Inducing lifestyle regularity in recovering bipolar disorder patients: results from the maintenance therapies in bipolar disorder protocol

On the basis of theories we articulated in earlier papers (Ehlers et al 1988: Arch Gen Psychiatry 45:948-952, 1993: Depression 1:285-293), we have developed an adjunctive psychosocial intervention for patients with bipolar 1 disorder. Central to this intervention is the establishment of regularity in daily routines. In this report, we present data from a controlled investigation comparing this new treatment, interpersonal and social rhythm therapy (IPSRT), with a conventional medication clinic approach. Despite comparable changes in symptomatology over a treatment period lasting up to 52 weeks, subjects assigned to IPSRT (n = 18) show significantly greater stability (p = .047) of daily routines with increasing time in treatment, while subjects assigned to the medication clinic condition (n = 20) show essentially no change in their social routines as measured by Social Rhythm Metric (SRM-Monk et al 1990: J Nerv Ment Dis 178(2):120-126) score. We conclude that IPSRT is capable of influencing lifestyle regularity in patients with bipolar 1 disorder, with the possible benefit of protection against future affective episodes.

Neurotrophin-3 promotes the differentiation of muscle spindle afferents in the absence of peripheral targets

The neurons of the dorsal root ganglia (DRG) that supply muscle spindles require target-derived factors for survival. One necessary factor for these neurons is neurotrophin-3 (NT3). To determine whether NT3 can promote the survival of these neurons in the absence of other target-derived factors, we analyzed the effects of exogenous NT3 after early limb bud deletion in the chick. In control embryos, limb bud deletion eliminated approximately 90% of the trkC-positive (trkC+) neurons in lumbar DRG on the deleted side. In addition, the deletion led to a dramatic loss of collateral sensory projections to motoneurons. Exogenous NT3 restored a normal population of trkC+ neurons in lumbar DRG on the deleted side and increased the number of trkC+ neurons in DRG with normal targets (contralateral lumbar and thoracic). The effect was highly selective; NT3 increased the number of trkC+ neurons without significantly changing the number of either trkA+ or trkB+ neurons. The effect of NT3 was attributable to the rescue of DRG neurons from cell death, because exogenous NT3 reduced the number of pyknotic nuclei without significantly altering proliferation. Analysis of spinal projections showed further that many of the trkC+ neurons rescued by NT3 projected to the ventral spinal cord. These neurons thus had central projections characteristic of muscle spindle afferents. Together, our results indicate that NT3 signaling is both necessary and sufficient for the development of the proprioceptive phenotype, even in the absence of other signals from limb muscle.

The panic-agoraphobic spectrum: a descriptive approach to the assessment and treatment of subtle symptoms

OBJECTIVE

Psychiatric classification is still a topic of considerable discussion and debate in spite of major advances in the past two decades. The debate involves categorical versus dimensional approaches, cutoff numbers of symptoms to define a case, degree of impairment, objective diagnostic criteria versus more theoretically based criteria, episodic versus trait-like symptoms, and the role of atypical and subclinical symptoms. All of these issues have been raised for the anxiety disorders and depression. This article presents the conceptualization of a relatively novel and testable approach to the diagnosis and classification of panic and agoraphobia, the panic-agoraphobic spectrum, and pilot data on a new questionnaire to assess it.

METHOD

Pilot testing of the Panic-Agoraphobic Spectrum Questionnaire was undertaken with 100 inpatients who had lifetime diagnoses of panic disorder, unipolar depression, comorbid panic and unipolar depressive disorders, or an eating disorder. The instrument emphasizes impairment related to 144 behaviors and experiences in seven panic-agoraphobic symptom domains.

RESULTS

Patients with panic disorder scored highest on the questionnaire, and those with comorbid depression showed even greater severity of illness. The scores of the patients with eating disorders and of the depressed patients differed from those of the other groups but also differed from 0.

