Journal of Affect& e Disordeu, 25 ( E992) 22 1-228 0 1992 Elsevier Science Publishers B.V. Al1 rights reserved 0165~0327/92/$X15.00
e sock
221
ar affective Remans and Heather M. McPherson Otago Medical .%hoo/, Unirersiry of C&ago,Dunedin, New Ze dand (Received 2 January 1992) (Revision received 13 April 1992) (Accepted 27 April 1992)
Summary The social interaction parameters of a carefully delineated group of bipolar patients were compared to those of a random New Zealand community sample. The bipolar subjects had significantly lower scores for perceived availability and adequacy of both intimate and diffuse social relationships. Their mean scores did not differ from those of the subgroup in the random community survey who were classified as showing psychiatric morbidity, most of whom were depressed. Social interaction scores were negatively correlated with the bipolar patients’ age and duration of illness. Those bipolar subjects with a predominance of manic episodes had lower mean values foi* their social interaction indices than those with more depressions. The results may suggest that the longer the illness continues, the greater is the impoverishment of the sufferer’s social interaction patterns. Overall, manic episodes appeared to have a more deleterious effect on social relationships than depressive episodes.
Key lords= Bipolar; Social networks; Social support; Depression;
ntroduction Good health, both psychological and physical, and good social relationships have frequently been linked statistically (Surtees 1980; Henderson et al., 1981; Henderson, 1984; Brugha, 1989). A recent review of several prospective studies showed that subsequent increased mortality was
Correspondence to: Sarah Romans, Department of Psychological Medicine, Otago Medical School, P.O. Box 913, Dunedin, New Zealand.
Mania; ISSI
preceded by poor social networks (House et al., 1988). Mechanisms involved in these relationships have not been delineated (Bloom, 1990). Most of the studies linking psychiatric illness to poor social networks have focused on neurotic or nonpsychotic disorders, probably because they are widely believed to be more reactive in nature and thus more likely to show differences in psychosocial factors such as social relationships. Bipolar affective disorder has been poorly studied. It is known that bipolar disorder is associated with an impaired ability to establis’? and
maintail? st;iblc marital relationships U3rodie alld Ecff. N71; kveckc ct al., lY75; Geene c1 al.. iY7(j: Dunner et al.. lY76: Hoover and Fitiger:lld. lYX1: Tat-gum et al.. 19Sl: Mcrkangas. 1983: &wdfyin and Jamison, 1990: McPherwn et al.. lYY2). However, there has been very little delineation of more diffuse or non-intimate r&tionships formed by bipolar patients. The destructive effi;cts of depressive illness on interpersonal relationships. both intimate and diffuse, have been described by several authors. Charney and colleagucc studied personality traits and disorder in 160 depressed patients. a quarter of whom were bipolar K’harney et al., lY,Yl). They identified the ongoing deleterious effect of depression and suggested that an earlier onset of depression may result in functional impairment that is later viewed as personality disorder. A detailed study of the spouses of depressed patients showed that living with the illness was burdensome and adverrely affected the couple’s marital and sexual relationship. their social and leisure activities and their financial security (Fadden et al., 1987). Spouses of the bipolar patients were more likely to consider marital separation than the spouses of unipolar depressive patients. The ability to confide was eroded and the patient’s tendencies to ‘worry and nag’ and their irritability were difficult for the spouse to endure. As these symptoms overlap with normal behaviour. they may not be conccptualised by the spouse as a symptom, due to the depressive illness. The view that relatives may cope better with symptoms which they clearly view as arising from an illness, has been made cogently recently (Hooley et al., 1987). The impact of manic behaviour on the patients’ close contacts has also been described (Janowsky et al., 1970, 1974; Ablon et al., 1975). During the episode, the manic person challenges. taunts, belittles and humili;ltes their loved ones. In contrast to the work of Fadden and colleagues, Janowsksy’s group has writterl that spouses of manic patients are more likely than spouses of depressed patients to consider separation from their marital partner. MacVane and colleagues noted anecdotally the subjective experience reported by manic-depres-
sivc paiients when describing their pre-lithiklm years; many related past feeling:; of helplessness, Lnd alarm associated with lack of control over t occurrcncc of scvcrc mood swings (MacVane et al.. 192iXJ.They spoke of the pervasively disruptive effects they thought I cse episodes had on their lives in terms of employment, family, social relationships and their self-concept. CJiven the import;mW of ~cial relations the onset and rccwery from unipolas depressive disorder, it is important io inwstigate their PO also in bipo!ar illness. It might be that the normal psychological function showa~ by bipoilx patients during euthymic periods protected social relationships, in contrast to the poor relationships of chronic schizophrenic p:ltients. This paper describes a study of bipolar patients which aimed is assess the importance of a number of psychosocial factors in the outcome of bipolar affective disorder prospectively over two years. The first year’s data on social networks, clinical course and demographic factors are reported.
