This review concludes that personality, temperament, life stress, and family discord are important influences on the course of BD, alone and in interaction with each other. Patients with comorbid personality disorders are more treatment-refractory and generally have poorer outcomes of their bipolar disorder. Temperamental attributes that are related to subsyndromal manic symptoms, such as hyperthymia, cyclothymia, and positive affectivity predict the onset of more severe manic symptoms. BD patients are highly sensitive to reward, and excessive goal pursuit after goal-attainment life events may be one pathway to mania. Negative life events and neuroticism are more closely associated with depressive recurrences than manic recurrences. High levels of intrafamilial criticism and other dimensions of family functioning (e.g., low cohesion, low warmth, or ineffective problem-solving) are most consistently associated with depressive symptoms and recurrences.
This summary relies on a small number of prospective studies, and there is a need for replication of most of the findings. Beyond this, few studies have directly tested multivariate vulnerability/stress models of episode onset and occurrence, so this is a fertile area for future research. For example, goal-attainment life events may be especially potent in predicting mania when patients have heightened reward sensitivity, but calming, low-intensity, and supportive marital or family interactions may help protect against manic symptoms during those moments. Patients from families with high-EE attitudes may be especially relapse-prone when they show emotion labeling deficits, but these risk factors may be especially potent when the patient has had early experiences of adversity. Studies that take a developmental perspective, examining the interactions of risk and protective processes at different phases of the life cycle, are likely to be more informative than cross-sectional studies, especially given that mood cycling patterns are a “moving target” in this disorder.
The course of BD is characterized by a multifinality of outcomes, which can include recovery, remission, relapse, recurrence, ongoing symptoms, or psychosocial impairments (Frank et al., 1991
; Martinez-Arán et al., 2008
). It is rare for psychosocial studies to distinguish recovery from remission (i.e., lengthy versus brief asymptomatic periods) or recurrence from relapse (i.e., periods of symptom exacerbation that follow lengthy periods of recovery versus those that follow briefer periods of remission). These distinctions could help determine whether psychosocial predictors (or moderators of treatment outcome) are equally relevant to the short-term and long-term course of the disorder.
Adjunctive psychotherapy is a vital part of the effort to stabilize episodes of bipolar depression, prevent recurrences, and enhance functioning. This observation is beginning to be reflected in practice guidelines (e.g., Yatham et al., 2005
; Goodwin & the Consensus Group of the British Association for Psychopharmacology, 2003
). A major limitation of the existing psychosocial approaches, however, is their inaccessibility to most community clinicians. Future research should examine the most cost-effective methods for training clinicians and monitoring their adherence in practice settings.
The mechanisms by which psychosocial treatments operate – through altering patients’ cognitive biases, enhancing the protective effects of the family, teaching interpersonal effectiveness or emotional self-regulation skills, or simply increasing patients’ adherence to medications – need to be clarified in randomized trials. Future trials should also attempt to identify the subgroups of patients who respond best to each form of treatment (for example, those who present with primarily depressive versus primarily manic illness courses, or those with bipolar I versus II disorder), as a means of further refining practice guidelines for different presentations of BD. Finally, the role of psychosocial stressors in accelerating the onset of BD among genetically at-risk children, and the role of psychosocial interventions in delaying or staving off the first onset of the disorder, are important areas for the next generation of research.