CONCLUSIONS

The spectrum model of panic and agoraphobia is a flexible and comprehensive means of describing this clinical complex. The proposed model, complementary to the categorical approach, presumably expresses a unitary pathophysiology. Its usefulness is discussed in terms of its value for patient-therapist communication, outcome measures, identification of subtle personality traits, and subtyping of patients for research and treatment.

Low rate of membrane lithium transport during treatment correlates with outcome of maintenance pharmacotherapy in bipolar disorder

Lithium is transported across cell membranes by an exchange diffusion process (Na(+)-Li+ countertransport) that is inhibited during lithium treatment. We hypothesized that low rates of lithium efflux (a potential manifestation of strong transport inhibition) would be associated with better clinical outcome of maintenance pharmacotherapy. We measured the erythrocyte (RBC) apparent rate constant for lithium efflux (kexch) in 22 patients with bipolar disorder who had been euthymic on lithium for 1 month. Subsequently, clinical mood ratings and in vivo RBC: plasma lithium ratios (LiR) were determined monthly. Outcome was categorized according to whether subjects completed 1 year of successful maintenance treatment (n = 10), experienced a recurrent affective episode (n = 8), or dropped out (n = 4). The kexch at the outset of the study was significantly lower (potentially because of greater transport inhibition) in 1-year completers than in patients with recurrences or those who dropped out (median kexch = 0.09, 0.24, and 0.27 h-1, respectively; P < .03). Moreover, 77% of patients with a kexch of 0.11 h-1 or lower were successfully maintained on lithium for 1 year, whereas only 23% of those with a kexch greater than or equal to 0.12 h-1 had a successful treatment outcome. LiR measured during the course of maintenance treatment was significantly higher (suggesting greater transport inhibition) in 1-year completers than in noncompleters (recurrences and dropouts). Measurement of kexch at an early point in treatment may provide a means for prospectively identifying those bipolar patients at greater risk for failure of maintenance lithium therapy.

Relative risk in the news media: a quantification of misrepresentation

OBJECTIVES

This study quantifies the representativeness with which the print news media depict mortality.

METHODS

The proportion of mortality-related copy in samples of national print media was compared with the proportion of actual deaths attributable to the leading causes of US mortality over a 1-year period.

RESULTS

For every tested cause of death, a significant disproportion was found between amount of text devoted to the cause and the actual number of attributable deaths. Underrepresented causes included tobacco use (23% of expected copy) and heart disease (33%); overrepresented causes included illicit use of drugs (1740%), motor vehicles (1280%), and toxic agents (1070%).

CONCLUSIONS

The news media significantly misrepresent the prevalence of leading causes of death and their risk factors. This misrepresentation may contribute to the public's distorted perceptions of health threats.

Identifying an abnormal electroencephalographic sleep profile to characterize major depressive disorder

There is little agreement as to the best definition of a categorically abnormal electroencephalographic (EEG) sleep profile to characterize major depressive disorder. Therefore, a series of classification, replication, and validation analyses were conducted to identify such a profile. The EEG sleep studies of healthy controls (n = 44), depressed inpatients (n = 44), and depressed outpatients (n = 181) were utilized, including subgroups of patients studied both before and after nonpharmacologic treatment with either cognitive behavior therapy (CBT) or interpersonal psychotherapy (IPT). A discriminant index score (based on reduced REM latency, increased REM density, and decreased sleep efficiency) was found to: 1) reliably discriminate between depressed inpatients, depressed outpatients, and controls; 2) show good test-retest reliability; and 3) identify a subset of depressed outpatients who were older, manifested a broader array of EEG sleep disturbances, and were less responsive to CBT or IPT. Posttreatment studies of patients indicated that normal sleep profiles were relatively stable, whereas abnormal profiles tended to normalize. These findings provide an empirically validated method that may improve the applicability, efficiency, and prognostic utility of EEG sleep studies of depressed patients.