A cohort of Research Diagnostic Criteria (RDC) bipolar patients is being foil tively in Dunedin. New Zealand lY78bI. In order to enter the c were required to have been adm the three local hospitals with an inpatient psychiatric ward between 1.1.1985 and 31.12.1987. Permission to search the hospital notes was obtained from the ethical committee of the Qtago Area Health Board. Patients with a current address in the greater Dunedin residential area, aged over fifteen and under sixty five years an nia or depression was not secondary to a known organiz disorder were designated for entry to the cohort. All hospital records wit an admission or discharge diagnosis of bipolar disorder definite or possible, were screened by the research psychiatrists to determine whether the clinical details suggested a classification of bipolar disorder. All such patients were then invited to attend a diagnostic interview using the Schedule for Schizophrenia and Affective Disorders (Spitzer et al.,
1978a). They underwent a detlrilcd initial interwhich collected clinical and socio-demoy a&-e being re-interviewed at three mont intervals and when a relapse occurs. The duration of eir illness was calculated by subtracting hOill t which they first experienced an a regardless of whethe view
network parameters of the bipolar cohort were assessed using t!-re Interview Schedule for Social Interaction Wenderson et al., 1981). fift;Nsvo item inte iew, taking some 30 n to administer. w h obtains informae instrumental and affectional aspects of social relationships. I3ot the availab%ty and equdcy of two classes of social relationship; a) intimate, cal!ed attachments and b) more diffuse interactions, called social integration by the authors, are quantified. To assess the adequacy of some aspect of an interpersonal relatiortship, the res o~dents were asked whether they would like more, err less of rhat element or whether they are satisfied with what they have at present. Etements of intimate relationships, or attashmcnts, assessed include: talking frankly, discussing irritating and unpleasant experiences, sharing happiness, being known well by, feeling able to lean on, confiding in and being comforted physically by someone else and having other pzople dependent for their welfare on oneself. The index, ADAT% gives the percentage of attachments which the respondent finds adequate. The elemen+s of social integration covered are casual conversations, recognising people on the street, knowing people with similar interests, socialising with work colleagues, receiving positive feedback, being able to ask small favours such as borrowing tools or cooking items, and turning to in times of difficulty. The original ISSI study found no gender differences in social interaction in subjects under sixty-five years of age (Henderson et al., 1980. This paper presents the results of the first qet of sociai interaction interviews, given towtirds the end of the first year of data collection. Care was taken to ensure that the subjects were euthymic at the time of their social network assessment in
order tc remove distorted judgement arising from a mood abnormality. ‘The fSSB had been used previously in Dunedin as part of a random community epidemiological study of fcmsfe psychiatric morbidity, the Otago Women’s Health Survey CRomans-Clarkson et al., 1988). The ISSI results from that study were used as a normative data set, to compare with the qualip] of the social interactions of this bipolar cohort. The randomly selected interview sample was chosen from three psychological strata on a preliminary postal questionnajre which used the General Health Questionnai e as a Screen for psychiatric morbidity (Roman+Clarkson et al., 1988). The results here are weighted back to the parent population. Both the results from the total community sample of women aged under sixty-five years (non-cases and case-!, and from only those women who were PST ,.rse~ awere conipareJ siatisticaliy to the r++ults for the bipolar group. Unlike the bipolar patients, the community sample had only one interview. Those classifies as cases were symptomatic at the time of their ISSI evaluation. The bipolar group was divided into rhose who had experienced more manic than depressive episodes during the course of their illness (N = 30. 517%) including nine with only manic episodes ;nd on the other hand those with more depressive than manic episodes (N = 28 or 38.3%). The social relationship USSI? indices of these two groups were also compared. Statistics used included Student’s t-tests, chi sq;lare and Pearson’s correlation coefficients as appropriaie. Results
The chart review indentified ninety-one patients with a likely diagnosis of bipolar disorder. Sixty-four of these (70%) responded to our request that they attend an assessment interview. Twelve had moved from the area and therefore were not available for the detailed quarterly interviews, one died frcm septicaemia consequent on osteomyelitis after agreeing to participate but before her assessment and thirteen (14.3%) refused outright. Of the sixty-four assessed, fifty-
eight were found to meet RDC criteria and they comprise the original Dunedin cohort. Some six subjects were lost from the study during the first year, two by suicide with four moving out of the research area. Thus fifty-two bipolar subjects have provided information on their social interactions. The average age of the original fifty-eight subjects, twenty-eight (48%) male and thirty female (52%) at entry to the study was 37 years, (SD 12 years, range 18 to 44 years). Only 14 (24.2%) were currently in a marital relationship, half (29) had never been married and over a quarter (15, 26%) were separated or divorced. The significantly fewer married and greater numbers who were either never married, separated or divorced when compared to the general population aged 18-65 years has been reported previously (McPherson et al., in press). Most, 34 (51%) were not in paid employment: 13 (22%) had part-time employment and 11(16%) full time employment. Married patients were much more likely than the non-married patients to be in paid employment (xl 10.52, df 1, P = 0.001). Most 40/S& 69% received a government sickness or unemployment benefit. The average age at which the subjects experienced their first episode of illness, whether hospitalised or not, was 24 years (SD 9.5 years, range 12-55 years). All met criteria for Bipolar der. The average number of manic episodes in-
eluding the index hospitalisation was five (SD 4, range l- 16). Twelve subjects (20.7%) had not experienced any depressive episodes. The average number of major depressions in the rest was 6.7 (SD 14, range l- 10 plus). There were 47 women in the co~~~~i~ sample of 232 women aged under sixty five classified as PSE (short) cases; these in with depression, two with generalised anxiety, four with phobia and two with mania/hypomania. When these raw data were weighted back to the parent population, 6.4% wet-2 found to show psychiatric morbidity, 85.7% of whom were depressed. Of those depressed, 63% were married or cohabiting, 12% had never marrie were widowed, separated or divorced. lar subjects (44/58, 76%) than random community depression cases of similar age (s/13, 38%) were not married (Fisher exact, 2-tailed P = 0.02). The numbers were too small to analyse the ‘never married’ separately from those widowed or separated/divorced.
