Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients

Journal of Affective Disorders 145 (2013) 54–61

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Research report

Is coping well a matter of personality? A study of euthymic unipolar and bipolar patients Carissa M. Coulston, Danielle M. Bargh, Michelle Tanious, Emma L. Cashman, Kimberly Tufrey, Genevieve Curran, Sandy Kuiper, Hugh Morgan, Lisa Lampe, Gin S. Malhi n CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, Australia; and Discipline of Psychiatry, Sydney Medical School, University of Sydney, NSW, Australia

a r t i c l e i n f o

a b s t r a c t

Article history: Received 10 May 2012 Received in revised form 16 July 2012 Accepted 16 July 2012 Available online 23 August 2012

Background: Euthymic bipolar disorder (BD) patients often demonstrate better clinical outcomes than remitted patients with unipolar illness (UP). Reasons for this are uncertain, however, personality and coping styles are each likely to play a key role. This study examined differences between euthymic BD and UP patients with respect to the inter-relationship between personality, coping style, and clinical outcomes. Methods: A total of 96 UP and 77 BD euthymic patients were recruited through the CADE Clinic, Royal North Shore Hospital in Sydney, and assessed by a team comprising Psychiatrists and Psychologists. They underwent a structured clinical diagnostic interview, and completed self-report measures of depression, anxiety, stress, personality, coping, social adjustment, self-esteem, dysfunctional attitudes, and fear of negative evaluation. Results: Compared to UP, BD patients reported significantly higher scores on levels of extraversion, adaptive coping, self-esteem, and lower scores on trait anxiety and fear of negative evaluation. Extraversion correlated positively with self-esteem, adaptive coping styles, and negatively with trait anxiety and fear of negative evaluation. Trait anxiety and fear of negative evaluation correlated positively with eachother, and both correlated negatively with self-esteem and adaptive coping styles. Finally, self-esteem correlated positively with adaptive coping styles. Limitations: The results cannot be generalised to depressive states of BD and UP, as differences in the course of illness and types of depression are likely to impact on coping and clinical outcomes, particularly for BD. Conclusions: During remission, functioning is perhaps better ‘preserved’ in BD than in UP, possibly because of the protective role of extraversion which drives healthier coping styles. & 2012 Elsevier B.V. All rights reserved.

Keywords: Bipolar disorder Unipolar depression Personality Coping

1. Introduction Relative to the general population, both Unipolar (UP) and Bipolar (BD) patients often exhibit higher rates of psychopathology when in remission, as reflected in greater levels of depression (Vieta et al., 2008), trait anxiety (Carolan and Power, 2011), and lower self-esteem (Serretti et al., 2005). However, studies of remitted patients have frequently demonstrated that BD individuals exhibit lower anxiety and depression (Vieta et al., 2008), and better self-esteem (Knowles et al., 2007) compared to UP individuals. Accordingly, UP patients have been shown to have significantly greater Axis I comorbidity than BD, specifically in the form of anxiety disorders (Mantere et al., 2006). Reasons for the observed differences in overall symptomatic profiles between euthymic BD and remitted UP could reflect differences in coping styles and personality factors specific to

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0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jad.2012.07.012

both illnesses. To date, however, the relationship between these two variables and clinical outcomes have not been examined in a single methodological design that has directly assessed and compared BD and UP patients. If differences in personality, coping methods, and corresponding clinical outcomes could be identified in these two populations, such findings would aid in the understanding of what factors might influence these differences, and subsequently drive targets for future interventions, for example, aimed at improving poor coping styles in particular. 1.1. The role of personality, coping, and clinical outcomes Personality traits are thought to influence affective states, thereby explaining long-term inter-individual patterns of emotion and mood (Smillie et al., 2009). According to the five-factor model of personality (McCrae and Costa, 1987; McCrae and John, 1992), extraversion (a tendency to experience positive emotions and be sociable, warm, assertive, talkative, and fun-loving) appears to be a stable construct that distinguishes BD and UP

