Adherence to treatment regimen in a lithium carbonate clinic.

Adherence to a prophylactic regimen for primary affective disorder was studied with the Standardized Compliance Questionnaire given to 48 outpatients to determine perceptions of their illness, treatment, mood state, and side effects. Clinicians rated the course of the illness for 12 months. Adherence was defined as lithium level between 0.5 and 1.5 mEq/L and attendance at 75% of clinic appointments for nine months. One patient was nonadherent with both indices, whereas 11 were nonadherent with neither medication regimen or appointment keeping, suggesting that each behavior should be scrutinized separately. Elevated mood was associated with overall nonadherence, marriage was associated with adherence to drug regimen, and perception of continuity of care was associated with appointment-keeping adherence. No association was found between nonadherence and diagnostic subcategory or between adherence and reported side effects. The relationship between nonadherence and poor outcome was significant.

The Family Attitudes Questionnaire. Patients' and spouses' views of bipolar illness.

A newly devised Family Attitudes Questionnaire has been employed to quantify the perceptions of 19 bipolar manic-depressive patients and their well spouses about the etiology, familial risk, and long-term burden of bipolar illness, and to assess their abilities about marriage and childbearing. In this study, 53% of well spouses compared with 5% of patients (P less than .01) would not have had children if they had known more about bipolar illness prior to making these decisions. The overall data suggest that the bipolar patients, compared with his or her spouse, minimizes the burden and denies the heritable/familial nature of affective illness. These findings should be borne in mind for genetic counseling as well as for psychotherapy.

Seasonal affective disorder. A description of the syndrome and preliminary findings with light therapy.

Seasonal affective disorder (SAD) is a syndrome characterized by recurrent depressions that occur annually at the same time each year. We describe 29 patients with SAD; most of them had a bipolar affective disorder, especially bipolar II, and their depressions were generally characterized by hypersomnia, overeating, and carbohydrate craving and seemed to respond to changes in climate and latitude. Sleep recordings in nine depressed patients confirmed the presence of hypersomnia and showed increased sleep latency and reduced slow-wave (delta) sleep. Preliminary studies in 11 patients suggest that extending the photoperiod with bright artificial light has an antidepressant effect.

A comparison of outcome in adolescent- and later-onset bipolar manic-depressive illness.

The authors hypothesized that childhood-and adolescent-onset bipolar manic-depressive patients might have a more severe or a different type of affective disorder; early-onset patients were therefore compared with patients whose illness onset was after the age of 45. The results indicate that early age of onset is not a factor in the variable course and prognosis of manic-depressive illness.

The impact of normal volunteers on a psychiatric research unit.

Normal subjects were admitted to a psychiatric unit devoted to the study and treatment of affective illness. Initially the authors were concerned about the difficulties volunteers might have living with psychiatric patients. However, the volunteers adjusted with relative ease, while the patients' depressive symptoms were exacerbated. Their confrontation with the volunteers "normality" triggered an acute awareness of their underlying sense of failure. This response is analogous to depressed patients' reactions before discharge, when they struggle not only with their special vulnerability to separation and loss but with inevitable challenges to their fragile self-esteem during reintegration into the outside world. The presence of normal volunteers highlighted these issues and led to increased therapeutic work and considerable resolution.

Rapidly cycling bipolar disorder and multiple sclerosis.

The authors describe two patients with rapidly cycling bipolar disorder who were found to have multiple sclerosis. They suggest that multiple sclerosis be considered in the differential diagnosis of patients who have affective disorders and minor neurological complaints.

Early child-rearing practices in families with a manic-depressive parent.

Nurturing attitudes and behaviors among seven married couples, each of which contained one partner who had manic-depressive illness, and their young children were compared with those of normal control families. Mothers from index families, in contrast to control mothers, were less attentive to their children's health needs, emphasized performance in some achievement-related areas, were more overprotective, and reported more negative affect toward the child. They also were more disorganized, less active with their children, and more unhappy, tense, and ineffective. Index parents secured lower scores in the areas of family interaction and social adjustment, and they experienced situational problems of considerable severity, including clinical depression in the well parent.

A follow-up investigation of offspring of parents with bipolar disorder.