The mean values obtained for t ISSI indices are shown in Table 1, which also gives the mean values from the random community sample of women All the ISSI scores fcr the
TABLE 1 Social network values ( + SD) of bipolar cohort vs. random community sample of Otago women Bipolar
P
Otago Women
;v
5’
232
Availability of Attachment
5.1 f2.3
5.9+ 1.3
Adequacy of Attachment % Attachment Adequate
6.4 t_3.3
9.5 f
Availability of Social Integration Adequacy of Social Integration
55.5% 7.2 f 4.2 11.1 k4.4
2.6
84.47c
< 0.02 < 2.001 < 0.001
9.1 i3.2
< 0.01
13.9 _t 2.8
-C0.001
225 TABLE 2 Marital status, employment
and social network values + SD sf bipolar patients
Married
Not married
N
14
AVAT ADAT ADAT% AVSI ADSH
7.4+ 8.4* 71.1+ 8.6+ 12.5&
1.1 1.9 15.2 3.3 3.0
P
Employed
NC3 employed
38
23
29
4.2* 2.0 5.7* 3.4 49.7 I 28.9 6.7d_ 4.4 10.6f 4.7
6.3& 1.9 ?.6+ 3.5 64.7 6 22.0 8.9+ 3.9 12.2t_ 3.2
4.1-L 2.1 5.5+ 3.5 48.2 f 29.5 5.9+ 3.9 10.2f 5.0
0.09
bipolar cohort were significantly less than the mean scores for the ran om community sample There were no gender differences in the ISSI mean scores of the bipolar affective disorder subjects, which confirmed the acceptability of a comparison group composed of female subjects only. There was no statistical difference on any ISSI index for the bipolar patients and those women in the community study who were cases of psychiwere married or in paid employment gave higher ISSI scores than did the notmarried and unemployed particularly on attachment indices. See Table 2. There was a negative correlation between age ent scores, both availability and adequacy. See Table 3. A trend at the IO% ievel was also present for older patients to have poorer availability of social integration. Patients with longer duration of their bipolar affective disorder had lower mean scores for availability of attach-
TABLE 3 Age, duration of biploar illness and sociai network values (Pearson’s correlations)
AVAT ADAT ADAT% AVSl ADSI
Age
P
r
P
Duration of Illness r P
- 0.26 - 0.22 -0.19 - 0.22 -0.07
0.03 0.05 0.09 0.06 ns
- 0.23 -0.16 -0.15 - 0.28 -0.01
0.05 ns ns 0.02 ns
P
< 0.001 0.02 0.02 0.008 0.09
ment and social integration; there was no such link for the adequacy indices. The patients with a predominance of manic episodes were more likely to be not married (either single, separated or divorced) than married or in a cohabiting relationship (A 2 3.96, df 1, P = 0.05). There were no differences in gender or paid employment between the mostly manic patients and the mostly depressed patients. There was a statistical trend present at the 10% level for the mostly manic patients to describe less adequate attachments (t = - 1.75, df 50, P = 0.086) and less available social integration (t = - 1.91, df 50, P = 0.062). They also had fewer recent arguments and rows (P = 0.03) and were more accepting of absent relationships (P = 0.04). Discussian This study showed clearly that bipolar affective disorder patients have impoverished social relationships, when compared to a random community New Zealand sample. The bipolar group has social interaction results that were as poor as the diagnosable cases in the community sample of women (Remans-Clarkson et al., 1992). In addition to their increased rates of marital fai!ure, this study shows that bipolar patients also have major problems with their more diffuse social relationships. The Interview Schedule for Social Interaction (ISSI) was chosen from amongst the many published instruments as the method of assessing social relationships because its reliability and va-
]j;t~e been asscSscd (Henderson ct al.. 1Wl: Orth-Gonlcr tind Undcn, 1087; O’Reilly, 1%8). &o. it had b~cn previously used in two large pr~,sptxti~vc studies. one Australian and one in the same New Zealand area as this bipolar affecfiir6: disorder study (Henderson et al.. lW1; Roman&larkson et al.. 198X). There were no gendcr differences in social interaction indices for the random community sample of adults under sixty-five (Henderson et al., 1981). Thus the social nctM’c,rk results from the New Zealand fcmalconly random community sample project seemed an appropriate control data sea There was one potentially relevant difference in the manner in which the ISSI data were collected for the community sample of women. Those cl:issificd as PSE ~1st‘~ were .qnlptomatic aa the time of the ISSI. They may have evalua.lted their social networks more negatively than they would have done when they were weil. The conclusion is that the bipolar patients had social network indices at Ieast as low as the community cases; it is possible that the community cases of depression had social interaction indicts that were artificially lowered by an abnormal mood state. This comparison would be better if conducted when both groclps were in remission. The importance of social networks and support in the genesis and maintenance of unipolar depression and anxiety disorders have been well described (Brown et al., 19Xh; Surtees, 1980). Th1‘s1‘ yJs>ChrJ\cGal dimensions are also clearly relevant in bipolar disorder. In general, being married and being in paid employment are associated with having good diffuse social relationships, and the bipolar patients wcrc not different in this regard. Paid employment provides enhanced opportunities for workbased social contacts as well as meaningful and socially valued activities. Good social function in the one area of intimate relationships is associatcd with good function in the more general interpersonal relationships as well as the employment arena. Theoretically, there are at ieast four ways in which poor social relationships and bipolar affective disorder might be causally linked; these putative mechanisms are not mutually exclusive. Poor social relationships may result in the onset or lidity
