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What does history teach us about factors associated with relapse in bipolar affective disorder?

When investigating treatments for any chronic condition it is essential to know the usual course of the illness concerned. The natural history of bipolar affective disorder has only been established relatively recently. This review examines the factors that affect the course of bipolar disorder from an historical perspective. These include the affective nature of the episodes and the influence of psychotic symptoms, age at onset of illness, length of episodes and cycles, gender, ethnicity, concurrent drug and alcohol use, occupational status and factors leading to chronicity. The pioneering work of Kraepelin and Angst established that episodes of illness in bipolar disorder increased in frequency over time and that earlier age of onset predicted more frequent episodes. More recent work has established that female subjects have a later onset of illness, that the frequency of episodes often decreases over time and that rapid cycling has a poorer response to treatment. Suggested criteria for inclusion of subjects into trials examining manic relapse are listed based on the findings from earlier work.