population is limited by the lack of random selection and represents a cohort willing to be treated and followed intensively in academic tertiary referral centers. While its characteristics are similar to many clinical study populations, the generalizability to non-clinic populations remains uncertain.

Development and validation of the Two-Dimensional Social Interaction Scale (2DSIS)

The Two-Dimensional Social Interaction Scale (2DSIS) is a newly developed 20-item observer rating scale to assess four distinct categories of social interaction: active participate; active non-participate; passive participate; and passive non-participate. The scale was submitted to a validation procedure based on video recording of 59 dyadic social interactions between a confederate enacting one of the four types of social behaviours and a participant. The 2DSIS observer ratings on the participants were associated with meaningful differences in participants' social behaviour and their scores on the Social Adaptation Self-evaluation Scale. The 2DSIS observer ratings on the confederates were associated with participants' Post Encounter Scale scores. Factor analysis suggested that the four category ratings did exist in the two dimensions as proposed. The 2DSIS could be used in conjunction with conventional assessment tools to evaluate the social functioning of individuals.

Determinants of functional outcome and healthcare costs in bipolar disorder: a high-intensity follow-up study

BACKGROUND

Review of published studies reveals few data regarding determinants of the poor functional outcome and high healthcare costs that are characteristic of bipolar disorder. In order to identify potential mechanisms, critical to designing optimal treatment strategies, this longitudinal study investigated (a) the degree to which disease outcome is correlated with functional outcome and direct treatment costs, and (b) whether similar demographic or clinical characteristics predict disease and functional outcome and healthcare costs.

METHODS

Disease and functional outcome were assessed in bimonthly structured interviews over 48 weeks in 43 outpatient veterans with bipolar disorder. Direct mental health treatment costs from the VA perspective were determined from the VA database and patient interview. Regression analysis was used to determine association among the three outcome domains, and to identify clinical or demographic variables that predicted each of the three domains.

RESULTS

Functional outcome was correlated with depressive, but not manic, symptoms during follow-up. Costs were not correlated with any measure of disease or functional outcome. Several demographic, but not clinical, characteristics predicted functional outcome. In contrast, several clinical, but not demographic, characteristics predicted symptom status. No predictors were associated with direct treatment costs.

LIMITATIONS

Subjects were predominantly male veterans of relatively homogeneous social class, followed prospectively for approximately one year in a clinic designed specifically to minimize barriers to care.

CONCLUSIONS

Data from this and prior studies indicate that ongoing depressive symptoms are strongly associated with functional outcome, although substantial variance remains unexplained. Optimal models to explain functional outcome and healthcare costs will need to address factors besides simply disease severity and chronicity. The authors present a heuristic paradigm for understanding both the research and therapeutic aspects of these findings.

Assessment of social functioning in depression

Impairment of social functioning is a significant aspect of depression distinct from the symptoms of depression. Social functioning defines an individual's interactions with their environment and the ability to fulfill their role within such environments as work, social activities, and relationships with partners and family. The analysis of social functioning has arisen from a growing interest in measuring the consequences of depression and antidepressant therapy. Impairment often persists long after the resolution of symptoms by pharmacotherapy, and is not extensively assessed by the traditional scales to measure the intensity of depressive symptoms. Assessment is influenced by the method used, and there is an increased awareness that the patient's perspective should be foremost. Several scales for the evaluation of social functioning have already been developed, ranging from those requiring a structured interview with a trained assessor to self-assessment scales. In constructing such tools, a balance must be found between the amount of detail required to produce a clear account of the patient's social functioning and the ease of use in large multicenter studies. The newest scale is the Social Adaptation Self-evaluation Scale (SASS), specifically for self-assessment of social functioning by patients with depression. It contains 21 items covering the different aspects of social interactions, global social attitude, and self-perception. The SASS has been validated and found to be simple to use and sensitive to changes in the different areas of social functioning. Recently, the SASS was used to demonstrate the greater efficacy of reboxetine, a new selective noradrenaline reuptake inhibitor (selective NRI), compared with the selective serotonin reuptake inhibitor (SSRI) fluoxetine, in improving social functioning in patients with depression. Specifically, the SASS was able to show that reboxetine improved patient motivation and self-perception. The SASS is another tool for the evaluation of the extent and quality of the response to treatment and may also help to elucidate the roles of noradrenaline and serotonin in depressive illness.

Psychosocial interventions for bipolar disorder

The limitations of pharmacotherapy and the emergence of data supporting a role for psychosocial factors in the course of bipolar disorder have led to increased interest in the use of psychosocial interventions to improve outcomes. Although this area of study has suffered from a lack of systematic data, preliminary evidence suggests that the combined use of psychosocial interventions and medication is superior to pharmacologic treatment alone. Further research is necessary to identify and the psychosocial risk factors associated with bipolar disorder to design effective interventions to diminish their effects and improve outcome. The introduction of formal, manual-based psychotherapeutic interventions that include specific educational components has been particularly promising.

