There is increasing evidence that social-environmental factors, particularly those within the family, are significant predictors of the course of major psychiatric disorders. Studies of schizophrenic patients and their family members indicate that levels of intrafamilial expressed emotion (EE) (emotional attitudes measured during an inpatient period) and affective style (AS) interactional behaviors (measured during an outpatient, aftercare period) in key relatives are strongly associated with the subsequent likelihood of psychotic relapse in patients. The proposed study will investigate whether the emotional climate of the family predicts the course of bipolar affective disorder, and whether family climate, in turn, is predicted by patient factors of known prognostic significance. The study asks three major questions: (1) Does the emotional climate of the family (EE and AS) predict the clinical and social adjustment course of bipolar disorder over the 2 years following an index hospitalization? (2) Are these family factors, their relative stability over time, and their association with patient outcomes mediated by patient attributes with known prognostic significance (medication compliance, symptom severity, associated Axis II disorders)? (3) What attributes of parents and patients predict the emotional climate of the family after an episode of bipolar disorder (psychopathology in parents, family history of affective disorder, personality disorders or temperamental disturbances in patients, or patients' attitudes toward or styles of interacting with parents)? These questions will be investigated in 75 initially hospitalized DSM- III-R bipolar, manic patients followed over a 2-year period and maintained on a standardized pharmacology regimen administered by study psychiatrists. Assessments of EE and AS in parents, and emotional attitudes/interactional behaviors in patients, will be conducted at baseline and at a 1-year follow-up. Psychopathology in parents, family history of affective disorder, and personality disorders/temperamental disturbances in patients will be assessed using structured interviews and self-report measures. Patients will be interviewed every 3 months over the 2-year follow-up using measures of symptomatology, social adjustment, substance and alcohol abuse, and medication compliance.
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