ABSTRACT
Fifty years after the discovery of lithium (1), bipolar disorder (BD) remains a major therapeutic challenge. Extensive research has demonstrated that people with BD typically suffer multiple recurrences of mania and/or depression throughout their lifetimes, often despite continuous maintenance pharmacotherapy (2-6). Markar and Mander (4), for example, followed a group of bipolar patients on lithium prophylaxis and found that only 30% to 40% remained well over a threeyear period. Recently, clinical research has begun to examine the efficacy of adding psychosocial treatments to pharmacotherapy for BD (7). Outcomes in these studies are often measured both in terms of symptom reduction and in terms of the duration of well periods (8-10). The inclusion of time to relapse as an outcome measure in these studies presumes that most individuals with BD will relapse over time, often despite use of so-called maintenance medications. The occurrence of breakthrough episodes coupled with the poor work, family, and social functioning found over the long-term course of illness in patients with BD (11) makes it critical that we examine environmental as well as biological factors in an effort to better understand mechanisms underlying the pathophysiology of BD.
