The McLean-Harvard First-Episode Mania Study: Prediction of Recovery and First Recurrence

doi:10.1176/appi.ajp.160.12.2099



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Am J Psychiatry 160:2099-2107, December 2003
© 2003 American Psychiatric Association

Article

The McLean-Harvard First-Episode Mania Study: Prediction of Recovery and First Recurrence

Mauricio Tohen, M.D., Dr.P.H., Carlos A. Zarate, Jr., M.D., John Hennen, Ph.D., Hari-Mandir Kaur Khalsa, A.B., Stephen M. Strakowski, M.D., Priscilla Gebre-Medhin, M.S., Paola Salvatore, M.D., and Ross J. Baldessarini, M.D.

OBJECTIVE: Since improved prediction of illness course earlyin bipolar disorder is required to guide treatment planning,the authors evaluated recovery, first recurrence, and new illnessonset following first hospitalization for mania. METHOD: Bipolardisorder patients (N=166) were followed 2–4 years aftertheir first hospitalization for a manic or mixed episode toassess timing and predictors of outcomes. Three aspects of recoverywere measured: syndromal (DSM-IV criteria for disorder no longermet), symptomatic (Young Mania Rating Scale score $<=$ 5 and HamiltonDepression Rating Scale score $<=$ 8), and functional (regainingof premorbid occupational and residential status). Rates ofremission (syndromal recovery sustained $>=$ 8 weeks),switching (onset of new dissimilar illness before recovery),relapse (new episode of mania within 8 weeks of syndromal recovery),and recurrence (new episode postremission) were also assessed.RESULTS: By 2 years, most subjects achieved syndromal recovery(98%, with 50% achieving recovery by 5.4 weeks); 72% achievedsymptomatic recovery. Factors associated with a shorter timeto syndromal recovery for 50% of the subjects were female sex,shorter index hospitalization, and lower initial depressionratings. Only 43% achieved functional recovery; these subjectswere more often older and had shorter index hospitalizations.Within 2 years of syndromal recovery, 40% experienced a newepisode of mania (20%) or depression (20%), and 19% switchedphases without recovery. Predictors of mania recurrence wereinitial mood-congruent psychosis, lower premorbid occupationalstatus, and initial manic presentation. Predictors of depressiononset were higher occupational status, initial mixed presentation,and any comorbidity. Antidepressant treatment was marginallyrelated to longer time to recovery and earlier relapse. CONCLUSIONS:Within 2–4 years of first lifetime hospitalization formania, all but 2% of patients experienced syndromal recovery,but 28% remained symptomatic, only 43% achieved functional recovery,and 57% switched or had new illness episodes. Risks of new manicand depressive episodes were similar but were predicted by contrastingfactors.

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