C.M. Coulston et al. / Journal of Affective Disorders 145 (2013) 54–61

(Lonnqvist et al., 2009; Meyer, 2002; Sariusz-Skapska et al., 2003). In euthymia, extraversion, at the very least, remains preserved in BD (i.e., falls within the normal range and does not necessarily differ significantly from healthy controls), but falls well below the normal range for UP patients (Canuto et al., 2010). Specifically, high levels of extraversion have been associated with mania and may therefore be related to excitement seeking and positive affect in BD (Lozano and Johnson, 2001; Quilty et al., 2009). Further, recovery from depression in UP has not consistently been found to be associated with higher levels of extraversion (Barnett and Gotlib, 1988; Widiger and Trull, 1992), indicating stability of this personality dimension. Conversely, neuroticism (the tendency to experience anxiety, self-consciousness, ineffective coping, and poor self-esteem) appears to be elevated in both BD and UP compared to the general population (Bagby et al., 1997, 1995; Barnett et al., 2011), and correlates with depression (Bagby et al., 1995; Meyer, 2002). Notably, there are generally no differences between BD and UP on this personality factor (Bagby et al., 1997). Personality traits may impact on the appraisal of stress and inform the utilisation of particular resources for coping (Folkman and Moskowitz, 2004). Coping is a complex, multidimensional process which is sensitive to the demands of one’s internal state and external environment (Folkman and Moskowitz, 2004; Lee et al., 2010). Psychological studies have revealed that adaptive and maladaptive coping strategies affect outcomes in psychiatric illness (Parikh et al., 2007). Adaptive coping strategies are largely problem- and emotion-focused in nature and include planning, suppression of competing activities, seeking support and advice from others, positive reinterpretation of events, humour, and drawing on religious faith (Carver et al., 1989; Litman, 2006; Vollrath et al., 2003). Extraversion is associated with the use of a range of adaptive coping styles, including rational action, positive reappraisal, social support-seeking, and less avoidance (Amirkhan et al., 1995; Cuijpers et al., 2007; Lysaker and Taylor, 2007; McCrae and Costa, 1986; McWilliams et al., 2003; Watson and Hubbard, 1996). Conversely, neuroticism has been associated with the use of a range of maladaptive coping styles, including escape/avoidance, rumination, self-blame, decreased use of social support, and reduced levels of problem–solving and positive reappraisal (Watson and Hubbard, 1996), all of which have been found to uniquely predict depression (Thompson et al., 2010; Wright et al., 2010). It therefore follows that the combination of low extraversion and high neuroticism is characteristic of anxiety-prone individuals (Bienvenu et al., 2001; Kristensen et al., 2009; Stein et al., 2005).

1.2. Summary and aims of the present study The personality trait of extraversion appears to be associated with more favourable clinical outcomes and adaptive coping styles, and this personality trait is generally more prevalent in BD than UP. These findings suggest that in BD, extraversion may play a protective role by driving healthier coping styles and better clinical outcomes. To date, however, no studies to our knowledge have examined personality, coping style, and their inter-relationship with clinical outcomes in BD or UP independently, or within the same study. Therefore this study aimed to explore the inter-relationship between personality factors using the five-factor model, coping styles, and clinical outcomes in a single sample of UP and BD patients to gain insight into how personality might be related to coping styles and outcomes, as this could guide the focus of treatment for patients in managing their illness.