Formation of specific monosynaptic connections between muscle spindle afferents and motoneurons in the mouse

In adult vertebrates, sensory neurons innervating stretch-sensitive muscle spindles make monosynaptic excitatory connections with specific subsets of motoneurons in the spinal cord. Spindle afferents (Ia fibers) make the strongest connections with motoneurons supplying the same (homonymous) muscle but make few or no connections with motoneurons supplying antagonistic or functionally unrelated muscles. In lower vertebrates these connections are specific from the time they first are formed, but there is comparatively little information about how these reflex connections form in mammals. We therefore studied the pattern of these synaptic connections during postnatal development in mice. Intracellular recordings were made from identified hindlimb motoneurons in an isolated spinal cord preparation, and monosynaptic inputs from Ia fibers in identified hindlimb muscle nerves were measured at different times during the first postnatal week. The pattern of connections was specific throughout this period. Ia fibers made strong connections with homonymous motoneurons but only weak connections with antagonistic motoneurons at every time point examined, from P0 through P7. Even when muscle nerves were stimulated at only 0.1 Hz, the pattern of connections was still highly specific, arguing against a special subpopulation of labile inappropriate connections. The absence of appreciable rearrangements in the pattern of these connections during the first postnatal week is, therefore, analogous to the situation in lower vertebrates, suggesting that mechanisms responsible for establishing this specificity have been conserved during evolution.

Which depressed patients will respond to interpersonal psychotherapy? The role of abnormal EEG sleep profiles

OBJECTIVE

The authors tested the hypothesis that patients whose episodes of major depression evidenced more neurobiological disturbance would be less responsive to psychotherapy.

METHOD

The study subjects were outpatients who were given a diagnosis of recurrent major depressive disorder (unipolar or bipolar II), according to the Research Diagnostic Criteria, following an interview with the Schedule for Affective Disorders and Schizophrenia. They were classified into a group with normal sleep profiles (N = 50) and a group with abnormal sleep profiles (N = 41) on the basis of a validated index score derived from three EEG sleep variables monitored for 2 nights: sleep efficiency, REM latency, and REM density. The groups' responses to short-term interpersonal psychotherapy were compared by means of chi-square tests and life table and random effects model analyses. Responses to the addition of pharmacotherapy for subjects who did not respond to interpersonal psychotherapy were also compared.

RESULTS

The patients with abnormal sleep profiles had significantly poorer clinical outcomes with respect to symptom ratings, attrition rates, and remission rates than the patients with more normal sleep profiles. Seventy-five percent of the patients who did not respond to interpersonal psychotherapy had remissions during subsequent pharmacotherapy.

CONCLUSIONS

These findings help to define further a neurobiological "boundary" that may limit response to psychotherapy in depression. An abnormal sleep profile may reflect a more marked disturbance of CNS arousal that warrants pharmacotherapy.

Basic demographic and professional characteristics of US women physicians

Women physicians are a rapidly growing percentage of the physician population in the United States; yet, their fundamental characteristics and largely unknown. The Women Physicians' Health Study is the first large, national study of US women physicians, comprising a random sample (n = 4,501 respondents) of women physicians aged 30 to 70. Data from the Women Physicians' Health Study showed that African-American and Latina or Hispanic physicians were underrepresented, and Asian-American and foreign-born physicians were overrepresented in proportion to their prevalence in the US female population. Women physicians were more likely to be married and less likely to have never married and less likely to have never married or to be divorced or widowed than other US women. Younger physicians were more likely to be residency trained and board-certified and to work more hours per week than older physicians. Younger physicians were also less likely to be in solo practice, government work, or inactive; they tended to be concentrated in group or hospital-based practices. We found that although US women physicians have some common characteristics that differentiate them from other US women, their practice and other characteristics vary substantially by age and specialty in ways that have not previously been reported.