Mania in the geriatric patient population: a review of the literature

The diagnosis of mania in the geriatric population is uncommon. However, it comprises significant healthcare utilization and cost requirements, which are expected to increase in the near future with the projected increase in the geriatric population. The authors review literature pertaining to geriatric mania and discuss epidemiology, psychopathology, neuropathology, differential diagnosis, evaluation, treatment, and outcomes. Literature searches were performed by GratefulMed for the years 1960-1997, with secondary- and tertiary-source follow-up. It is clear from this review that geriatric mania is a complex illness with many possible etiologies and treatments. Much more research needs to be conducted in all of the areas reviewed.

Lithium prophylaxis of recurrent bipolar affective disorder: long-term outcome and its psychosocial correlates

BACKGROUND

Discrepancy between efficacy of prophylactic lithium and its effectiveness in ordinary clinical practice necessitates long-term follow-up data from specialised lithium clinics. Also, role of psychosocial factors in influencing the outcome is unclear.

METHODS

One hundred and eighteen patients of bipolar affective disorder attending a lithium clinic were followed-up for approximately 11 years (range 2-27 years). Demographic and clinical data, measures of social support and psychosocial stress were obtained at the intake in 1989-1990. Study design combined retrospective chart-review (till the time of intake) with prospective follow-up till July 1995.

RESULTS

On lithium, the patients had a mean of 0.43 relapses per year (manic, 0.26; depressive, 0.17) which was significantly less (p < 0.01) than the pre-lithium episode frequency. The figure for entirely relapse-free patients was 24%, and 62% had relapses up to one episode per year (median = 0.3 per year). Fifty-eight (49%) patients were good responders to lithium (relapses < or = 0.30 per year). In comparison to good responders, partial/poor responders had a significantly greater number of pre-lithium depressive episodes, poor lithium compliance, more psychosocial stress and lower social support at intake. These variables correlated well with relapses and explained 32% of the variance of the data.

CONCLUSIONS

Lithium had a definite prophylactic effect on long-term outcome. Social support and stressful life events are significant correlates of response to lithium.

CLINICAL IMPLICATIONS

Lithium prophylaxis of bipolar affective disorders seems justified though psychosocial factors appear to modulate its effectiveness.

LIMITATIONS

Other psychotropic medications were used during relapse and the assessment of psychosocial factors was cross-sectional.

Familial bipolar disorder: preliminary results from the Otago Familial Bipolar Genetic Study

OBJECTIVE

This paper outlines the methodologies used, and preliminary descriptive data collected, on a cohort of familial bipolar disorder (BPD) probands and first-degree relatives taking part in a descriptive and genetic study into familial BPD in New Zealand.

METHOD

Fifty-five bipolar probands and 67 first-degree relatives were interviewed using the modified Diagnostic Interview for Genetic Studies (DIGS) and Family Interview for Genetic Studies (FIGS). Data was also collated from other sources. Blood samples were taken for DNA genomic analysis.

RESULTS

New Zealand families in which BPD segregates proved willing participants in this familial based genetic research. The methodologies used were acceptable. High rates of comorbidity were found in probands (27.3% met DSM-IV criteria for panic disorder/sub-threshold panic disorder; 12.7% for phobic disorder; 1.8% for obsessive-compulsive disorder; 9.1% for alcohol-related disorders and 7.3% for an eating disorder) and relatives (major depression 34.3%; panic disorder/sub-threshold panic disorder 12.0%; phobias 11.9% and alcohol-related disorders 11.9%). The polarity of index BPD illness was related to age of onset and frequency of comorbidity. Suicidal behaviour was common.

CONCLUSIONS

Psychiatric genetic research in New Zealand families is highly feasible. Emerging trends in the familial transmission of BPD include high rates of comorbidity, illness patterns based on polarity of index episode and frequent suicidal behaviour. Such trends will be delineated further as numbers accrue, perhaps enabling identification of more homogenous phenotypic subgroups than currently produced by diagnostic schemes.

Development and validation of a social functioning scale, the Social Adaptation Self-evaluation Scale

The Social Adaptation Self-evaluation Scale (SASS) is a 21-item newly developed scale for the evaluation of patient social motivation and behaviour in depression. The scale was submitted to a validation procedure based on the data from a general population survey in 4000 individuals and from two controlled studies comparing the new selective noradrenaline reuptake inhibitor (NARI), reboxetine, with placebo and/or fluoxetine in 549 patients with major depression. The scale was shown to be valid, reliable and sensitive to change. The results of the multivariate analyses allowed the identification of three principal factors and five clusters. In view of its simplicity of use, and of its peculiar characteristic of investigating patient perspective on self and environment perception and on social motivation and behaviour, the scale represents a useful additional tool for the evaluation of social functioning in depression and will facilitate the development of new antidepressants with differential effects in this domain in depressed patients.