by Sheri Johnson, Ph.D.
After several years of conducting clinical and research work on unipolar
depression, I sought an internship at Brown University to gain further
exposure to inpatient mood disorders. During my first interview at the
new internship, the client threatened me and angrily left the room. Within
3 days, the same client spent several hours gently explaining his life
and problems with bipolar disorder to me in a softspoken, incredibly well
mannered way. The image of this patient's dramatic and quick changes stayed
with me, and was compounded by watching other patients experience equally
rapid shifts in their moods.
Over the next several years, this image became juxtaposed against unanswered
questions of what contributed to the timing of these shifts. I became
fascinated by questions about whether changes in the psychosocial environment,
particularly life stressors, might influence the timing of recovery and
relapse within bipolar disorder. Although there are certainly strong biological
contributions to the course of bipolar disorder, other diseases, such
as diabetes and cancer, had shown strong relationships with stress.
In 1993, I received a small grant from the National Alliance for Research
on Schizophrenia and Depression (NARSAD) to examine the impact of life
events on the timing of recovery and relapse within bipolar disorder.
Two hypotheses were primary. First, individuals who experienced severe
stressors during their episode were expected to demonstrate slower recovery
than individuals without severe stressors. Second, individuals who experienced
severe stressors following an episode were expected to relapse more quickly
than individuals who did not experience severe stressors.
Preliminary research had examined the relationship between stress and
relapse, but several important confounds would need to be addressed to
understand these relations better.
I became fascinated by questions about whether changes
in the psychosocial environment, particularly life stressors, might influence
the timing of recovery and relapse within bipolar disorder.
First, much of the previous research had asked people to evaluate their
own stress. Unfortunately, depressed individuals tend to perceive their
stressors more negatively (even if the actual events are comparable),
making it difficult to use self ratings of stress within this area. Beyond
problems in accurately capturing stress levels, symptoms of mania and
depression might in fact contribute to stressful environments. For example,
depressed people might develop difficulties at work due to decreased concentration
or difficulties in interpersonal relationships due to social withdrawal
and lack of ability to enjoy pleasurable activities. Similarly, manic
episodes might lead to stress due to overspending, impulsive behavior,
and irritability. To control for these factors would require attention
to whether stressors occurred independently of disorder.
To begin to tease apart stress more carefully, I relied on an interview
based method of assessing life events developed by George Brown and Tirril
Harris, the "Life Events and Difficulties Schedule" (LEDS).
To assess life events, I would interview each subject carefully regarding
a full range of possible stressors in their environment. I reviewed all
stressors with raters who were blind to diagnostic status, who would evaluate
the extent to which the stressor would be severe for the average person,
and the extent to which the stressor might have been created by symptoms
of depression or mania. Events which appeared to be a consequence of a
symptomatology were excluded from all analyses. All subjects were initially
approached during an inpatient hospitalization for bipolar disorder and
were interviewed extensively to verify their diagnosis. After hospital
discharge, my research assistant and I contacted subjects once a month
by telephone to complete standardized interviews of depression and mania
symptoms. Then, at two, six, and twelve months after discharge, I interviewed
subjects regarding life events. To date, 57 subjects have, completed the
study, with ongoing data collection in progress. The data from this small
number of subjects provides some speculative findings.
Life Events and Recovery
Recovery was defined using previously established criteria of minimal
or absent symptoms during symptom interviews and no hospitalizations for
two consecutive months. Individuals were categorized for the presence
(n = 15) or absence (n = 42) of severe events within the first two months
of the episode. Examples of severe events included a sister's diagnosis
with cancer, a series of breakins during the night for a single woman,
and financial disasters which were beyond the influence of the subjects.
To examine the data, I conducted a survival analysis. This procedure
allowed me to compare the median number of months from symptom onset to
recovery for subjects with and without a severe stressor.
Results revealed that subjects who experienced a stressor during the
episode had a median episode duration of 365 days, while subjects who
did not experience a stressor had a median episode duration of 103 days.
In other words, subjects with a stressor took more than three times as
long to recover as subjects without a stressor. While only 60% of the
subjects with a severe stressor had achieved recovery within the follow
up period, 74% of the subjects without a severe stressor had achieved
Life Events and Relapse
Data was available to examine relapse in 33 subjects who achieved full
recovery within the follow up period. Relapse was defined by high scores
on symptom severity measures or the need to be re hospitalized for mood
symptoms. For each of the 33 subjects, the presence or absence of a severe
event after recovery and prior to relapse was determined.
The primary analysis was a survival analysis, to contrast subjects with
and without a severe event on the median number of months from recovery
to relapse. The median survival time for subjects who did not experience
an event was 366 days. For subjects who experienced an event, the median
survival time was 214 days. This would suggest that subjects with a stressor
were able to stay well for two thirds as long as subjects without a severe
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.
Life events appear to have an important role in the
recovery from 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
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
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
(This article was first published in 1995)
SHERI JOHNSON, Ph.D. is am assistant clinical professor at Brown University
and a staff psychologist at Butler Hospital in Providence, Rhode Island.