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Year : 2019  |  Volume : 41  |  Issue : 2  |  Page : 199-200  

Comments on “Stressful Life Events and Relapse in Bipolar Affective Disorder”

1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Govt. Medical College and Hospital, Sector 32, Chandigarh, India
3 Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Web Publication4-Mar-2019

Correspondence Address:
Dr. Satish Suhas
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPSYM.IJPSYM_42_19

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How to cite this article:
Suhas S, Singh GP, Gorthi NV, Andrade C. Comments on “Stressful Life Events and Relapse in Bipolar Affective Disorder”. Indian J Psychol Med 2019;41:199-200

How to cite this URL:
Suhas S, Singh GP, Gorthi NV, Andrade C. Comments on “Stressful Life Events and Relapse in Bipolar Affective Disorder”. Indian J Psychol Med [serial online] 2019 [cited 2020 Feb 22];41:199-200. Available from:


Sam et al.[1] studied presumptive stressful life events (PSLEs) in 128 consecutive patients who were treated for relapse of bipolar disorder. Their study has many limitations and breaks no new ground. The principal limitation is that there was no control group. It is quite likely that many healthy people would have had PSLEs in the past month.[2] Therefore, unless it is demonstrated that the clinical sample had a larger burden of PSLEs than a control sample, studying PSLEs in the clinical sample serves little purpose.

If the clinical sample did have a higher burden of PSLEs, it might merely have been because the PSLEs, recorded for the 1 month before the patient was recognized by the informants to be “obviously abnormal,” may have included dependent life events that resulted from subsyndromal illness behaviors. Family and in-law conflicts and change in sleeping habits are examples of potentially dependent events. Although the authors acknowledged this as a limitation, they described no effort to exclude such dependent events from the analysis.

The authors did not have a preset hypothesis, nor did they explain for what outcome they had powered their sample size calculations. Their sample size estimation, therefore, serves no purpose. Also, if their sample size estimation was a valid exercise, then their recruitment of more patients than necessary could actually be considered unethical.

The analyses examining relationships between PSLEs and sociodemographic and clinical variables were exploratory and not hypothesis-driven; no primary outcome had a priori been defined. Therefore, the authors should have considered measures to protect against a Type 1 error.[3]

Many of the reported PSLEs were almost certainly chronic conditions, including unemployment, conflicts with in-laws, and financial problems; therefore, a chronic medical disease in the proband should not have been set as an exclusion criterion in sample selection. Chronic illness is an important and clinically relevant stressor.

The mean interval between the PSLEs and relapse was 20 days. This number has questionable meaning because it was constrained by the study definition of “preonset” as the 1 month before relapse. Had the authors defined preonset as 6 or 8 weeks, the mean interval may have been 30 days or longer. Furthermore, how would the authors calculate an interval for patients who had more than one PSLE, and for patients who had chronic PSLEs?

Delaying the assessment of PSLEs to the time when the patient attained remission is problematic because different patients would have remitted at different rates. Though the authors acknowledged this, the recall of the occurrence and importance of the PSLEs might have varied as a function of time.

Finally, because the authors studied patients in remission and because they presented PSLE results for the full sample, do they imply that the remission rate in the “128 consecutive patients” was 100%? This is an extraordinarily high remission rate[4] considering that the study population had 53 (41.4%) patients[1] suffering from bipolar depression.

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   References Top

Sam SP, Nisha A, Varghese PJ. Stressful life events and relapse in bipolar affective disorder: A cross-sectional study from a tertiary care center of Southern India. Indian J Psychol Med 2019;41:61-7.  Back to cited text no. 1
  [Full text]  
Singh G, Kaur D, Kaur H. Presumptive stressful life events scale (PSLES) — A new stressful life events scale for use in India. Indian J Psychiatry 1984;26:107-14.  Back to cited text no. 2
[PUBMED]  [Full text]  
Andrade C. Multiple testing and protection against a type 1 (false positive) error using the Bonferroni and Hochberg corrections. Indian J Psychol Med 2019;41:99-100.  Back to cited text no. 3
  [Full text]  
Thase ME. Bipolar depression: Diagnostic and treatment considerations. Dev Psychopathol 2006;18:1213-30.  Back to cited text no. 4


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