maintczznce of illness episodes, the illness may adversely affect social relationships, both the illness and social relationships may adversely affect each other in a cumulative way or fin the illness and the poor social function caused by a third factor, such experiences or personality. here are consistent with t progressively erodes the socia ships of the bipolar group. only come from prospectiv out bipolar reriearch lends some support to the view that the bipolar disorder is deleterious to social networks Joyce, replicating previous found no difference in the quality of chil relationships with parents between 58 bipolar patlcnts and 100 general practice patie 1%4. He concluded that, unlike minor psychiatric morbidity, bipolar disorder is not caused by early childhood experiences. The implication from this study was that any interpersonal difficulties arose later, in adult life, around the time of illness onset. The association between tion and greater psycl~osoci been described previously. that the frequent marital an Polish bipolar patients wcrc with age (Bidzinska, 19831. ported that older bipolar pa episodes had very small social networks (Sclare and Creed., I990). Two studies superficially a ar to suggest that bipolar patients function wesl ychosocially, and might seem to contradict hero. Careful reading shows t bet h these works was to corn group when stabilised on modern treatments with their lives before they were adequately treated. unner and colleagues ex six areas of socinl adjustment (work, ime, marital, parental, family and extended family) in patients with primary affective disorder, 85% (N = 143) of whom were bipolar C unner et al 1978). The results suggested ‘good although not optimum’ adjustment although in the absence of a control group it is difficult to assess the extent of the impairment. The authors cautioned against ‘indiscriminant treatment with psychotherapy’, leav-
E
Fadden. G.. Bebbington. P. and Kuipers, L. (1987) Caring and its burdens: a study of the spouses of depressed patients. Br. J. Psychiat. 151. 660-667. Gooduin. F.K. and Jamison, K.R. i 1990) Manic-depressive illness. Oxford University Press. New York. Greene, B.L.. Lustig. N. and Lee, R.R. (1976) Marital therapy when one spouse has L(primary affective disorder. Am. J. Psychiat. 133, 827-830. Henderson, AS. (1984) Interpreting the evidence on social support. Social Psychiat. 19. 39-52. Henderson, S., Byrne, D.G. and Duncan-Jones. P. (1981). Neurosis and the social environment. Acad. Press. Sydney. Hooley. _’M., Richters. J.E.. Weintraub. S. and Neale. J.M. (1987) Psychopathology and marital distress: the positive side of positive symptoms. J. Abnorm. Psychol. 96. 27-33. House. J.S.. Landis. K.R. and Umberson. D. (1988). Social relationships and health. Science 241. 530-535. Hoover, C.F. and Fitzgerald. R.G. (1981) Marital conflict of manic-depressive patients. Arch. Gen. Psychiat. 38. hS--67. Janousky. D.S.. Leff. M. and Epstein. R.S. (1970) Playing the manic game: interpersonal maneuvers of the acutely manic patient. Arch. Gen. Psychiat . .“..s, 71 w* ?7-261. _ Janowsky. D.S., Yousef. M.K. and Davis. J.M. (1974) Interpersonal manoeuvres of manic patients. Am. J. Psychiat. 131, 250-25s. Joyce. P. (1983) Parental bonding in bipolar affective disorder. J. Affect. Dis. 7, 319-324. Lepkifker. E.. Horesh, N. and Floru. S. (1988) Life satisfaction and adjustment in lithium-treated affective patients in remission. Acta Psychiat. &and. 7X. 391-395. MacVane. J.R.. Lange. J.D.. Brown, W.A. and Zayat, M. (1978) Psychological functioning of bipolar manic-depressive patients in remission. Arch. Gen. Psychiat. 35. 13511354. McPherson. H.M.. Dot-e. G.L.. Loan. P.A. and Remans. S.E.
(1992) Socio-economic characteristics of a Dunedin sample of bipolar patients, N. Zealand Med. J. 105, 161-162. Merikangas, K.R. (1984) Divorce and assortive mating among depressed patients. Am. J. Psychiat. 141. 74-76. O’Reilly, P. (1988) Methodological issues in social support and social network research. Sot. Sci. Med. 26, 863-873. Orth-Gomer, K. and Unden, A.L. (19871 The measurement of social support in population surveys. Sot. Sci. Med. 24, x3-94. Roman+Clarkson, S.E., Walton, V.A., Herbison, G.P. and Mullen. P.E. (19881 Marriage, motherhood and psychiatric morbidity in New Zealand. PsychoLog. Med. I$, 983-990. Roman+Clarkson. S.E., Walton, V.A., Herbison, 6. Mullen, P.E. 419921 Social networks and psychiatric morbidity in New Zealand women. Austral. New Zealand J. Psychiat. Sclare. P. and Creed, F. (1990) Life events and the onset of mania. Br. J. Psychiat. 156, SO&S14. Spitzer. R.L. and Endicott, J. il978aS Schedule for Affective Disorders and Schizophrenia. New York: Biometrics Research, Evaluation Section, New York State Psychiatric Institute. Spitzer. R., Endicott, J. and Robins, E. (1978b3) Research diagnostic criteria: rationale and reliability. Arch Gen. Psychiat. 35, 773-782. Surtees. P.G. (1980) Social support, residual adversity and depressive outcome. Sot. Psychiat. 71-80. Targum. S.D.. Dibble. E., Davenport, Y.B. and Gershon, E.S. (19811 The family attitudes questionnaire; patients’ and spouses’ views of bipolar illness. Arch. Gen. Psychiat. 38, 562-568. Weeke. A.. Billc. M., Videbech, T.. Dupont, A. and JueJ-Neilson, N. Incidence of depressive syndromes in a Danish county. The Aarhus Study. Acta Psychiat. Scawd. 51.28-41.