Electroencephalographic sleep correlates of episode and vulnerability to recurrence in depression

The study of electroencephalogram (EEG) sleep in depressed patients before and after treatment with psychotherapy can distinguish episode-related and persistent biological features. With longitudinal follow-up, we can also assess whether EEG sleep measures are associated with recurrence of depression. In the current study, we examined EEG sleep during the depressed state and during symptomatic remission after treatment with interpersonal psychotherapy in 42 outpatients with major depression. Analyses included both visually-scored and computer-analyzed measures. Patients showed significant increases in sleep latency (p = .01) and rapid eye movement (REM) latency (p = .04) from baseline to remission, as well as a decrease in REM sleep percent (p = .03). Total delta EEG counts decreased from baseline to remission (p = .03), specifically in the second nonrapid eye movement (NREM) period (p = .03); as a result, the relative distribution of delta activity shifted toward sleep onset (i.e., increased delta sleep ratio; p = .03). Automated REM counts also decreased from depression to remission (p = .006). Compared to patients who remained well through one year of follow-up, those who suffered a recurrence of depression had less delta EEG activity at baseline and remission (p = .01), particularly in the lowest delta frequency band of 0.5-1.0 Hz. Specific components of sleep (total delta activity, delta ratio, REM activity) constitute episode-related biological features. Other components (slowest delta activity) may represent vulnerability factors for recurrence.

Synapse elimination: for nerves it's all or nothing

At birth, several motoneurons supply neural signals to each muscle fiber, but 2 weeks later all but the input of a single neuron is gone. This process of synapse elimination has now been carefully described in electrophysiological terms in this week's issue in a report by Colman et al . ( p. 356 ). In his Perspective, Frank explains how the new data fit with what we already know about the changes occurring during synapse elimination and predicts that molecular understanding of this key process will come soon.

Role of psychosocial factors in the onset of major depression

Although the role of psychosocial factors in the onset of major depression has been well recognized for several decades, we argue that an integrated theory embracing psychosocial and biological domains will most likely provide a full understanding of the pathogenesis of depression. Advances in biology and psychopharmacology for depression provide the stimuli to examine the potency of different sets of variables to "predict" onset of depression. Recent attempts to develop new strategies for assessing both psychosocial and biological risk factors and examples of how such strategies might apply to depression are discussed.

Enhancing patient outcomes: treatment adherence

Barriers to patient adherence to antidepressant therapy include lack of knowledge in several important areas, including the nature of depression, the nature of treatments and how they can be expected to work, and the efficacy of pretreatment education. Other obstacles include unpleasant side effects of medications and negative attitudes and beliefs about medication on the part of patients and their families and treating physicians. Such barriers can be surmounted by approaches based on principles of good medical management, including: use of a multidisciplinary treatment team; education of patients and their families regarding the nature of depression and its treatments; the formation of an alliance among clinicians, patients, and family members; and the establishing of a clinic atmosphere that fosters such an alliance. Strategies to promote adherence should also address issues in practitioner disposition and training and barriers that arise as a result of the direct effects of depressive illness on the patient. In addition, such strategies must include measures appropriate to the different stages of depression treatment, including increased frequency of contact and intensity of support during acute treatment, regular monitoring during ongoing treatment, and the establishment of long-term relationships with those patients who have a history suggesting vulnerability to relapse.

Psychoeducational workshops for elderly patients with recurrent major depression and their families

OBJECTIVE

This report details an extension of the use of psychoeducational workshops with psychiatric patients and their families to families of elderly patients with recurrent unipolar late-life depression.

METHODS

Subjects were 132 participants in a study of maintenance therapies for late-life depression and their 182 family members and significant others who accepted invitations to single-session family workshops. Participants provided feedback on their satisfaction with the content and quality of the workshops. Associations between workshop attendance, preworkshop demographic and clinical characteristics, treatment adherence, and outcome were explored through comparisons between 108 patients who attended workshops and 24 patients who declined the workshop invitation.

RESULTS

Favorable feedback from participants suggested that the extension of the workshops to families of elderly patients with depression was successful. Workshop attendance was associated with a lower rate of dropout during continuation treatment.