Seven male children who each had a manic-depressive parent (five alos had a parent with unipolar depression) and 12 control children were studied. The proband children had shown a range of adjustment problems as infants and toddlers. Four years later, they continued to have substantial behavior problems, including ones that could be classified as DSM-III psychiatric diagnoses. On the basis of psychiatric interviews and psychological assessments, the proband children received more DSM-III diagnoses than the control children. Proband children reported internalizing symptoms; this pattern was corroborated by their mothers, who also characterized these children as showing antisocial behavior patterns.

Problem behaviors and peer interactions of young children with a manic-depressive parent.

By the age of 2 years, children with a manic-depressive parent were already found to be experiencing substantial psychiatric problems. The authors examined the ways in which these early problems then become embedded in social relationships. Naturalistic observations and experimental manipulations of the emotional environment were used to measure 2-year-old children's regulation of emotion, aggression, and altruism during peer interactions. Children with a manic-depressive parent had difficulty in sharing with their friends and in handling hostility, showing maladaptive patterns of aggression. The social and emotional problems of these children were similar to the interpersonal problems of their manic-depressive parents.

A comparison of nonpatient and bipolar patient-well spouse couples.

The authors compared responses of 16 couples, in which one partner had a diagnosis of remitted bipolar illness, to a lengthy self-report questionnaire (KDS-15) designed to assess many aspects of marital adjustment with those of 16 matched nonpatient couples. The bipolar patient-well spouse couples had marital adjustments closely resembling those of the nonpatient couples; three of four global ratings of satisfaction failed to discriminate between the two groups. Perceptions of the courtship, first year of marriage, and the degree to which the marriage had met expectations were also similar for both groups.

Monoamine metabolites in cerebrospinal fluid of depressive subgroups.

Lumbar punctures were performed on 69 patients who met Research Diagnostic Criteria (RDC) for major affective disorder, while they were drug-free and depressed. None of the patients met RDC for alcoholism. Cerebrospinal fluid 5-hydroxyindoleacetic acid (5-HIAA) and homovanillic acid (HVA) were measured by fluorometry and 3-methoxy-4-hydroxyphenylglycol (MHPG) by gas chromatography. Family histories were ascertained by systematic interviews of patients and their relatives, and diagnoses were made by family history diagnostic criteria (Andreasen et al., 1977). Depressed patients with alcoholism in a first degree relative had significantly lower levels of 5-HIAA and MHPG than patients without a family history of alcoholism (p < 0.05). No difference in HVA levels was found. The metabolite differences remained significant when the influence of sex ratio was considered. These results are in agreement with previous work linking alcoholism to abnormal serotonin metabolism. They provide further biochemical evidence of distinct genetic subtypes of affective disorder along lines suggested by Winokur (1979a, 1979b), and illustrate the usefulness of the family history method in defining patient subgroups.

Couples group therapy as an adjunct to lithium maintenance of the manic patient.

Use of couples therapy groups in conjunction with lithium in the long-term management of married manic-depressive patients is described. Among bipolar patients on lithium, those in couples group therapy had more benign posthospital course than those given minimal support beyond medication. The structure and benefits of the couples group are discussed.

The married manic.

In group psychotherapy and follow-up studies, the interpersonal relationships and psychodynamics of the married manic depressive patient and spouse were studied. Prominent among these subjects were massive denial of grief, rage, and dependency in the context of symbiotic relationships; and the absence of a father during early development. Clinical expressions of these factors are presented, and therapeutic implications are discussed.

Advanced technology within the cardiac transplant process.

The field of cardiac transplantation is still undergoing changes in every sphere from donor management to long-term care of the recipients as research-based experience highlights new and exciting boundaries. This paper contains discussion of one aspect of the pretransplant support that some patients may require, including examples of the impact of technology on nursing care with specific reference to 'bridges to transplantation', and some dilemmas faced by transplant teams. Consideration of some effects of bridging is followed by suggestions for transplant nursing teams' ongoing development within this changing field in order to provide optimum nursing care.

Postpartum mania in bipolar manic-depressive patients withdrawn from lithium carbonate.

Three women, previously diagnosed as bipolar I manic-depressive, were withdrawn from lithium carbonate prophylaxis immediately prior to their pregnancies. The patients had been euthymic while on lithium carbonate for at least 3 1/2 years prior to their pregnancies. Two of the three patients developed a manic syndrome within 2 weeks postpartum. The use of lithium carbonate during pregnancy, and particularly in the postpartum period, requires reassessment. We advocate an ongoing clinical relationship and the reinstitution of lithium in the third trimester in most cases.