e sock
221
ar affective Remans and Heather M. McPherson Otago Medical .%hoo/, Unirersiry of C&ago,Dunedin, New Ze dand (Received 2 January 1992) (Revision received 13 April 1992) (Accepted 27 April 1992)
Summary The social interaction parameters of a carefully delineated group of bipolar patients were compared to those of a random New Zealand community sample. The bipolar subjects had significantly lower scores for perceived availability and adequacy of both intimate and diffuse social relationships. Their mean scores did not differ from those of the subgroup in the random community survey who were classified as showing psychiatric morbidity, most of whom were depressed. Social interaction scores were negatively correlated with the bipolar patients’ age and duration of illness. Those bipolar subjects with a predominance of manic episodes had lower mean values foi* their social interaction indices than those with more depressions. The results may suggest that the longer the illness continues, the greater is the impoverishment of the sufferer’s social interaction patterns. Overall, manic episodes appeared to have a more deleterious effect on social relationships than depressive episodes.
Key lords= Bipolar; Social networks; Social support; Depression;
ntroduction Good health, both psychological and physical, and good social relationships have frequently been linked statistically (Surtees 1980; Henderson et al., 1981; Henderson, 1984; Brugha, 1989). A recent review of several prospective studies showed that subsequent increased mortality was
Correspondence to: Sarah Romans, Department of Psychological Medicine, Otago Medical School, P.O. Box 913, Dunedin, New Zealand.
Mania; ISSI
preceded by poor social networks (House et al., 1988). Mechanisms involved in these relationships have not been delineated (Bloom, 1990). Most of the studies linking psychiatric illness to poor social networks have focused on neurotic or nonpsychotic disorders, probably because they are widely believed to be more reactive in nature and thus more likely to show differences in psychosocial factors such as social relationships. Bipolar affective disorder has been poorly studied. It is known that bipolar disorder is associated with an impaired ability to establis’? and
maintail? st;iblc marital relationships U3rodie alld Ecff. N71; kveckc ct al., lY75; Geene c1 al.. iY7(j: Dunner et al.. lY76: Hoover and Fitiger:lld. lYX1: Tat-gum et al.. 19Sl: Mcrkangas. 1983: &wdfyin and Jamison, 1990: McPherwn et al.. lYY2). However, there has been very little delineation of more diffuse or non-intimate r&tionships formed by bipolar patients. The destructive effi;cts of depressive illness on interpersonal relationships. both intimate and diffuse, have been described by several authors. Charney and colleagucc studied personality traits and disorder in 160 depressed patients. a quarter of whom were bipolar K’harney et al., lY,Yl). They identified the ongoing deleterious effect of depression and suggested that an earlier onset of depression may result in functional impairment that is later viewed as personality disorder. A detailed study of the spouses of depressed patients showed that living with the illness was burdensome and adverrely affected the couple’s marital and sexual relationship. their social and leisure activities and their financial security (Fadden et al., 1987). Spouses of the bipolar patients were more likely to consider marital separation than the spouses of unipolar depressive patients. The ability to confide was eroded and the patient’s tendencies to ‘worry and nag’ and their irritability were difficult for the spouse to endure. As these symptoms overlap with normal behaviour. they may not be conccptualised by the spouse as a symptom, due to the depressive illness. The view that relatives may cope better with symptoms which they clearly view as arising from an illness, has been made cogently recently (Hooley et al., 1987). The impact of manic behaviour on the patients’ close contacts has also been described (Janowsky et al., 1970, 1974; Ablon et al., 1975). During the episode, the manic person challenges. taunts, belittles and humili;ltes their loved ones. In contrast to the work of Fadden and colleagues, Janowsksy’s group has writterl that spouses of manic patients are more likely than spouses of depressed patients to consider separation from their marital partner. MacVane and colleagues noted anecdotally the subjective experience reported by manic-depres-
sivc paiients when describing their pre-lithiklm years; many related past feeling:; of helplessness, Lnd alarm associated with lack of control over t occurrcncc of scvcrc mood swings (MacVane et al.. 192iXJ.They spoke of the pervasively disruptive effects they thought I cse episodes had on their lives in terms of employment, family, social relationships and their self-concept. CJiven the import;mW of ~cial relations the onset and rccwery from unipolas depressive disorder, it is important io inwstigate their PO also in bipo!ar illness. It might be that the normal psychological function showa~ by bipoilx patients during euthymic periods protected social relationships, in contrast to the poor relationships of chronic schizophrenic p:ltients. This paper describes a study of bipolar patients which aimed is assess the importance of a number of psychosocial factors in the outcome of bipolar affective disorder prospectively over two years. The first year’s data on social networks, clinical course and demographic factors are reported.