CONCLUSIONS

Results associating workshop refusal and treatment dropout, as well as the overall treatment compliance and retention rates in this randomized clinical trial involving geriatric patients, support the need for further study of factors relating to elderly patients' willingness to engage in family-centered interventions.

Immunotherapy with an alum-adsorbed Parietaria-pollen allergoid: a 2-year, double-blind, placebo-controlled study

A double-blind, placebo-controlled study was performed in order to confirm the safety, suitability, and efficacy of an alum-adsorbed Parietaria judaica-pollen allergoid, Allergovit, for allergen-specific immunotherapy. Parietaria pollen is an important cause of pollinosis, particularly in the Mediterranean zone, where it may be encountered for up to 8-9 months of the year. It is an aggressive allergen, and the doses tolerated during immunotherapy are less than those achieved with grass pollen. This factor increases the desirability of using therapeutic preparations with minimal IgE-binding activity, such as allergoids, in order to reduce the risk of side-effects and enable patients to tolerate a higher dose of allergen, thereby increasing the chances of successful specific immunotherapy. Forty patients with rhinitis and/or asthma were allocated at random to active- or placebo-treatment groups at the beginning of the study. All patients received the active preparation during the second year of the study. Immunotherapy was well tolerated by all patients and the incidence of side-effects was low. Treatment resulted in significant reductions in specific cutaneous reactivity and increases in nasal tolerance. A progressive improvement in nasal inspiratory peak flow in association with the immunotherapy indicated a reduction in nasal inflammation. These objective assessments of efficacy endorsed the results from the patients' diary cards, which indicated significant improvements in symptoms and reductions in the use of medication. The immunologic activity of the therapeutic preparation was demonstrated by the induction of a significant specific-IgG antibody response, with increases in IgG4 during the second year of treatment. We conclude that the safety and efficacy of immunotherapy with the Parietaria allergoid make it suitable for consideration in the treatment of patients with Parietaria-pollen-induced rhinitis or asthma.

Restriction in cell fates of developing spinal cord cells transplanted to neural crest pathways

At early neural tube stages, individual stem cells can generate neural crest cells as well as dorsal or ventral spinal cord cells. To determine whether this pluripotency is lost as development proceeds, we back-transplanted quail spinal cells from different developmental stages and different spinal locations into the crest migratory pathways of st 16-20 chicken host embryos. The transplanted spinal cells from st 27 dorsal cord and st 18 ventral cord differentiated within the new crest environment into sensory and sympathetic neurons, satellite and Schwann cells, and melanocytes. St 27 ventral cells still generated several crest derivatives but not sensory or sympathetic neurons. This loss in ability to produce neurons correlates with the end of neurogenesis in ventral cord. The end of neurogenesis in the cord, therefore, results from an intrinsic change in the potential of spinal neuroepithelial cells to generate neurons.

Transitioning to the breast at six weeks: use of a nipple shield

After forceful help with breastfeeding on the first day after birth, a baby began to refuse to latch onto the breast. The mother received help maintaining her milk supply and advice on feeding methods and use of a nipple shield from a lactation consultant after leaving the hospital and was eventually able to breastfeed with the help of a nipple shield. Important aspects of this case were the treatment in the hospital, which included forcing the baby to the breast and using a tube-feeding device with artificial baby milk. Also critical was this mother's commitment to breastfeeding and the long-term support she received.

An updated basal body temperature method

Basal body temperature (BBT) readings are handicapped as fertility predictors by exogenous influences on women's temperatures, many of which could be adjusted for by the presence of a non-cycling control. We, a married, cohabiting couple, tracked our BBTs for two months. We found substantial temperature covariability. When there were difficult-to-explain changes in the female partner's temperature, similar changes in the male partner's temperature suggested that these fluctuations were not attributable to ovulation. Additionally, a clear mid-cycle widening of our temperature gap suggested that ovulation had occurred. This is a limited trial of a new method. However, the potential for substantially improving the accuracy and usefulness of a globally utilized method, coupled with its inexpensiveness, ease, and painlessness, call for a larger study.