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2. Methods 2.1. Participants A sample of 173 adults with mood disorders were referred by their treating doctor (General Practitioner and/or Psychiatrist) between August 2007 and March 2012 to the CADE Clinic (Clinical Assessment Diagnostic Evaluation, www.cadeclinic.com). The CADE Clinic is an outpatient service that is based within a university teaching hospital in Sydney. It provides psychological and psychiatric assessment of patients for the purpose of clarifying diagnosis and offering recommendations for the treatment of mood disorders. Participants were excluded if another lifetime Axis I or II diagnosis predominated their mood disorder, and/or there was any history of developmental/intellectual disability or neurological event. Approval for this study was granted through the Northern Sydney Local Health District Human Research Ethics Committee, and all participants provided signed consent. 2.2. Materials and procedure Prior to attending the CADE Clinic, participants completed a battery of self-report questionnaires which included measures of mood and anxiety symptoms, personality traits, dysfunctional attitudes, self-esteem, coping methods, and social adjustment. Personal information, demographics, and details of medical and psychiatric history were also collected. Measures of mood and anxiety included the Depression Anxiety Stress Scales (DASS) (Lovibond and Lovibond, 1995), State-Trait Anxiety Inventory (STAI-X1 and X2) (Spielberger, 1983), Brief Fear of Negative Evaluation Scale (BFNE) (Leary, 1983), and the Mood Disorders Questionnaire (MDQ) (Hirschfeld, 2002). The latter was administered to ascertain lifetime presence of (hypo)manic symptoms, and therefore served to support the differentiation of BD and UP psychiatric diagnoses. Personality was measured with the NEO Five-Factor Inventory (NEO-FFI) (Costa PT Jr, 1989) incorporating the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Dysfunctional attitudes were measured with the Dysfunctional Attitudes Scale (DAS) (Weissman and Beck, 1978). Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965), and social adjustment was measured with the Social Adjustment Scale-Self-Report (SAS-SR) (Weissman and Bothwell, 1976). Finally, coping strategies, both adaptive and maladaptive, were measured using the COPE inventory (Carver et al., 1989). On arrival at the CADE Clinic, participants were administered a structured diagnostic interview to assess a wide range of DSM-IV Axis I Disorders, including disorders of mood, anxiety, psychosis and substance use. Approximately half of the sample were administered the Mini International Neuropsychiatric Interview (MINI) (Lecrubier et al., 1997), and the other half completed the computerised Composite International Diagnostic Interview-Auto (CIDI-Auto) (World Health Organization, 1997). This occurred because of a change in the clinic structure, and the need for a shorter assessment battery. After completing the structured diagnostic interview, the participants were seen by a senior Psychiatrist or senior Registrar (under the supervision of the senior Psychiatrist) for further evaluation. The Psychiatrist then presented the case to a multidisciplinary team consisting of other Psychiatrists, a Clinical Psychologist, and Research Psychologists to discuss and confirm diagnosis and recommendations for treatment. 2.3. Data analysis Data from the questionnaires were entered into PASW Statistics 18 (SPSS, 2010) and analysed in several ways. First, demographics

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were collated and potential confounding differences between the UP and BD groups were explored using One-Way Analysis of Variance (ANOVA) for continuous variables, and Chi-square tests for categorical variables. These included age, gender, marital/relationship status, years of education, current/state levels of depression and anxiety, age first diagnosed with a psychiatric illness, number of psychiatric medications taken, and lifetime comorbid diagnoses. Any differences between the UP and BD groups on these variables were treated as confounds in subsequent analyses. Second, Multivariate Analyses of Co-Variance (MANCOVAs) were performed to examine the differences between the UP and BD groups on scales containing continuous data. These comprised the NEO-FFI, STAI (Trait component), RSES, DAS, and COPE. Third, differences between the UP and BD groups on items from the SAS-SR (which comprises ordinal and categorical data) were explored using the Mann–Whitney U-test and Chi-square tests. Fourth, bivariate inter-correlations were performed between the dimensions of personality, coping methods, and clinical outcome measures that significantly differentiated the UP and BD groups. The critical alpha level was set at 0.05 and Bonferroni corrections were applied to control for multiple comparisons.

3. Results 3.1. Demographic characteristics and potential confounds Of the 173 patients recruited, 96 were diagnosed with lifetime UP and 77 were diagnosed with lifetime BD on the basis of the multidisciplinary team discussion in which the initial diagnosis by the senior Psychiatrist or Registrar was tempered by feedback from all other clinicians. The level of agreement in diagnosis of UP and BD between the clinicians and the MINI/CIDI structured diagnostic interviews was moderate (kappa ¼0.59), underscoring the importance of both a structured and clinical assessment. The BD group also reported a significantly higher level of lifetime (hypo)manic symptoms on the MDQ (M ¼10.07, SD¼3.45) than the UP group (M¼5.66, SD¼4.47) [F(1,57)¼17.54, po0.001], which was consistent with the respective lifetime diagnoses. Table 1 provides details of the demographic characteristics and potential confounding variables in the two groups. There were no differences between the UP and BD groups in terms of age, proportion of males and females, marital/relationship status, years of education, and current/state levels of depression, anxiety, and stress. The mean age of psychiatric diagnosis for the BD group was significantly younger than the UP group, and the BD group was taking a significantly greater number of medications than the UP group. Therefore, the latter two variables were treated as confounding variables in subsequent analyses.

3.2. Lifetime comorbid diagnoses Table 2 shows that a total of 38 UP patients and 15 BD patients had a lifetime comorbid diagnosis. ‘Other’ diagnoses comprised disorders of eating, pain, adjustment, and poor self-esteem, whilst the ‘mixed’ category comprised any combination of lifetime Axis I and II disorders. The overall higher rate of lifetime comorbid diagnoses in the UP compared to the BD group was most prominently represented by anxiety disorders which included social anxiety, generalised anxiety, specific phobias, PTSD, and OCD. As such, the association between lifetime comorbid diagnoses and mood disorder was significant, and this was treated as a confound in subsequent analyses.

