Patients
Patients in this study fulfilled DSM-IV criteria for bipolar I disorder.
In order to identify a subgroup vulnerable to relapse, patients
also had to have had at least two episodes in the last 2 years
or three episodes in the last 5 years prior to recruitment. The only
two exclusion criteria were actively suicidal (score of 3 on the
Beck Depression Inventory suicide item) or currently fulfilling
criteria for a substance use disorder. The characteristics of the
subjects in the cognitive therapy and control condition groups
are summarized in Table 1.
Instruments
1. The Mania Rating Scale (9) consists of 11 items that reflect
common manic symptoms such as motor activity, flight of
thoughts, voice/noise level, and amount of sleep. Each item
is rated on a 5-point scale. A total score of 0–5 is interpreted
as no mania; 6–9=hypomania (mild); 10–14=probable mania;
≥15=definite mania. The scale has good interrater reliability
and construct validity.
2. For the Coping With Bipolar Prodromes Schedule (10), patients
were asked, from their experience of past episodes,
what the early warnings (prodromes) were that made them
think they were “going either high or low” and what they did
when they had these prodromes. Patient reports of prodromes
and the way they coped with them for both depression
and mania were recorded verbatim. Coping was rated
on a 7-point scale (0=poor; 3=adequate; 6=extremely well).
3. The Social Functioning Schedule (11) is an observer-rated
scale based on a semistructured interview with patients
that provides a quantitative assessment of social performance
in the last month. The interview is directed toward
actual behavior and performance over eight areas of social
performance, each rated on a 4-point scale. In the original
paper, the authors reported a better than chance interrater
agreement. The interrater reliability in this study ranged
from kappa of 0.91 to 0.76 for the different areas of social
functioning with 10 training cases. A slightly modified version
of the schedule was used to interview key relatives of
the patients.
4. The short version of the Dysfunctional Attitude Scale for Bipolar
Disorder (12) consists of 24 items. It is derived from a
principal component analysis study that used 143 patients
with bipolar I disorder in which three factors were derived.
Factor 1, “goal attainment,” accounted for 25.0% of the total
variance. Factor 2, “dependency,” accounted for 11.0% of
the total variance. Factor 3, “achievement,” accounted for
8.2% of the total variance. The goal attainment subscale was
thought to capture the highly motivated attitudes in the
cognitive model for bipolar affective disorder.
5. The medication compliance questionnaire reported compliance
with any prescribed mood stabilizers. Respondents
had a choice of noting whether the patient in the past month
had 1) never missed taking their medication, 2) missed taking
it once or twice, 3) missed taking it between three to seven
times, 4) missed taking it more than seven times, or 5) stopped
taking it altogether (14).
Data Analysis
Differences between the cognitive therapy and control conditions
were assessed by a chi-square test for dichotomous variables
and analysis of variance for continuous variables. Cox regression
was used for survival analysis, with the number of weeks