A cohort of Research Diagnostic Criteria (RDC) bipolar patients is being foil tively in Dunedin. New Zealand lY78bI. In order to enter the c were required to have been adm the three local hospitals with an inpatient psychiatric ward between 1.1.1985 and 31.12.1987. Permission to search the hospital notes was obtained from the ethical committee of the Qtago Area Health Board. Patients with a current address in the greater Dunedin residential area, aged over fifteen and under sixty five years an nia or depression was not secondary to a known organiz disorder were designated for entry to the cohort. All hospital records wit an admission or discharge diagnosis of bipolar disorder definite or possible, were screened by the research psychiatrists to determine whether the clinical details suggested a classification of bipolar disorder. All such patients were then invited to attend a diagnostic interview using the Schedule for Schizophrenia and Affective Disorders (Spitzer et al.,
1978a). They underwent a detlrilcd initial interwhich collected clinical and socio-demoy a&-e being re-interviewed at three mont intervals and when a relapse occurs. The duration of eir illness was calculated by subtracting hOill t which they first experienced an a regardless of whethe view
network parameters of the bipolar cohort were assessed using t!-re Interview Schedule for Social Interaction Wenderson et al., 1981). fift;Nsvo item inte iew, taking some 30 n to administer. w h obtains informae instrumental and affectional aspects of social relationships. I3ot the availab%ty and equdcy of two classes of social relationship; a) intimate, cal!ed attachments and b) more diffuse interactions, called social integration by the authors, are quantified. To assess the adequacy of some aspect of an interpersonal relatiortship, the res o~dents were asked whether they would like more, err less of rhat element or whether they are satisfied with what they have at present. Etements of intimate relationships, or attashmcnts, assessed include: talking frankly, discussing irritating and unpleasant experiences, sharing happiness, being known well by, feeling able to lean on, confiding in and being comforted physically by someone else and having other pzople dependent for their welfare on oneself. The index, ADAT% gives the percentage of attachments which the respondent finds adequate. The elemen+s of social integration covered are casual conversations, recognising people on the street, knowing people with similar interests, socialising with work colleagues, receiving positive feedback, being able to ask small favours such as borrowing tools or cooking items, and turning to in times of difficulty. The original ISSI study found no gender differences in social interaction in subjects under sixty-five years of age (Henderson et al., 1980. This paper presents the results of the first qet of sociai interaction interviews, given towtirds the end of the first year of data collection. Care was taken to ensure that the subjects were euthymic at the time of their social network assessment in
order tc remove distorted judgement arising from a mood abnormality. ‘The fSSB had been used previously in Dunedin as part of a random community epidemiological study of fcmsfe psychiatric morbidity, the Otago Women’s Health Survey CRomans-Clarkson et al., 1988). The ISSI results from that study were used as a normative data set, to compare with the qualip] of the social interactions of this bipolar cohort. The randomly selected interview sample was chosen from three psychological strata on a preliminary postal questionnajre which used the General Health Questionnai e as a Screen for psychiatric morbidity (Roman+Clarkson et al., 1988). The results here are weighted back to the parent population. Both the results from the total community sample of women aged under sixty-five years (non-cases and case-!, and from only those women who were PST ,.rse~ awere conipareJ siatisticaliy to the r++ults for the bipolar group. Unlike the bipolar patients, the community sample had only one interview. Those classifies as cases were symptomatic at the time of their ISSI evaluation. The bipolar group was divided into rhose who had experienced more manic than depressive episodes during the course of their illness (N = 30. 517%) including nine with only manic episodes ;nd on the other hand those with more depressive than manic episodes (N = 28 or 38.3%). The social relationship USSI? indices of these two groups were also compared. Statistics used included Student’s t-tests, chi sq;lare and Pearson’s correlation coefficients as appropriaie. Results
The chart review indentified ninety-one patients with a likely diagnosis of bipolar disorder. Sixty-four of these (70%) responded to our request that they attend an assessment interview. Twelve had moved from the area and therefore were not available for the detailed quarterly interviews, one died frcm septicaemia consequent on osteomyelitis after agreeing to participate but before her assessment and thirteen (14.3%) refused outright. Of the sixty-four assessed, fifty-
eight were found to meet RDC criteria and they comprise the original Dunedin cohort. Some six subjects were lost from the study during the first year, two by suicide with four moving out of the research area. Thus fifty-two bipolar subjects have provided information on their social interactions. The average age of the original fifty-eight subjects, twenty-eight (48%) male and thirty female (52%) at entry to the study was 37 years, (SD 12 years, range 18 to 44 years). Only 14 (24.2%) were currently in a marital relationship, half (29) had never been married and over a quarter (15, 26%) were separated or divorced. The significantly fewer married and greater numbers who were either never married, separated or divorced when compared to the general population aged 18-65 years has been reported previously (McPherson et al., in press). Most, 34 (51%) were not in paid employment: 13 (22%) had part-time employment and 11(16%) full time employment. Married patients were much more likely than the non-married patients to be in paid employment (xl 10.52, df 1, P = 0.001). Most 40/S& 69% received a government sickness or unemployment benefit. The average age at which the subjects experienced their first episode of illness, whether hospitalised or not, was 24 years (SD 9.5 years, range 12-55 years). All met criteria for Bipolar der. The average number of manic episodes in-
eluding the index hospitalisation was five (SD 4, range l- 16). Twelve subjects (20.7%) had not experienced any depressive episodes. The average number of major depressions in the rest was 6.7 (SD 14, range l- 10 plus). There were 47 women in the co~~~~i~ sample of 232 women aged under sixty five classified as PSE (short) cases; these in with depression, two with generalised anxiety, four with phobia and two with mania/hypomania. When these raw data were weighted back to the parent population, 6.4% wet-2 found to show psychiatric morbidity, 85.7% of whom were depressed. Of those depressed, 63% were married or cohabiting, 12% had never marrie were widowed, separated or divorced. lar subjects (44/58, 76%) than random community depression cases of similar age (s/13, 38%) were not married (Fisher exact, 2-tailed P = 0.02). The numbers were too small to analyse the ‘never married’ separately from those widowed or separated/divorced.
