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Affective instability and the course of bipolar depression: Results from the STEP-BD randomised controlled trial of psychosocial treatment

  • Jonathan P. Stange (a1), Louisa G. Sylvia (a2), Pedro Vieira da Silva Magalhães (a3), David J. Miklowitz (a4), Michael W. Otto (a5), Ellen Frank (a6), Christine Yim (a1), Michael Berk (a7), Darin D. Dougherty (a2), Andrew A. Nierenberg (a2) and Thilo Deckersbach (a2)...



Little is known about predictors of recovery from bipolar depression.


We investigated affective instability (a pattern of frequent and large mood shifts over time) as a predictor of recovery from episodes of bipolar depression and as a moderator of response to psychosocial treatment for acute depression.


A total of 252 out-patients with DSM-IV bipolar I or II disorder and who were depressed enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) and were randomised to one of three types of intensive psychotherapy for depression (n = 141) or a brief psychoeducational intervention (n = 111). All analyses were by intention-to-treat.


Degree of instability of symptoms of depression and mania predicted a lower likelihood of recovery and longer time until recovery, independent of the concurrent effects of symptom severity. Affective instability did not moderate the effects of psychosocial treatment on recovery from depression.


Affective instability may be a clinically relevant characteristic that influences the course of bipolar depression.

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Corresponding author

Thilo Deckersbach, PhD, Bipolar Clinic and Research Program, Massachusetts General Hospital, Department of Psychiatry, 50 Staniford Street, 5th Floor Boston, MA 02114, USA. Email:


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STEP-BD was funded in part by contract N01MH80001 from the National Institute of Mental Health (NIMH, Gary Sachs). Support for the development of the psychosocial treatments was provided by grants MH29618 (E.F.), MH43931 (D.J.M.) and MH55101 (D.J.M.) from the NIMH and by the National Alliance for Research on Schizophrenia and Depression (D.J.M.). J.S. was supported by National Research Service Award F31MH099761 from NIMH. L.G.S. received research support from NIMH (grant no. 1K23MH91182-1A1 and N01MH80001-01). D.J.M. has received research support from NIMH (grant no. HR01mh093676 and R33MH097007), Brain and Behavior Research Foundation, American Foundation of Suicide Prevention, Danny Alberts Foundation, Deutsch Foundation, Kayne Foundation, and Attias Family Foundation; M.B. is supported by a NHMRC Senior Principal Research Fellowship (1059660) and has received grant/research support from the NIH (grant no. 1R34MH091384-01A1), Cooperative Research Centre, Simons Autism Foundation, Cancer Council of Victoria, Stanley Medical Research Foundation, MBF, NHMRC, Beyond Blue, Rotary Health, Geelong Medical Research Foundation. T.D. was supported in part by a K-23 NIMH Career Award 1K23MH074895-01A2. His research has also been funded by NARSAD, TSA, OCF and Tufts University.

Declaration of interest

L. S. served as a consultant for Bracket Global and Clintara. M.O. has served as a consultant for MicroTransponder Inc. E.F. has served as a consultant for Servier International. M.B. has received research support from Bristol-Myers Squibb (BMS), Eli Lilly, GlaxoSmithKline (GSK), Organon, Novartis, MaynePharma and Servier, has been a speaker for AstraZeneca, BMS, Eli Lilly, GSK, Janssen Cilag, Lundbeck, Merck, Pfizer, SanofiSynthelabo, Servier, Solvay and Wyeth, and served as a consultant to AstraZeneca, BMS, Eli Lilly, GSK, Janssen Cilag, Lundbeck Merck and Servier. A.A.N. has received honoraria or travel expenses from: American Society of Clinical Psychopharmacology, Australasian Society for Bipolar Disorder, Bayamon Region Psychiatric Society, Belvoir Publishing, Boston Center for the Arts, Corcept, Controlled Risk Insurance Company, Dartmouth, Dey Pharma L.P./Mylan Inc, Israel Society for Biological Psychiatry, Johns Hopkins University, National Association of Continuing Education, PAI, Pamlabs, Physicians Postgraduate Press, Ridge Diagnostics, Slack Publishing, Sunovion, Teva Pharmaceuticals, University of Florida, University of Michigan, University of New Mexico, University of Miami, University of Wisconsin, Wolters Klower Publishing. Potential consulting honoraria from AstraZeneca, BMS, Forest, Pfizer, Ridge Diagnostics. Potential support of research at Massachusetts General Hospital (MGH) through Biogen Idec, Dey Pharmaceuticals, Pamlabs, Shire and Sunovian. He owns stock options in Appliance Computing Inc ( and BrainCells Inc. Additional income is possible from but no revenue has been received to date. Through MGH, A.A.N. is named for copyrights to: the Clinical Positive Affect Scale and the MGH Structured Clinical Interview for the Montgomery–åsberg Depression Scale exclusively licensed to the MGH Clinical Trials Network and Institute (CTNI). T.D. has received honoraria, consultation fees and/or royalties from the MGH Psychiatry Academy, BrainCells Inc, Systems Research and Applications Corporation, Boston University, the Catalan Agency for Health Technology Assessment and Research, the National Association of Social Workers Massachusetts, the Massachusetts Medical Society, Tufts University and National Institute on Drug Abuse. He has also participated in research funded by National Institutes of Health, National Institute on Aging, Agency for Healthcare Research and Quality, Janssen Pharmaceuticals, The Forest Research Institute, Shire Development Inc, Medtronic, Cyberonics and Northstar.



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Affective instability and the course of bipolar depression: Results from the STEP-BD randomised controlled trial of psychosocial treatment

  • Jonathan P. Stange (a1), Louisa G. Sylvia (a2), Pedro Vieira da Silva Magalhães (a3), David J. Miklowitz (a4), Michael W. Otto (a5), Ellen Frank (a6), Christine Yim (a1), Michael Berk (a7), Darin D. Dougherty (a2), Andrew A. Nierenberg (a2) and Thilo Deckersbach (a2)...


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