High relapse rate after discontinuation of adjunctive medication for elderly patients with recurrent major depression

OBJECTIVE

The authors documented outcomes of elderly depressed patients requiring adjunctive medication during acute-phase pharmacotherapy because of slow or partial response to nortriptyline. Twenty-eight patients (17.7%) received inpatient care at some point during acute-phase treatment.

METHOD

Rates of response, relapse, and sustained remission were examined in 158 elderly patients with recurrent major depression, grouped by whether they received brief treatment with adjunctive medication (lithium, perphenazine, or paroxetine) (N = 39) or did not (N = 119).

RESULTS

The group receiving adjunctive medication had a lower rate of response to acute therapy (64.1% versus 83.2%), a higher relapse rate during continuation therapy (52.0% versus 6.1%), and a lower rate of sustained remission (recovery) (48.7% versus 76.5%) than did the group without augmentation.

CONCLUSIONS

Elderly depressed patients requiring augmented pharmacotherapy to achieve remission may need continuation of adjunctive medication to remain well and to avoid early relapse. Alternatively, factors that lead to augmentation in the first place (e.g., heightened anxiety) may also increase the risk of relapse.

Life stress and treatment course of recurrent depression: II. Postrecovery associations with attrition, symptom course, and recurrence over 3 years

Life stress was studied in relation to postrecovery attrition, symptom course, and recurrence of depression over 3 years. Participants were 67 individuals with recurrent depression who had responded to treatment. Life stress was assessed for the prior 12 weeks at acute treatment entry (T1), initial recovery (T2), and after 17 weeks of sustained recovery (T3). Severe life events at T1 predicted greater attrition, a more favorable postrecovery symptom course, and a lower likelihood of recurrence over 3 years. Life stress at T2 was not predictive of outcomes. Finally, undesirable life events at T3 tended to predict a worse symptom course and a higher likelihood of recurrence, particularly for individuals on medication. The findings are discussed in terms of (a) different processes influenced by life stress over time and (b) limitations of existing longitudinal research for studying the effects of life stress over prolonged intervals.

Changes in perceived health status of depressed elderly patients treated until remission

OBJECTIVE

The authors predicted that depressed elderly patients who responded to treatment would rate their baseline health more positively than nonresponders, that responders would again rate their health more positively once they were in remission, and that lower baseline self-ratings of health would predict lack of response to protocol treatment.

METHOD

The Perception of Illness Scale was administered to 61 depressed elderly patients at baseline and again upon completion of the acute phase of a depression treatment protocol. A logistic regression was performed to ascertain whether Perception of Illness Scale scores predicted response to protocol treatment.

RESULTS

Baseline Perception of Illness Scale scores were poorer among the nonresponders, accurately predicted response or lack of response in 75% of the subjects, and showed before-to after-treatment improvement among the responders.

CONCLUSIONS

Patients who initially rated their health as fair to poor were less likely to recover from depression in a standardized treatment protocol. Self-ratings of health improved with resolution of depression.

Treatment outcome in recurrent major depression: a post hoc comparison of elderly ("young old") and midlife patients

OBJECTIVE

The authors compared response rates, the temporal course of response to acute treatment, and relapse rates during continuation treatment of elderly and midlife patients with recurrent major depression.

METHOD

They analyzed results from two separate controlled studies of maintenance therapies for recurrent major depression, in which 148 elderly patients (mean age = 67.9 years) and 214 midlife patients (mean age = 38.5 years) were treated in open acute and continuation therapy with a combination of interpersonal psychotherapy and a tricyclic antidepressant (nortriptyline for the elderly, imipramine for the midlife patients). In an intent-to-treat analysis, remission rates during acute treatment and relapse rates during continuation treatment were examined. Random regression analysis of weekly Hamilton depression scale ratings was used to compare the temporal course of response.