The mean values obtained for t ISSI indices are shown in Table 1, which also gives the mean values from the random community sample of women All the ISSI scores fcr the
TABLE 1 Social network values ( + SD) of bipolar cohort vs. random community sample of Otago women Bipolar
P
Otago Women
;v
5’
232
Availability of Attachment
5.1 f2.3
5.9+ 1.3
Adequacy of Attachment % Attachment Adequate
6.4 t_3.3
9.5 f
Availability of Social Integration Adequacy of Social Integration
55.5% 7.2 f 4.2 11.1 k4.4
2.6
84.47c
< 0.02 < 2.001 < 0.001
9.1 i3.2
< 0.01
13.9 _t 2.8
-C0.001
225 TABLE 2 Marital status, employment
and social network values + SD sf bipolar patients
Married
Not married
N
14
AVAT ADAT ADAT% AVSI ADSH
7.4+ 8.4* 71.1+ 8.6+ 12.5&
1.1 1.9 15.2 3.3 3.0
P
Employed
NC3 employed
38
23
29
4.2* 2.0 5.7* 3.4 49.7 I 28.9 6.7d_ 4.4 10.6f 4.7
6.3& 1.9 ?.6+ 3.5 64.7 6 22.0 8.9+ 3.9 12.2t_ 3.2
4.1-L 2.1 5.5+ 3.5 48.2 f 29.5 5.9+ 3.9 10.2f 5.0
0.09
bipolar cohort were significantly less than the mean scores for the ran om community sample There were no gender differences in the ISSI mean scores of the bipolar affective disorder subjects, which confirmed the acceptability of a comparison group composed of female subjects only. There was no statistical difference on any ISSI index for the bipolar patients and those women in the community study who were cases of psychiwere married or in paid employment gave higher ISSI scores than did the notmarried and unemployed particularly on attachment indices. See Table 2. There was a negative correlation between age ent scores, both availability and adequacy. See Table 3. A trend at the IO% ievel was also present for older patients to have poorer availability of social integration. Patients with longer duration of their bipolar affective disorder had lower mean scores for availability of attach-
TABLE 3 Age, duration of biploar illness and sociai network values (Pearson’s correlations)
AVAT ADAT ADAT% AVSl ADSI
Age
P
r
P
Duration of Illness r P
- 0.26 - 0.22 -0.19 - 0.22 -0.07
0.03 0.05 0.09 0.06 ns
- 0.23 -0.16 -0.15 - 0.28 -0.01
0.05 ns ns 0.02 ns
P
< 0.001 0.02 0.02 0.008 0.09
ment and social integration; there was no such link for the adequacy indices. The patients with a predominance of manic episodes were more likely to be not married (either single, separated or divorced) than married or in a cohabiting relationship (A 2 3.96, df 1, P = 0.05). There were no differences in gender or paid employment between the mostly manic patients and the mostly depressed patients. There was a statistical trend present at the 10% level for the mostly manic patients to describe less adequate attachments (t = - 1.75, df 50, P = 0.086) and less available social integration (t = - 1.91, df 50, P = 0.062). They also had fewer recent arguments and rows (P = 0.03) and were more accepting of absent relationships (P = 0.04). Discussian This study showed clearly that bipolar affective disorder patients have impoverished social relationships, when compared to a random community New Zealand sample. The bipolar group has social interaction results that were as poor as the diagnosable cases in the community sample of women (Remans-Clarkson et al., 1992). In addition to their increased rates of marital fai!ure, this study shows that bipolar patients also have major problems with their more diffuse social relationships. The Interview Schedule for Social Interaction (ISSI) was chosen from amongst the many published instruments as the method of assessing social relationships because its reliability and va-
]j;t~e been asscSscd (Henderson ct al.. 1Wl: Orth-Gonlcr tind Undcn, 1087; O’Reilly, 1%8). &o. it had b~cn previously used in two large pr~,sptxti~vc studies. one Australian and one in the same New Zealand area as this bipolar affecfiir6: disorder study (Henderson et al.. lW1; Roman&larkson et al.. 198X). There were no gendcr differences in social interaction indices for the random community sample of adults under sixty-five (Henderson et al., 1981). Thus the social nctM’c,rk results from the New Zealand fcmalconly random community sample project seemed an appropriate control data sea There was one potentially relevant difference in the manner in which the ISSI data were collected for the community sample of women. Those cl:issificd as PSE ~1st‘~ were .qnlptomatic aa the time of the ISSI. They may have evalua.lted their social networks more negatively than they would have done when they were weil. The conclusion is that the bipolar patients had social network indices at Ieast as low as the community cases; it is possible that the community cases of depression had social interaction indicts that were artificially lowered by an abnormal mood state. This comparison would be better if conducted when both groclps were in remission. The importance of social networks and support in the genesis and maintenance of unipolar depression and anxiety disorders have been well described (Brown et al., 19Xh; Surtees, 1980). Th1‘s1‘ yJs>ChrJ\cGal dimensions are also clearly relevant in bipolar disorder. In general, being married and being in paid employment are associated with having good diffuse social relationships, and the bipolar patients wcrc not different in this regard. Paid employment provides enhanced opportunities for workbased social contacts as well as meaningful and socially valued activities. Good social function in the one area of intimate relationships is associatcd with good function in the more general interpersonal relationships as well as the employment arena. Theoretically, there are at ieast four ways in which poor social relationships and bipolar affective disorder might be causally linked; these putative mechanisms are not mutually exclusive. Poor social relationships may result in the onset or lidity
