Retrospective Studies

Several retrospective studies relied on review of medical charts to assess life events in patients with bipolar disorder. Based on retrospective chart review, Leff, Fischer, and Bertelson (1976) found that 35% of bipolar inpa-tients reported a stressful event rated as independent of their behavior in the month prior to onset of episode. Clancy, Crowe, Winokur, and Morrison (1973) also used retrospective chart review and found that 39% of unipolar, 27% of bipolar, and 11% of schizophrenic patients had a stressful event in the 3 months prior to onset of their disorder. No significant differences were found for types of precipitating stressful events for bipolar versus unipolar patients. Ambelas (1979, 1987) conducted two retrospective chart review studies. In the 1979 study, 28% of 67 hypomanic or manic inpatients versus 6% of 60 surgical control patients had experienced an independent stressful event during the 4 weeks prior to hospital admission. In almost all the cases reported, the stressful event precipitating mania or hypomania was a loss or threat event. In his study of 90 bipolar manic in-patients, Ambelas (1987) found that compared with 8% of an age-matched surgical control group, 66% of first episode bipolar patients and 20% of repeat admission bipolar patients reported a severe independent event in the 4 weeks before admission.

An improvement over retrospective chart reviews is represented by retrospective studies that actually conducted interviews with or administered questionnaires to bipolar individuals regarding their past experiences of life events. Only some of these studies assessed the independence of the events from bipolar individuals' behavior and differentiated manic from depressive episodes. Glassner, Haldipur, and Dessauersmith (1979) retrospectively interviewed 25 bipolar patients and their relatives about the patients' life events preceding their first and most recent episodes of disorder. They found that 75% of first episode and 56% of subsequent episode patients reported a stressful event prior to onset. Utilizing the same methodology with 46 bipolar patients and their relatives, Glassner and Haldipur (1983) reported that 64% of late onset (onset after age 20) versus 23% of early onset bipolar patients reported a stressful event preceding their initial episode. Bidzinska (1984) reported that acute and chronic stress preceded the onset of illness in 90% of bipolar and 89.4% of unipolar patients in Warsaw, with no differences between men and women in either group. However, bipolar patients reported more work-related stressors than did unipolar patients. In a study of 79 bipolar patients attending a lithium clinic that did distinguish between manic and depressive episodes, Dunner, Patrick, and Fieve (1979) retrospectively assessed stressful events occurring in a 3-month period prior to the initial or later episodes of depression or mania. About one half of the patients recalled a stressful event in the 3 months before their initial episode and an increase in work and interpersonal difficulties was associated with onset of a manic versus a depressed episode.

Most of the retrospective studies that examined relatively independent stressful events also found that bipolar individuals experienced increased stress prior to episode onsets. Kennedy, Thompson, Stancer, Roy, and Persad (1983) found that compared to control participants or to the period following admission to the hospital, manic patients experienced twice as many stressful events during the 4-month period prior to hospital admission. Life events having significant objective, negative, and traumatic impact were distinctly more common prior to admission, independent of the affective illness. Among bipolar patients in a lithium clinic, Aronson and Shukla (1987) found a significant increase in relapse 2 weeks after a major hurricane, a severe independent life event. Although there were no differences between relapsers and nonrelapsers in age, duration of illness, or lithium level, relapsers had less symptom stability before the hurricane than did nonrelapsers. Joffe, MacDonald, and Kutcher (1989) matched 14 recently relapsed manics to more stable bipolar patients and also found significantly more uncontrollable and unexpected life events among the relapsers prior to onset. Similarly, Davenport and Adland (1982) reported a 50% onset rate of mood disorder episodes among 40 bipolar men during or immediately following their wives' pregnancies.

In a sample of remitted depressed bipolar and unipolar patients retrospectively assessed over a long 1-year interval, Perris (1984) found that bipolar patients reported an average of 2.5 independent events and unipolar patients reported an average of 1.9 independent events in the year prior to episode onset. Using both a retrospective and prospective design, Sclare and Creed (1990) reported that manic patients experienced more independent events prior to onset than after recovery. In a study of manic, psy-chotically depressed, and schizophrenic patients and nonpsychiatric controls, Bebbington et al. (1993) reported that the psychotically depressed patients experienced more severe, independent life events in the 6 months prior to onset of psychosis than did both manic and schizophrenic patients. However, the manic patients also reported more severe, independent events prior to relapse than did the nonpsychiatric controls. In contrast, Chung, Langeluddecke, and Tennant (1986) found that the rate of independent threatening events in the 26 weeks prior to onset for 14 manic patients did not differ significantly from that of controls (even though the rate was twice as high in the manics). Finally, in a retrospective study of childhood stressful events, Grandin, Alloy, and Abramson (2004) pointed out that compared to demographically matched normal controls, bipolar spectrum (Bipolar II, Cyclothymic, Bipolar NOS) participants experienced more childhood stressors that were independent of their behavior prior to the age of onset of their bipolar symptomatology.

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