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Pslchiatr Research,) 1) 4

PoliticalChangeand Courseot Affective Psychoses:

Jens Bohlken and Stefan Priebe

rcvied v^ian p.e edJanualr11,I99l: accepted

Receiw.lOctobet18,1990; Januatr24,

Abstnct.In thissludy.lhepoliticajchange asso.iated sith thefau oflhe Berlit

Wallin November t989wasexaninedasashared lifeevenlforthepopulationof
WeslBerlin-I1sinfluence or thecouneoi affeclive psychoses wd studiedin 67
parientsin lorg-tem lrealnenr.Recurences f.on Noledbe. 1989to March
1990werecompared vith the sameperiodI yearbetore.while palieolswith
bipolaralfectivepsycbo.isdid not showa difference id recurrenc€sbetweetthe
twoperiods, patients
withunipolardepresion hadasignificandy belt€randthose
wilh schizoaffeclivepsychosha significanlly of illnes afler
November 1989thanin theyearbefor€.
K.y wo.ds.Affectiv€ lifeevent.no.bidiryind€x.

Ahhoughth€ effecloflifeeventson the courseofaffectivepsychoses is believed10be

limited (Payk€I, 1978,1983;Katschnig,1986;Wittchen, 1987;Sclare and Creed,
1990),i1 has repeatedlybeenshownrhat stressfactorsin generaiand life eventsin
and Haidipur, 1983;
parlicularmay influencethe onset(Patrick€t al., 1978;Glassner
Bidzinska,1984;Ambelas,1987)andthe course(PaykelandTanner,1976;Murphy,
1983;Billingsand Moos, 1985;Monroeet al., 1983;Ghaziuddinet al-, 1990)of
affectiv€ psychoses.In this study, the political change in 1989 and its social
cons€quences wereregardedasa sharedlife eventfor the populationof WestBertin.
On November9, 1989,the BerlinWallwasopened.That changecameunpredictabiy,
or was at leastsurprisinglysudden,for mos! peoplein West Berlin. Peoplewere
affectedby favorableas well as unfavorableconsequ€nces in different ways and
viewedthem differently.
F'rom the openingof lhe Beriin Wall, West Berlin was far more crowdedthan
before,with on somedays-hundredsofthousandsofvisirorsfrbm EastG€rmany.
Many W€st Berlinerswent to th€ Wall and to EastBerlinto get an impr€ssion,and
take advantage,ofthe ongoingchanges.Potentialsand dangersofthe newsituation
werc the subjec.tof most public and privatediscussions.
We investigatedthe way in
which that changeaff€ctedthe courseof illnessin pali€ntswho were in long term .
rreatmentfor an affectivepsychosis.

JensBohl*en,M.D., D'pl. Soc'ologist.is Resea.cFelior, Depa.tmentofCli.ical Psychiaty,andSleian

Piiebc, M.D., Dipl. Psycholosist,is Rs€arch A$istant, Depannenr oi Social Psvchlatrv,FEr
Udivcrsith!Berlin,Cemaay. (Reprint requestsloDr. S Priebe,Deparhenr ofSocial Psvcbiatv,FEie
U.iversidl Berlin-Plaianemtlce19, 1000Bedin 19,Ccrm.nv)

0165-lt8l/91/!03.50o l99l ElsevierScienlificPlblishersIrelandLid

The sludy was caried oul in the lilhiuo clinic of the Freie UniversilerBerlin (Mrjller-
Oerlinghausenel al-, 1990).We studieda sample of 67 patientswho had a diagnosisof
schizoaffective, bipolar affective.or unipolardepressive
diso.de.accordingro 1CD9 (World
Heallh Organizalion,1978).had a routine appointmentin the lilhium clinic betweenthe
middteof March and beginninSofApnl 1990.and had continuouslyb€enin treatmenral the
lilhiun cliric sinceOctoberI988.Therewe.eno other selectionc.ileria.
The courseof iUnesswar'aslessedby a modificalionof the "morbidjty index," o.iginally
proposedby Coppenei al. (1973;Priebeer al., 1989).The indexreflecrslhe severityaDdlength
olrecurrences(numberof daysspenlin the hospiralmultipliedby 3, plus all dayson which a
lemporarydlidepresul or neurolepticmedicationin additionto lilhium or carbamdepine
wasgivennultiplied by 2, and thendividedby the numberofdays oflhe obscrvalionperiod).
The norbidity index wascalculatedfo.4 monthsafle. Novenber 9, 1989,and for rhe same
time pe.iod I yea. before.Morbidity indicesfor thetwo lime periodswerecomparedfo.each
In addilion.palientswereaskedon a l()-itemquesdonnai.eabouttheir vie*s ofthe change
and ofits effecton their personallives.