3.3. Establishing euthymia Scores on current levels of mood and anxiety as measured by the DASS and STAI (State) anxiety subscales were evaluated against normative data provided by Crawford et al. (2011), and confirmed that current average depression, anxiety, and stress scores for each of the UP and BD groups as a whole fell within 1.0 Standard Deviations (SDs) of the mean. These scores represent non-clinical levels of mood and anxiety for the two groups, as 1.0–1.5 SDs from the mean of the normal population is often used to indicate clinical abnormality (Thomas and Hersen, 2010). This is in keeping with the nature of the CADE Clinic which is wholly outpatient based, and its focus on diagnosis and long-term treatment evaluation.

Table 2 Lifetime comorbid diagnoses in the unipolar and bipolar groups. Lifetime comorbid Diagnosis

None Anxiety Personality Substance misuse Mixed Other Total n

Group Unipolar N (%)

Bipolar N (%)

58 (60.4) 24 (25.0) 3 (3.1) 3 (3.1) 3 (3.1) 5 (5.2) 96 (100.0)

62 (80.5) 7 (9.1) 4 (5.2) 1 (1.3) 2 (1.3) 2 (2.6) 77 (100.0)

v2

df

p

sig.

10.93

5

0.036

*

significant.

Table 1 Demographic characteristics of the unipolar and bipolar groups. Group Unipolar

Age (years) Gender (M:F) ^ Marital status (Single: relationship) ^ Education (years) DASS depression DASS Anxiety DASS stress State anxiety (STAI) Age first diagnosed with illness Number psychiatric meds

Bipolar

Mean/N

SD

Mean/N

SD

F/v2

df

p

sig.

41.98 50:46 45:47 13.29 12.18 5.44 11.47 42.35 30.81 1.28

14.38

39.56 31:46 45:28 13.17 10.69 6.29 10.58 41.70 24.90 2.01

12.84

1.33 2.40 2.66 0.11 2.24 1.42 1.07 0.11 10.58 15.44

1171 1 1 1159 1160 1160 1158 1147 1148 1152

0.25 0.13 0.12 0.73 0.14 0.24 0.30 0.74 0.001 o0.001

ns ns ns ns ns ns ns ns

ns not significant; n significant ^ Chi-square results are reported.

2.17 5.81 3.83 5.18 11.58 12.13 1.11

2.34 6.82 5.23 5.75 12.55 9.76 1.20

n n

C.M. Coulston et al. / Journal of Affective Disorders 145 (2013) 54–61

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mean age of psychiatric diagnosis, number of medications currently taken, and lifetime comorbid diagnoses. The BD-II group had a significantly higher level of stress on the DASS (M¼12.96, SD¼4.48) than the BD-I group (M¼9.11, SD¼5.99) [F(1,69)¼ 8.29, p ¼0.005], however, this score remained well within the normal range as defined by less than 1.0 SD from the mean of the general population (Crawford et al., 2011). When controlling the DASS stress scores, the results from three respective One-Way MANCOVAs showed that there were no overall significant differences between the BD-I and BD-II groups in terms of personality factors, clinical outcomes, and coping styles (p 40.05), and the results from non-parametric tests did not show any significant differences between the BD-I and BD-II groups on social adjustment styles, measured by the SAS-SR.

