Recurrence was frequent and associated with the presence of residual mood symptoms at initial recovery. Targeting residual symptoms in maintenance treatment may represent an opportunity to reduce risk of recurrence.

Anxiety disorders, including those present during relative euthymia, predicted a poorer bipolar course. The detrimental effects of anxiety were not simply a feature of mood state. Treatment studies targeting anxiety disorders will help to clarify the nature of the impact of anxiety on bipolar course.

Context: Psychosocial interventions have been shown to enhance pharmacotherapy outcomes in bipolar disorder.Objective: To examine the benefits of 4 disorderspecific psychotherapies in conjunction with pharmacotherapy on time to recovery and the likelihood of remaining well after an episode of bipolar depression.Design: Randomized controlled trial.Setting: Fifteen clinics affiliated with the Systematic Treatment Enhancement Program for Bipolar Disorder.Patients: A total of 293 referred outpatients with bipolar I or II disorder and depression treated with protocol pharmacotherapy were randomly assigned to intensive psychotherapy (n = 163) or collaborative care (n=130), a brief psychoeducational intervention.Interventions: Intensive psychotherapy was given weekly and biweekly for up to 30 sessions in 9 months according to protocols for family-focused therapy, interpersonal and social rhythm therapy, and cognitive behavior therapy. Collaborative care consisted of 3 sessions in 6 weeks. Main Outcome Measures:Outcome assessments were performed by psychiatrists at each pharmacotherapy visit.Primary outcomes included time to recovery and the proportion of patients classified as well during each of 12 study months.Results: All analyses were by intention to treat. Rates of attrition did not differ across the intensive psychotherapy (35.6%) and collaborative care (30.8%) conditions. Patients receiving intensive psychotherapy had significantly higher year-end recovery rates (64.4% vs 51.5%) and shorter times to recovery than patients in collaborative care (hazard ratio, 1.47; 95% confidence interval, 1.08-2.00; P=.01). Patients in intensive psychotherapy were 1.58 times (95% confidence interval, 1.17-2.13) more likely to be clinically well during any study month than those in collaborative care (P=.003). No statistically significant differences were observed in the outcomes of the 3 intensive psychotherapies.Conclusions: Intensive psychosocial treatment as an adjunct to pharmacotherapy was more beneficial than brief treatment in enhancing stabilization from bipolar depression. Future studies should compare the costeffectiveness of models of psychotherapy for bipolar disorder.

We examined the interaction of cognitive styles and life events in predicting the depressive and hypomanic mood swings of 43 undergraduates meeting criteria for a subsyndromal mood disorder (i.e., cyclothymia, dysthymia, or hypomania) or no lifetime diagnosis. Participants completed symptom, cognitive style, and life events measures on three separate occasions as the different mood states characteristic of their subsyndromal disorder naturally occurred. Normal controls were assessed in three separate normal mood states at times yoked to participants in the three disorder groups. All groups’ attributional styles and dysfunctional attitudes remained stable across large changes in mood and symptomatology and cyclothymics’ cognitive styles were as negative as those of dysthymics. Moreover, hierarchical regression analyses indicated that participants’ attributional styles, as measured in a normal mood state (Time 1), in interaction with intervening life events predicted prospectively their depressive symptom changes at Times 2 and 3 and their hypomanic symptom changes at Time 2. These findings provide support for the cognitive vulnerability-stress hypothesis of the Hopelessness theory of depression (Abramson, Metalsky, & Alloy, 1989) and suggest that the logic of the Hopelessness theory’s vulnerability-stress hypothesis extends to the prediction of manic/hypomanic symptoms.

This study examined the interaction of cognitive style (as assessed self-report and information-processing battery) and stressful life events in predicting the clinician-rated depressive and manic symptomatology of participants with Research Diagnostic Criteria lifetime diagnoses of bipolar disorder (n = 49), unipolar depression (n = 97), or no lifetime diagnosis (n = 23). Bipolar and unipolar participants' attributional styles, dysfunctional attitudes, and negative self-referent information processing as assessed at Time 1 interacted significantly with the number of negative life events that occurred between Times 1 and 2 to predict increases in depressive symptoms from Time 1 to Time 2. Within the bipolar group, participants' Time 1 attributional styles and dysfunctional attitudes interacted significantly, and their self-referent information processing interacted marginally, with intervening life events to predict increases in manic symptoms from Time 1 to Time 2. These findings provide support for the applicability of cognitive vulnerability-stress theories of depression to bipolar spectrum disorders. The role of cognitive processes in the phenomenology, onset, course, and treatment of unipolar depression has been the subject of fruitful scientific investigation over the past two decades. Both Beck's (1967) theory and the hopelessness theory (Abramson, Metalsky, & Alloy, 1989; Alloy, Abramson, Metalsky, & Hartlage, 1988) are cognitive vulnerability-stress models of depression that view maladaptive cognitive patterns as vulnerabilities that heighten the risk both for becoming depressed and for expe-Guest Editors' Note. Jacqueline B. Persons served as the action editor for this article.-DJM/LBA

Verbal episodic memory problems in individuals with bipolar I disorder and OCD are mediated to different degrees by difficulties using semantic clustering encoding strategies compared with control participants.

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