maintczznce of illness episodes, the illness may adversely affect social relationships, both the illness and social relationships may adversely affect each other in a cumulative way or fin the illness and the poor social function caused by a third factor, such experiences or personality. here are consistent with t progressively erodes the socia ships of the bipolar group. only come from prospectiv out bipolar reriearch lends some support to the view that the bipolar disorder is deleterious to social networks Joyce, replicating previous found no difference in the quality of chil relationships with parents between 58 bipolar patlcnts and 100 general practice patie 1%4. He concluded that, unlike minor psychiatric morbidity, bipolar disorder is not caused by early childhood experiences. The implication from this study was that any interpersonal difficulties arose later, in adult life, around the time of illness onset. The association between tion and greater psycl~osoci been described previously. that the frequent marital an Polish bipolar patients wcrc with age (Bidzinska, 19831. ported that older bipolar pa episodes had very small social networks (Sclare and Creed., I990). Two studies superficially a ar to suggest that bipolar patients function wesl ychosocially, and might seem to contradict hero. Careful reading shows t bet h these works was to corn group when stabilised on modern treatments with their lives before they were adequately treated. unner and colleagues ex six areas of socinl adjustment (work, ime, marital, parental, family and extended family) in patients with primary affective disorder, 85% (N = 143) of whom were bipolar C unner et al 1978). The results suggested ‘good although not optimum’ adjustment although in the absence of a control group it is difficult to assess the extent of the impairment. The authors cautioned against ‘indiscriminant treatment with psychotherapy’, leav-
E
Fadden. G.. Bebbington. P. and Kuipers, L. (1987) Caring and its burdens: a study of the spouses of depressed patients. Br. J. Psychiat. 151. 660-667. Gooduin. F.K. and Jamison, K.R. i 1990) Manic-depressive illness. Oxford University Press. New York. Greene, B.L.. Lustig. N. and Lee, R.R. (1976) Marital therapy when one spouse has L(primary affective disorder. Am. J. Psychiat. 133, 827-830. Henderson, AS. (1984) Interpreting the evidence on social support. Social Psychiat. 19. 39-52. Henderson, S., Byrne, D.G. and Duncan-Jones. P. (1981). Neurosis and the social environment. Acad. Press. Sydney. Hooley. _’M., Richters. J.E.. Weintraub. S. and Neale. J.M. (1987) Psychopathology and marital distress: the positive side of positive symptoms. J. Abnorm. Psychol. 96. 27-33. House. J.S.. Landis. K.R. and Umberson. D. (1988). Social relationships and health. Science 241. 530-535. Hoover, C.F. and Fitzgerald. R.G. (1981) Marital conflict of manic-depressive patients. Arch. Gen. Psychiat. 38. hS--67. Janousky. D.S.. Leff. M. and Epstein. R.S. (1970) Playing the manic game: interpersonal maneuvers of the acutely manic patient. Arch. Gen. Psychiat . .“..s, 71 w* ?7-261. _ Janowsky. D.S., Yousef. M.K. and Davis. J.M. (1974) Interpersonal manoeuvres of manic patients. Am. J. Psychiat. 131, 250-25s. Joyce. P. (1983) Parental bonding in bipolar affective disorder. J. Affect. Dis. 7, 319-324. Lepkifker. E.. Horesh, N. and Floru. S. (1988) Life satisfaction and adjustment in lithium-treated affective patients in remission. Acta Psychiat. &and. 7X. 391-395. MacVane. J.R.. Lange. J.D.. Brown, W.A. and Zayat, M. (1978) Psychological functioning of bipolar manic-depressive patients in remission. Arch. Gen. Psychiat. 35. 13511354. McPherson. H.M.. Dot-e. G.L.. Loan. P.A. and Remans. S.E.
(1992) Socio-economic characteristics of a Dunedin sample of bipolar patients, N. Zealand Med. J. 105, 161-162. Merikangas, K.R. (1984) Divorce and assortive mating among depressed patients. Am. J. Psychiat. 141. 74-76. O’Reilly, P. (1988) Methodological issues in social support and social network research. Sot. Sci. Med. 26, 863-873. Orth-Gomer, K. and Unden, A.L. (19871 The measurement of social support in population surveys. Sot. Sci. Med. 24, x3-94. Roman+Clarkson, S.E., Walton, V.A., Herbison, G.P. and Mullen. P.E. (19881 Marriage, motherhood and psychiatric morbidity in New Zealand. PsychoLog. Med. I$, 983-990. Roman+Clarkson. S.E., Walton, V.A., Herbison, 6. Mullen, P.E. 419921 Social networks and psychiatric morbidity in New Zealand women. Austral. New Zealand J. Psychiat. Sclare. P. and Creed, F. (1990) Life events and the onset of mania. Br. J. Psychiat. 156, SO&S14. Spitzer. R.L. and Endicott, J. il978aS Schedule for Affective Disorders and Schizophrenia. New York: Biometrics Research, Evaluation Section, New York State Psychiatric Institute. Spitzer. R., Endicott, J. and Robins, E. (1978b3) Research diagnostic criteria: rationale and reliability. Arch Gen. Psychiat. 35, 773-782. Surtees. P.G. (1980) Social support, residual adversity and depressive outcome. Sot. Psychiat. 71-80. Targum. S.D.. Dibble. E., Davenport, Y.B. and Gershon, E.S. (19811 The family attitudes questionnaire; patients’ and spouses’ views of bipolar illness. Arch. Gen. Psychiat. 38, 562-568. Weeke. A.. Billc. M., Videbech, T.. Dupont, A. and JueJ-Neilson, N. Incidence of depressive syndromes in a Danish county. The Aarhus Study. Acta Psychiat. Scawd. 51.28-41.
