The long-term treatment outcome of 248 bipolar patients in an out-patient lithium programme was assessed. Over half of the patients (138 or 56%) had no affective episodes in the year observed. Patients were divided into outcome groups according to GAS scores: the outcome for 40% of patients was good, for 41% fair, and for 19% poor. More frequent psychiatric admissions before starting lithium treatment was the best predictor of poor outcome, followed by a negative affective style in the family and lower social class. Current alcohol and drug abuse was associated with poor outcome. Although familial and psychosocial factors were significantly associated with outcome, the findings suggest there may be inherent differences in the pathophysiology of bipolar disorder reflected in an increased frequency of episodes which account for a large variance in lithium treatment outcome.

Single-photon emission computed tomography (SPECT) imaging with n-isopropyliodoamphetamine (IMP) was performed on 11 patients with bipolar mania, 21 acute schizophrenics, and 15 healthy control subjects. Subjects were evaluated with neuropsychological tests and psychiatric rating scales. SPECT brain studies were blindly evaluated to assess the degree of radiopharmaceutical uptake in three neuroanatomical regions of interest in each hemisphere. All the control subjects, 1 manic patient, and 1 schizophrenic patient had normal brain SPECT uptake patterns. The scans of all others were read as abnormal. Hypofrontality was noted in some schizophrenics and maniacs. A significant increase in tracer uptake in temporal lobes was observed in both patient groups, more prominently in the manic patients. Increased and decreased basal ganglia uptake was also observed in patients. Both manic and schizophrenic patients showed cortical tracer heterogeneity of varying degree. The patterns of cerebral SPECT uptake seen in these acute psychoses were not specific for a diagnosis, but may be associated with dimensions of psychopathology. Because the patterns are different from those seen in cerebrovascular disease and the dementias, they may prove to be helpful in differential diagnosis.

The failure rate in long-term lithium treatment of bipolar affective disorder is in the range of 20 to 30%, even with rigorous diagnostic criteria an adequate serum lithium levels. This may be due to a variety of biologic and psychosocial factors. Psychosocial factors affecting treatment outcome were studied in 60 RDC diagnosed bipolar patients treated with lithium for one year. Outcome was measured using an affective episode score, a social adjustment scale and a global assessment scale. Social support was the factor most strongly correlated with a good outcome on all three measures.