Bipolar disorders across the lifespan

For several decades, psychological research on bipolar disorder languished. The robust heritability of the disorder (Vehmanen, Kaprio, & Loennqvist, 1995), coupled with the great gains provided by lithium (Keller et al., 1992), led to a biological zeitgeist. Few psychologists considered the disorder as a target for their work, and the portfolio of NIMH grants for the disorder was quite small. In 1988, an NIH task force was convened to evaluate the state of findings, and their recommendations led to a significant change in the field (Prien & Potter, 1988). Acknowledging the high relapse rates on medications alone, they pushed for more basic research on the predictors of symptoms, as well as more research on psychosocial treatments to supplement medication approaches. Within a few years, a set of psychological treatment outcome trials were funded. These trials did more than supply a set of treatment outcome findings; they increased the visibility of the disorder in psychology departments and at psychology conferences. Within the last 10 years, this visibility has paid off in a new generation of trainees who are entering the field and tackling a broader and broader array of topics. During this time, several issues have become particularly pertinent. Of concern, the rate of bipolar diagnoses among children and adolescents has ballooned; by one recent estimate, treatment visits for childhood and adolescent bipolar disorder have increased 50-fold within the past 10 years (Moreno et al., 2007). Questions have been raised about how to validate developmentally appropriate criteria, while attending to the significant costs of either under- or over-diagnosing the disorder. In this vein, perhaps the most significant public health need is the development of reliable and valid tools to facilitate accurate diagnosis among children and adolescents. Hence, our first articles in this section provide new data regarding these issues. Dr. Henry and colleagues provide an excellent psychometric summary of a parent-report instrument they have developed to facilitate identification of childhood and adolescent bipolar disorder. Dr. Youngstrom and associates provide data on the appropriate role of teacher data in diagnosing bipolar disorder among youth. Second, it has become clear that the risk factors for mania are quite distinct from those involved in other psychopathologies, including anxiety and depression (cf. Johnson, 2005). There is a need to understand the predictors of the course of symptoms. In this special issue, we are fortunate to be able to include articles on several key risk factors: temperament, family environment, and cognitive variables. Dr. West and colleagues provide data about the role of temperament in early-onset bipolar disorder. Dr. Schenkel and colleagues examine parent-child relationships in young children with bipolar disorder, while Dr. Miklowitz and associates also examine how family patterns of expressed emotion relate to the clinical features of adolescents with bipolar disorder. Dr. Mansell and his colleagues report on the HAPPI scale, designed to capture a set of cognitive dimensions related to mania, from beliefs about poor control over mood to overly confident reactions to success. Findings from their study suggest that each of the five subscales correlate with a measure of hypomania risk. While much remains to be learned, these works contribute to a growing understanding of psychosocial variables associated with the course of illness. Third, with rates of treatment disengagement as high as 50%, a key question is how to predict who will take part in medication treatments. Drs. Johnson and Fulford provide findings on a brief self-report scale that predicts lithium adherence and symptom levels over time. Fourth, given current levels of treatment nonresponse, treatment development is a core goal. Two articles, one by Shen and colleagues and another by Totterdell and colleague, provide data on whether social rhythms can be modified among persons with bipolar spectrum disorders and whether this then yields symptom improvements. The designs are intriguing for their specificity. Whereas most empirically supported treatments have incorporated a broad range of intervention strategies, these two articles focus on directly changing social rhythms, in keeping with previous case studies demonstrating that sleep regulation can be helpful in reducing bipolar symptoms (Wehr et al., 1998). These two articles are unique in examining intervention ideas within less severe bipolar spectrum disorders. Although Shen’s brief intervention, instruction to improve social rhythms, improved the regularity of schedules, they did not find that symptom scores were significantly improved by the intervention. Dr. Totterdell and Kellett, though, report on a much more intensive case study of a circadian rhythm intervention offered to a person with cyclothymia, which achieved some excellent outcomes. Taken together, this section provides some intriguing evidence that social rhythms can be improved, but that fairly intensive intervention might be needed before achieving symptom gains with this approach. Finally, previous research has indicated disturbing rates of suicide attempts and completed suicides in bipolar disorder. For example, people with bipolar disorder have been found to demonstrate a 12- to 15-fold increase in completed suicide compared to the general population (Angst, Staussen, Clayton, & Angst, 2002). Dr. Bryan and colleagues examine a host of personality and symptom variables, and they find that hypomanic symptoms are an important predictor of recurrent suicide attempts among military personnel with a history of suicidal behavior. Dr. Klimes-Dougan and her colleagues report on the first adulthood follow-up on offspring of unipolar and bipolar parents. Findings suggest that the offspring of unipolar mothers demonstrate an earlier onset of suicidality and higher frequency of recurrence throughout adolescence and early adulthood. By early adulthood, though, both groups reported comparable levels of suicidal content. Taken together, these findings suggest that clinicians working with persons who have bipolar disorder would do well to consider the risks of recurrent suicidal behavior, as well as the effects bipolar illness can have on the offspring of these persons, including increased risk for suicidality. That is, the scope of concerns may be broad and long-term. In sum, the findings that appear in this special issue help inform the reader about early and adulthood forms of the disorder. These articles provide better assessment tools, more specificity about the multiple risk factors to be considered in predicting the course of disorder, and bolster treatment development ideas. Most important, they provide insight into one of the most significant public health needs: suicidality within this disorder. Although the findings in this special issue provide a number of informative and helpful suggestions for clinicians, they also highlight how much more we need to learn about this disorder. We hope these findings provide a framework for clinicians to think more broadly about relevant issues and also for researchers to think about the next steps in the field.