3.4. Comparisons between the UP and BD groups on personality, coping, and clinical measures The UP and BD groups were compared on the five factors of personality, dysfunctional attitudes, trait anxiety, self-esteem, fear of negative evaluation, and methods of coping using a series of OneWay MANCOVAs and non-parametric tests. The results of subsequent univariate, Mann–Whitney and chi-square tests that reached significance with the Bonferroni adjustment are detailed in Table 3. The results of the MANCOVAs demonstrated an overall significant difference between the UP and BD groups across the five personality factors [Wilks D ¼0.82; F(5,79)¼3.57, p¼0.006] and clinical measures (comprising trait anxiety, self-esteem, dysfunctional attitudes, and fear of negative evaluation) [Wilks D ¼0.88; F(4,93)¼ 3.20, p ¼0.016]. There was no overall significant difference across the full set of 15 subscales of the COPE (p40.05), however, four pertinent subscales of the COPE did differentiate the two groups with the Bonferroni adjustment. The results of the subsequent univariate tests showed that compared to the UP group, the BD group had a significantly higher score on the personality factor of extraversion, lower scores on trait anxiety and fear of negative evaluation, higher self-esteem scores, and higher scores on methods of adaptive coping which included active coping, use of instrumental social support, planning, and positive re-interpretation. Furthermore, compared to the UP group, the BD group reported a greater tendency to talk about feelings and problems with friends, go out socially, have contact with outside family members, depend on relatives for help, and were less inclined to feel shy or uncomfortable with people. There were no significant differences between the two groups on the personality factors of neuroticism, openness, agreeableness, conscientiousness, dysfunctional attitudes, or the remaining subscales of the COPE (p 40.05).

3.6. Inter-correlations between personality, coping, and clinical measures Bivariate correlations were performed between the personality, coping and clinical factors that significantly differentiated the UP and BD groups. These correlations were performed across the entire sample of patients having combined both the UP and BD groups. Table 4 demonstrates significant inter-correlations between personality, adaptive coping methods and clinical measures. Specifically, extraversion was positively correlated with selfesteem, and negatively correlated with trait anxiety and fear of negative evaluation. Trait anxiety and fear of negative evaluation were positively correlated with one another, and both were negatively correlated with self-esteem and several adaptive coping methods. Finally, self-esteem was positively correlated with several adaptive coping methods. Fig. 1 summarises the results for the personality factors, adaptive coping methods, and clinical measures that significantly differentiated the UP and BD groups.

3.5. Comparing Bipolar I and II patients 4. Discussion

As a matter of interest, the BD group was further broken down into Bipolar I (BD-I: n ¼47) and Bipolar II (BD-II: n ¼30) patients. There were no differences between these two groups in terms of age, proportion of males and females, marital/relationship status, years of education, current/state levels of depression and anxiety,

The findings of our study have shown that compared to UP, in remission, individuals with BD have higher levels of extraversion, and report a greater degree of adaptive coping, and less clinical

Table 3 Comparisons between the unipolar and bipolar groups on personality, coping and clinical measures. Diagnosis Unipolar

Personality (NEO-FFI) Extraversion Trait anxiety (STAI) Self-esteem (RSES) Fear of negative evaluation (BFNE) Coping (COPE) Active coping Use of instrumental social support Planning Positive re-interpretation and growth Social functioning in past 2 weeks (SAS-SR): Able to talk about feelings and problems with friends How often gone out socially a Shy or uncomfortable with people a Contact with outside family members Depended on relatives for help a

a

Bipolar

Mean

SD

Mean

SD

F

df

p

20.29 51.72 22.57 41.52

7.24 10.24 5.37 10.94

25.84 45.63 24.63 38.44

8.81 12.91 5.92 9.09

13.36 9.45 7.36 4.62

183 196 196 196

o0.001 0.003 0.008 0.034

8.86 8.53 8.83 8.64

2.65 2.92 2.83 2.57

10.31 10.62 10.41 10.38

3.12 3.17 3.35 3.25

4.71 5.10 4.32 8.19

160 160 160 160

0.034 0.028 0.042 0.006

Mean/%

SD

Mean/%

SD

U/X2

r

p

3.82 2.94 2.97 73.9% 2.08

1.33 1.41 1.48

2.85 2.50 2.40 91.5% 2.63

1.29 1.41 1.22

1926.5 2657.00 2537.00 6.69 1875.00

 0.36  0.16  0.18

o0.001 0.044 0.019 0.011 0.007

A higher score on this measure indicates a lower level of that behavior.

1.07

1.26

 0.23

58

C.M. Coulston et al. / Journal of Affective Disorders 145 (2013) 54–61

Table 4 Inter-correlations between the key personality, coping, and clinical measures. Clinical measure Trait anxiety

Extraversion

 0.463

nn

Trait anxiety Fear of negative evaluation Self-esteem ns

not significant;

n

p o 0.05;

nn

Coping style

Fear of negative evaluation

Self-esteem

 0.232n 0.501 nn

0.435  0.726  0.464

nn nn nn

Active coping

0.254  0.247  0.379 0.366

n n n n

Use of instrumental social support 0.321  0.278  0.325 0.270

n n n n

Planning

0.372  0.197  0.314 0.287

n

ns n n

Positive reinterpretation and growth 0.538  0.310  0.096 0.310

nn n

ns n

po 0.001.