RESULTS

During acute-phase therapy, 78.4% (N = 116) of the elderly patients and 69.6% (N = 149) of the midlife patients had remissions. The midlife patients had a faster reduction of Hamilton depression ratings. Following stabilization, 15.5% of the elderly patients and 6.7% of the midlife patients relapsed. Ultimately, 66.2% of the late-life patients and 57.0% of the midlife patients recovered fully.

CONCLUSIONS

Older patients appear to benefit as much as, but perhaps more slowly then, midlife patients from treatment of major depression. Continuation treatment should be vigorous and closely monitored, given the apparently higher relapse rates among the elderly. These conclusions should be viewed as preliminary because of the post hoc nature of the analysis reported here.

A critical period for the influence of peripheral targets on the central projections of developing sensory neurons

During development, the projections that sensory neurons make within the spinal cord are influenced by the specific targets they contact in the periphery. If sensory ganglia normally supplying principally cutaneous targets are forced to grow into limb muscles, in early stage tadpoles, many sensory neurons within these ganglia innervate limb muscles and subsequently develop spinal projections appropriate for muscle spindle afferents. If the same procedure is performed with adult frogs, however, these novel projections do not form. In this study, we have determined the developmental stages at which this sensitivity to peripheral targets exists. Axons from sensory neurons in thoracic (largely cutaneous) dorsal root ganglia were re-routed into the front leg at various stages through metamorphosis, and the central spinal projections of these re-routed fibers were assessed with HRP labeling. We found that thoracic sensory axons could be made to project to limb muscles throughout development, but that the central projections of these neurons were only appropriate for spindle afferents if the fibers were re-routed before stage XVIII, shortly before metamorphic climax. Because sensory neurons can regenerate specifically into the appropriate spinal laminae even in adult frogs, these results suggest that changes in either the DRG or the arm musculature occur by stage XVII so that DRG neurons cannot respond to novel peripheral targets.

Prodromal and residual symptoms in bipolar I disorder

The objective of the current study was to better understand the nature of prodromal and residual symptoms of mania and depression, as reported by patients with bipolar I disorder and their family members. Prodromal and residual symptoms of mania and depression were elicited from 74 patients with bipolar I disorder. In 45 cases, an adult family member provided similar information. Three clinicians classified the symptoms into six broad categories: behavioral, cognitive, mood, neurovegetative, social, and other. The clinicians also categorized symptoms as typical or idiosyncratic. Seventy-eight percent of the patients reported prodromal depressive symptoms and 87% reported prodromal manic symptoms; greater than half of the patients disclosed residual symptoms of depression (54%) and mania (68%). Within each of these four illness categories, cognitive symptoms were consistently the most common symptoms reported by patients. A substantial number of symptoms were idiosyncratic, particularly those reported for residual depression. Agreement between patient and family members on reported symptoms was strong for the prodromal phase of both polarities, but less so for the residual phases. These preliminary results suggest that patients with bipolar I disorder and their family members can identify prodromal and residual symptoms, that these symptoms are quite common, and that prodromal symptoms may be more prevalent or easier to identify than residual symptoms. Cognitive symptoms were consistently the most common symptoms reported by patients.

Life stress and treatment course of recurrent depression: II. Postrecovery associations with attrition, symptom course, and recurrence over 3 years

Life stress was studied in relation to postrecovery attrition, symptom course, and recurrence of depression over 3 years. Participants were 67 individuals with recurrent depression who had responded to treatment. Life stress was assessed for the prior 12 weeks at acute treatment entry (T1), initial recovery (T2), and after 17 weeks of sustained recovery (T3). Severe life events at T1 predicted greater attrition, a more favorable postrecovery symptom course, and a lower likelihood of recurrence over 3 years. Life stress at T2 was not predictive of outcomes. Finally, undesirable life events at T3 tended to predict a worse symptom course and a higher likelihood of recurrence, particularly for individuals on medication. The findings are discussed in terms of (a) different processes influenced by life stress over time and (b) limitations of existing longitudinal research for studying the effects of life stress over prolonged intervals.