Based on the clinical observation that episodes are often precipitated by disruptions of sleep or other daily routines, a group of NIMH-funded researchers developed interpersonal and social rhythm therapy (IPSRT) to help stabilize the course of bipolar disorder. IPSRT teaches patients techniques to regularize their daily routines and improve their interpersonal relationships. In preliminary studies, IPSRT, in combination with ongoing medication maintenance, reduced depressive symptoms and improved the quality of remission from active bipolar disorder. Patients who received IPSRT as a preventive intervention spent more time in a balanced state and less time in a subclinical depressive condition.

NIMH researchers are currently investigating the influence of stress, life events, and social support on the course of bipolar disorder. These relationships can be determined most accurately by studies that follow patients forward through time - that is, by prospective research. One prospective, NIMH-funded study is examining the impact of life events and social support on the time to recovery and relapse in people with bipolar disorder.

Another prospective study supported by NIMH is investigating the influence of psychosocial factors - life events, stress, cognitive processes, and personality factors - on the onset and course of cyclothymia (periods of mild hypomanic symptoms alternating with periods of mild depressive symptoms), and on the onset and course of bipolar disorder among people with cyclothymia. Cyclothymia is a known risk factor for developing bipolar disorder. However, little is known about what factors determine which people with cyclothymia will develop bipolar disorder, or about the mechanisms involved in the change from cyclothymia to the more severe illness. Findings from this study will help clarify the role of various psychosocial factors in the course of cyclothymia and in the initial onset and subsequent course of full-blown bipolar disorder; help explain the relationship between unipolar major depression and the depressive phases of bipolar disorder; and suggest new methods for treating and preventing bipolar disorder.

The most common co-occurring illnesses among people with bipolar disorder are substance abuse disorders. Approximately 60 percent of people with bipolar disorder have drug and/or alcohol abuse or dependence problems - the highest rate across all patients with major psychiatric illnesses. Research suggests that many factors likely contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either initiated or perpetuated by substance abuse, and risk factors that may influence the occurrence of both disorders.

A review of multiple research studies revealed several factors that increase the risk for co-occurring substance use among individuals with bipolar disorder, including early age of illness onset, family history of substance use disorders, and presence of mixed symptoms. A current NIMH-funded study is investigating how substance abuse affects the frequency, duration, and severity of episodes in people with bipolar disorder. Better understanding of the relationship between substance use and bipolar disorder will help improve both treatment and preventive interventions for co-occurring substance use, leading to better mental health outcome.

Other research has indicated that certain anxiety disorders may co-occur with bipolar disorder. In one recent NIMH-supported study of post-traumatic stress disorder (PTSD) in people with bipolar disorder or schizophrenia, almost all patients reported having experienced at least one traumatic event in their lifetime. While 43 percent of study participants met criteria for PTSD, only two percent had the diagnosis listed in their medical charts. The results suggest that PTSD commonly co-occurs with severe mental disorders. Routine screening for PTSD during medical visits would lead to improved diagnosis and treatment of this anxiety disorder, thus allowing the other co-occurring illness - bipolar disorder, schizophrenia, etc. - to be more effectively treated.

Both children and adolescents can develop bipolar disorder. NIMH research efforts are attempting to clarify the diagnosis, course, and treatment of bipolar disorder in youth. Evidence suggests that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder. When the illness begins before or soon after puberty, it is often characterized by a continuous, rapid-cycling, irritable, and mixed symptom state that may co-occur with disruptive behavior disorders, particularly attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or may have features of these disorders as initial symptoms. In contrast, later adolescent- or adult-onset bipolar disorder tends to begin suddenly, often with a classic manic episode, and to have a more episodic pattern with relatively stable periods between episodes. There is also less co-occurring ADHD or CD among those with later onset illness.