Fig. 1. The differences between BD and UP patients on personality, coping styles, and clinical outcomes, and their inter-relationships.

severity as reflected by lower trait anxiety, fear of negative evaluation, and higher self-esteem. Furthermore, there were significant inter-correlations between personality, coping style, and clinical outcomes across the full sample. Specifically, extraversion was positively correlated with several adaptive coping styles and self-esteem, and negatively correlated with trait anxiety and fear of negative evaluation. Trait anxiety and fear of negative evaluation correlated positively with one another, and both were negatively correlated with self-esteem and several adaptive coping methods. Finally, self-esteem was positively correlated with several adaptive coping methods. Regarding coping, the results revealed that the BD group used more adaptive coping strategies, specifically those concerning social functioning and adjustment derived from both the COPE and SAS-SR measures. These included instrumental social support, ability to talk about feelings and problems with friends, lower shyness, greater frequency of going out socially, and more contact with/dependence on relatives for help. These results are consistent with previous research that has shown that extraversion is linked to better social coping (Cuijpers et al., 2007; McWilliams et al., 2003). Accordingly, lower levels of extraversion in the UP group could have accounted for reduced social coping, self-esteem, and greater fear of negative evaluation, as opposed to any other factor. Indeed, whilst the UP group in our study had a significantly higher rate of lifetime comorbid anxiety disorders, which is in keeping with previous findings (Mantere et al., 2006), it is unlikely that comorbid anxiety accounted for the results, as this variable was controlled in the analyses. Further, the rates of social anxiety specifically were explored, and there was not a significant predominance of this disorder in the UP compared to the BD group. Other aspects of adaptive coping that were also more highly reported in the BD compared to the UP group included active coping, planning, and positive re-interpretation and growth. It is

possible that the propensity towards (hypo)manic features in BD also plays a protective role in assisting individuals to manage their illness, and again, this may be due to the personality dimension of extraversion. For example, manic and hypomanic states have been associated with greater excitement and dangerous risk-taking behaviours (Thomas and Bentall, 2002; Thomas et al., 2007; van der Gucht et al., 2009), more active-coping such as distraction and problem–solving, and less rumination in comparison to both euthymic and depressed bipolar states (Thomas and Bentall, 2002; Thomas et al., 2007). Such findings have been interpreted in line with the ‘manic defense’ hypothesis, which posits that mania arises out of an attempt to avoid feelings of dysphoria (Thomas et al., 2007). However, even within the euthymic phase of the illness, studies have shown BD patients to utilise problemoriented coping (Parikh et al., 2007), and compared to healthy controls, these patients have maintained a greater ‘palliative reaction’ to problems (i.e., undertake activities to divert themselves from problems), greater social support seeking (Goossens et al., 2008), and tendencies towards spiritual beliefs, found to be beneficial for managing the illness (Mitchell and Romans, 2003). Thus, subsyndromal (hypo)mania, or indeed its vestigial effects, may still offer a protective role in euthymic BD, by promoting lower trait anxiety and better self-esteem as compared to UP. 4.1. Implications for intervention Psychological intervention is ideal to implement when patients are in remission, at which time they are optimally receptive to, and able to acquire cognitive and behavioural strategies. Indeed, many studies and clinical practice recommendations suggest that after remission, ‘maintenance therapy’ for unipolar depression is important (Malhi et al., 2009b), and should be continued for several months for the purpose of relapse prevention (Harter et al., 2010). Research has also shown that UP patients who receive therapy beyond the acute phase have better outcomes than those who discontinue treatment (Rapaport, 2009). With respect to psychological intervention for BD during remission, therapy also needs to reinforce maintenance cognitive therapy in patients who are highly vulnerable to relapse (Lam et al., 2005; Zaretsky et al., 2008). 4.1.1. Treating UP in remission The results of this study suggest that for UP patients in remission, interventions may need to target reduced adaptive coping strategies that may remain compromised even during remission. These would include the behavioural dimensions of social withdrawal and avoidance, as well as deficits in the cognitive skills of planning and re-interpretation/challenging of perceived negative events. In terms of deficits in social skills, several decades of research on interpersonal aspects of depression have clearly established interpersonal problems as being important in conceptualising the

