The present study was designed to examine whether the occurrence of recent stressful life events was associated with delayed functional recovery after symptomatic recovery in a sample treated for a manic episode, and predict time to recovery for groups differing in stress occurrence. It is always hoped and intended that successful treatment will mean clinical recovery accompanied by return to adequate functioning in key roles, but it has become evident that there may be gaps between clinical, and work and social outcomes. The majority of patients in the present study did in fact show concurrent clinical and role functioning recovery, but some showed a notable delay between clinical and functional recovery, and a small number had persisting impairment in role domains throughout the follow-up despite recovery from a manic episode.
As hypothesized, those who had delayed functional recovery were significantly more likely than those with concurrent functional recovery to have experienced at least one recent stressful life event. The relationship between stress and delayed recovery was apparent in the friend, family, and work/school domains (but not in home duties). Stress occurrence predicted delay in functional recovery even after controlling for the effects of residual depressive and manic symptoms. Further, survival analyses indicated that the presence of at least one stressful life event was associated with a statistically significant delay in functional recovery after clinical recovery, ranging from 26 days (family functioning), to 58 days (friendship functioning), and 112 days (work/school functioning). The occurrence of stressors in the 3 months prior to functional recovery was not predicted by medication compliance, clinical history, or demographic factors, although factors that contribute to stress exposure are an important topic for future study (Hammen, 2005
The study adds to the increasing emphasis on the importance of understanding the nature and predictors of functional recovery (e.g., Altshuler et al., 2006
; Goldberg et al., 1995
; MacQueen et al., 1997
; Tohen et al., 2000
). Previous studies have found that subsyndromal symptoms contribute to impaired functional recovery (e.g., Altshuler et al., 2002a
; Chengappa et al., 2005
; Judd et al., 2005
). The current study builds on the literature implicating the occurrence of stressful life events in the course of unipolar depression, and in the growing body of research on stress in bipolar disorder—particularly bipolar depression (reviewed in Johnson and Roberts, 1995
). The limited existing research has suggested that stress may delay clinical improvement (Johnson and Miller, 1997
), but it appears to have an even greater disruptive effect on role functioning than clinical outcomes for some individuals, especially in friendship and work/school domains.
The mechanisms that account for the disruptive effects of stress on functional recovery in relation to clinical recovery need further study. It could be speculated that stress affects a variety of neuroendocrine, neurocognitive, affective, attitudinal, and behavioral processes that undermine adaptive coping and problem-solving necessary to sustain effective performance of role requirements. The content of stressful life events may of course differ from person to person, but common events such as having problems with family members, changing jobs or work conditions, and or problems in relation to a loved one, can all cause a variety of emotional and behavioral disruptions. Such disruptions may not only affect functioning in the same domain but may also create a cascade of challenges and adjustments in other domains as well. For example, loss or change of employment not only affects functioning in that domain but may also lead to changes in schedules, finances, and personal confidence that can have an impact on adjustment in relations with friends and family. It may also be speculated that stressful events and their impact may further challenge the supportive relationships that help individuals function adequately in the face of adversity, especially given that those supports may have already been strained by the experience of a patient’s manic episode. Moreover, different domains of functioning may differ in their susceptibility to and tolerance for emotional and behavioral consequences of stressful events. In a previous study we reported on predictors of work functioning (Hammen et al., 2000
), but functioning in close relationships may have different antecedents.
The current study's finding that stressful life events disrupt the process of returning to premorbid functioning has important implications for treatment. The results suggest that patients may benefit from therapies which focus on helping them cope more effectively with and even prevent negative life events. There is ample evidence of the benefits, in terms of symptom reduction, delay of recurrence, as well as better interpersonal functioning, of combining pharmacotherapy with psychotherapies focused on psychoeducation, interpersonal, family, and cognitive-behavioral interventions (reviewed in Miklowitz & Johnson, 2009
It must also be noted that stressors and mood symptoms likely each affect the occurrence of each other in a bidirectional process (Hammen, 1991
). Thus, adjunctive psychosocial interventions may be beneficial in helping not only to alleviate the negative impact of stressors but also attempt to anticipate and mitigate the ways in which individuals’ symptoms, characteristics, and circumstances may contribute to the occurrence of acute events.
The results should be considered in light of several limitations. The samples of those with delayed or nonrecovery of premorbid functioning in key roles were relatively small. Many individuals who did not attain concurrent clinical and functional recovery dropped out and were not followed for the entire follow-up period, which would have permitted more extensive observation of the effects of stress. Nevertheless, all participants had at least a baseline stress evaluation covering a comparable 3 months prior to their current status. Reasons for nonrecovery of functioning despite clinical remission at baseline remains an issue for further study, as those participants’ symptomatology and stress levels were generally not different from those who had delayed recovery of functioning. Why some individuals did functionally recover after a delay while others did not may be due to additional personal and situational characteristics not examined in the present study, but are of considerable clinical interest. All of the functional outcome assessments were based on self-reported data. The instrument employed has been shown to be valid and reliable, but future studies with objective, independent ratings would be useful. As noted earlier, the mechanisms by which the occurrence of recent stressors may have contributed to delays in achieving adequate functioning in various roles remain to be investigated.
Our study had several advantages: it was longitudinal and included both outpatients and inpatients with a recent manic episode. It explored 4 different domains of functioning that are important in most people’s lives, employing a psychometrically established measure of role impairments. Also, the assessment of stressful life events used a well-established interview to obtain full details of the nature and timing of the events, not dependent on subjective interpretations by the participants.
In conclusion, the return of patients who have recently experienced a manic episode to premorbid functioning in multiple roles is an important goal of treatment. The experience of stressful life events may create delays in attaining adequate functional outcomes even after symptomatic recovery. Thus, even after patients recover symptomatically from mania, clinicians should consider how they can be vigilant and helpful in dealing with the disruptions caused by stressful events, thus promoting patients’ rapid return to adequate levels of functioning in important roles.