Discussion

Life events appear to have an important role in the recovery from bipolar disorder. Individuals who experienced a major stressor after onset were likely to take longer to achieve a full recovery than individuals without a major stressor. Life events also appear to have an important impact on the timing of relapse. Life events were associated with a higher risk for relapse, and relapse occurred more quickly among subjects who experienced a severe life event. These results indicate the need for more careful attention to the role of life events within bipolar disorder.

Several possible explanations can be given for an effect of life events on course. One model would suggest that life events directly influence physiological aspects of bipolar disorder.

Alternatively, life events may change motivation for treatment or compliance with medications, which would then influence symptoms. In other words, individuals experiencing significant stress may experience disruptions in seeing their doctor and taking their medications, which would then be reflected in higher levels of symptoms.

To examine this hypothesis, we compared subjects with and without severe stress on follow up treatment and medication compliance. Life events did not appear to influence treatment involvement, suggesting that the impact of life events on course of disorder was not mediated by pharmacotherapy changes.

Despite the promise of these results, they are very limited and should be interpreted with extreme caution. These findings are based on a very small number of subjects. It is highly possible that the sample studied is not representative of the broader group of individuals with bipolar disorder; individuals who believed stress was linked to their episodes may have been more willing to sign up for the study. It remains questionable whether these findings could be replicated with a larger number of subjects. Although this magnitude of finding would be important if replicated, the small number of subjects makes it impossible to determine if this is a reliable difference.

If these results generalize to a larger group of subjects, then much work is necessary to understand the relationship between stress and the course of bipolar disorder. Little is known regarding factors which link the life events with episodes. For example, some individuals would argue that life events may disrupt schedules and sleep, so that sleep is more casually linked with symptoms. Knowing more about the mechanisms linking stress and symptoms might help identify certain kinds of stressors which are most risky for individuals with bipolar disorder.

In addition to understanding the mechanism linking stress and disorder, there is a fundamental need to understand whether there are certain individuals with bipolar disorder who are more vulnerable than others to illness following stress. The extent to which social support buffers the impact of events remains unknown for bipolar disorder. Similarly, knowing how effectively medication buffets the effects of stress is of prime importance. More research is necessary on these possibilities to help guide clinical interventions.

To begin to examine these questions, I have applied for a larger grant from the National Institute of Mental Health to examine life events and bipolar disorder. If provided, funding would allow for examination of many of these questions. Most importantly, funding would allow me to examine whether these preliminary findings can be replicated if tested with a larger group of individuals.

Here's how bipolar disorder can result in family tensions and how to reduce those tensions.

(This article was first published in 1995)

About the author: SHERI JOHNSON, Ph.D. is am assistant clinical professor at Brown University and a staff psychologist at Butler Hospital in Providence, Rhode Island.

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