C.M. Coulston et al. / Journal of Affective Disorders 145 (2013) 54–61

cause and course of depression (Segrin, 2000). In keeping with the results of our study, the UP group reported a diminished capacity to talk about feelings and problems with friends, alongside other relevant indices of social skills. Cognitive and behavioural strategies to enhance deficits in social skills in UP therefore target: (i) interpersonal communication, including paralinguistic behaviours (such as rate, volume, pitch and pause duration in speech), speech content, facial expression, gaze and eye contact, posture and gesture (Segrin, 2000); (ii) self-confidence (Brown et al., 2008); (iii) distorted negative perceptions of self-image and self-evaluation (Reed, 1994); and, (iv) perceived negative evaluation by others (Collins et al., 2005; Giesler et al., 1996; O’Connor et al., 2002; Wilson and Rapee, 2005). Cognitive behavioural strategies have been shown to be effective in maintaining wellness and preventing future relapse (Hollon et al., 2006). By training patients to continuously re-appraise negative thoughts and underlying core beliefs about the self through cognitive restructuring, patients are able to modify their reactions to negative life events and hence prevent depression (Hollon et al., 2006). 4.1.2. Treating BD in remission The results from this study, in agreement with previous research, suggest that adaptive coping styles already appear to be operational during the euthymic phase of BD (Goossens et al., 2008; Mitchell and Romans, 2003; Parikh et al., 2007). Clinical practice recommendations for BD (Malhi et al., 2009a) therefore advocate a range of other maintenance treatment strategies, including psychoeducation and mood monitoring for early warning signs of relapse during euthymia. In maintenance treatment for BD, the core goal is to prevent future mood episodes and ultimately improve quality of life (Malhi et al., 2012). Strong evidence exists for interventions which help patients with BD to recognise early signs of recurrence in this phase of the disorder (Morriss et al., 2007). The efficacy of self-monitoring may be attributable to milder changes in mood state being more readily treatable than more severe and prolonged symptoms (Morriss et al., 2007). Further, these treatments are likely to be beneficial because they foster a sense of empowerment in patients by allowing them to regain a sense of control over their illness (Morriss et al., 2007). Psychoeducation and mood monitoring have proven to be efficacious in delaying time to relapse (Colom et al., 2003; Perry et al., 1999), and in patients not currently meeting criteria for a bipolar episode, cognitive therapy incorporating mood monitoring has been associated with fewer bipolar episodes, days in a bipolar episode, and hospitalisations (Colom et al., 2003; Lam et al., 2003). In addition to psychoeducation and mood monitoring, it is important for maintenance treatment in BD to reinforce healthy coping and communication styles (Malhi et al., 2009a), even if these may appear functional in the euthymic patient. Psychosocial intervention via family focused therapy in particular has been shown to decrease the frequency of depressive and manic episodes by reducing stress, increasing communication between bipolar patients and their families, and problem–solving skills training (Hollon et al., 2006; Miklowitz et al., 2003). 4.2. Limitations The CADE Clinic is a specialist outpatient clinic that receives secondary and tertiary referrals, and as such, the patients in this study are likely to be different to those in community settings. This is reflected in part by the fact that there were no significant differences in the male: female gender distribution between our

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UP and BD patients, whereas in community samples, there is female predominance in UP, but male: female equivalence in BD (Merikangas et al., 2011; Ustun et al., 2004). With regards to establishing euthymia, current levels of mood and anxiety on the DASS and the STAI (State) anxiety subscales were calculated using scores for the whole group of UP and BD patients, rather than each patient individually. Therefore, whilst the patients’ scores fell within the normal (non-clinical) range on average, we cannot fully generalise these findings to euthymic patients. Further, whilst the results of this study suggest that euthymic BD may be a more ‘functional’ illness than remitted UP, the results cannot be generalised to how both would compare in a depressive state, specifically, due to the nature and course of BD relative to UP illness.

4.3. Considerations for further research The course of BD illness and profile of BD depression are typically very different to those of UP, and many consider depression in BD to be ‘more severe’ than that in UP. This is because BD is deemed a more biologically driven illness, indicated by its high degree of heritability (Akiskal et al., 2006; McGuffin et al., 2003), greater mood instability (Ahearn and Carroll, 1996; Akiskal et al., 2006; Hofmann and Meyer, 2006), earlier age of onset (Abla et al., 2006), and a more complex medication regime consisting of mood stabilisers, antidepressants, and antipsychotics (Bauer et al., 2010). An earlier age of onset and need for a wider range of medications were exemplified in our BD group. Certain types of depression may also occur with a higher frequency in BD compared to UP patients (Rybakowski et al., 2007). These authors found that BD patients had significantly more episodes of psychotic depression, atypical depression, and treatment-resistant depression. Abla et al. (2006) further found that compared to UP patients, BD patients reported more suicidal attempts, a greater degree of substance abuse, more somatic comorbidity, more anxiety manifestations, and greater occupational impairment. In terms of coping, depressive symptoms in BD have been related to greater rumination and negative cognitive styles (van der Gucht et al., 2009). Thus, although the euthymic BD patients in the present study would appear to be more ‘functional’ than the UP patients, they remain a highly vulnerable group of individuals. This was apparent in two other aspects of data in our study when the range of scores derived from other measures were evaluated against normative data. First, the extraversion scores of the euthymic BD group did not exceed those of the normative data published by Costa and McCrae (1989), but were within normal limits, whilst those of the remitted UP group did indeed fall more than 1.5 SDs below the mean of the general population. These findings were consistent with other research (Canuto et al., 2010), and demonstrate that the protective role of extraversion in euthymic BD is likely to be due to its preservation, rather than an abnormally elevated level of extraversion that could possibly surmount the most difficult challenges of a depressive state imposed on coping and clinical outcomes. Second, consistent with previous studies of personality in UP and BD (Bagby et al., 1997) and self-esteem (Jones et al., 2005; Nilsson et al., 2010; Serretti et al., 2005), the neuroticism and selfesteem scores for the BD as well as the UP group deviated more than 1.0–1.5 SDs from the normative data published by Costa and McCrae (1989) and Bagley et al. (1997) respectively. Neuroticism in particular has been shown to be associated with hospitalisation for bipolar depression (Kim et al., 2011) and a range of maladaptive coping strategies including the increased use of escape/ avoidance, self-blame, and reduced levels of problem–solving

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and positive reappraisal (Lysaker and Taylor, 2007; Watson and Hubbard, 1996). 4.4. Conclusions The findings from this preliminary study indicate that BD may be a more ‘functional’ illness during remission as compared to UP, and underline the importance of non-pharmacological interventions that target cognitive factors and adaptive coping in UP. Further research is clearly warranted to directly compare depressed UP and BD individuals, and examine the inter-relationship between personality, coping styles and clinical outcomes during the depressive phase, as it is evident that both groups are highly vulnerable to episodes of functional and emotional impairment beyond remission.

Role of funding source The authors acknowledge the NHMRC Program Grant (510135) for essential financial support.

Conflict of interest GM has received grant or research support from NHMRC, NSW Health, AstraZeneca, Eli Lilly & Co., Organon, Pfizer, Servier, and Wyeth; has been a speaker for AstraZeneca, Eli Lilly & Co., Janssen Cilag, Lundbeck, Pfizer, Ranbaxy, Servier, and Wyeth; and has been a consultant for AstraZeneca, Eli Lilly & Co., Janssen Cilag, Lundbeck, and Servier. HM serves on the Australian Advisory Board convened by Shire in relation to ADHD and lisdexamfetamine dimesylate. During the past 5 years he has helped develop a training program for health professionals for the identification and management of ADHD in adults supported by Janssen–Cilag. He has served on Advisory Boards convened by the drug industry in relation to specific antidepressants, including escitalopram, mirtazapine, venlafaxine, and desvenlafaxine. He has been an advisor/consultant for, and/or received honoraria for talks, and/or has received conference attendance support from: AstraZeneca, Bristol–Myers Squibb, Eli Lilly, Janssen–Cilag, Lundbeck, Organon, Pfizer, Servier, and Wyeth. LL has been a consultant or served on Advisory Boards for AstraZeneca, Wyeth Australia, Lundbeck Institute and Pfizer; has received travel support from AstraZeneca, Wyeth Australia and Pfizer; has been a speaker for AstraZeneca, Lundbeck, Pfizer, and Wyeth; and is a Board member of the Anxiety Disorders Association of NSW. CC, DB, MT, EC, KT, GC, and SK have no conflicts of interest to report.

Acknowledgements We would like to thank Ms. Karen Searle for assistance with data entry and management of the CADE Clinic database.

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