/aD-, pslchralricdiagnoses were a. follo\as:22 parienlsbad a schiTodllective
psychosis(ll females,ll males),25 palientsa bipolar affectivepsychosis(14 fe
males, ll males), and 20 palients a unipolar depressjvedisorder (15 fernales,
5 males).Table I summarizesage,duration of illness,and numb€r of previous
hospitalizationsin eachgroup.
Patiefltswith a unipolard€pressiv€
disorderweresignificantlyolder than parients
with bipolar affective(r = 3.83, df= 41,p < 0.001)or schizoaffective psychoses
(t = 6.07,df :38, p <0.001). Other differencesb€lweenthe threegroupswerenot

Table 1. Age, duration ot illness, and number ot hospitalizalions in

Unipolardepressive Schizoallective Bipolaraffeclive
psychosis psychosis psychosrs
ln = 20) ln = 22) {n:25)
Mean so Mean SD Mean SD
Ase{vi 637 93 42.3 49.8 14.9

203 13.9 4.2 17.1 11.7

4.4 3.6 6.3 3.8 4.8 3.4

Table2 showsmorbidity indicesfor the 4 monthsafter November9, I 989,and I he

sarneperiod in 1988-89.
Morbidity indi€esforth€ two tim€ periodsdo not differ significanllyin the whole
sampieor in pa.ientswith bipolar affectivepsychosis.How€ver,in 1989-90,palients
psychoshhad a morbidi.y index fiv€ limeshigherthan a yeaf
with a schizoaffeclive
before.The oppositetendencywass€enin patientswith unipolardepressive disorder:
ihe morbidity indexin 1989-90wasjusl a third ofwhat it had beenI yearbefore.The

diff€rencesin patientswith schizoaff€ctive psychosisand in rhos€ with unipolar

depressiv€ psychosis werestatisticallysignificant.
In the group of palientswith a schizoaffective psychosis,frequencyof relapses
leadingto a hospitaladmissionchangedfrom threein 1988-89to sevenin 1989-90,
and in patientswilh unipolardepressive disordersfrom five in I988-89lo only onein
1989-90.In patientswillr a bipolar affe€tivepsychosis,there were four hospital
admissionsin €achp€riod. ln thosepatienrswho receivedprophylacticlithium or
carbamazepine, serumlevelsdid not differ significanllybetwe€nthe two periods.
Mosl patientsexpressedpositivesubjecliveviews of the political changeon th€
queslionnaire,and there were no significanldifierencesbelweenthe diagnostic
subgroups.Regardless ofdiagnosis,thosepalientswho had a highermorbidityindex
in 1989-90than in 1988-89 rnoreollen statedthat thejr liveswerestitl affecledby thc
politicalchange(X' = 8.33,.{= t, p <0.01).

Table 2. Morbidity indices tor the 2 time periods (November 1989-l!larch

and November 1988-March 1989) in diagnostic subgroups
1989-90 1988-89
Mean Mean SD

0.55 0.10 022 < 0 05 {t = 2.65,d/= 21)l

0.48 0.75 0.39 066 NS

0.16 0.48 0.55 081 < 0.05(t = 2 11,dt = 19)

To study the possibleinfluence of political change on the course of affeclive
psychoses, we comparedihe morbidity index after the changewith the index for lhe
sam€period rhe year before.This methodhas somemethodologicalproblems.In
particular, the effect of sponraneouschangesin lhe cours€of illnesscannot be
conirolled. However, since treatment variableswere consistentduring the two
periodsoflime and diff€rences in rnorbidityindiceswerestarisdcalll,significant,the
findings suggestsome;nnuenceo{ poiilical chang€on the courseof illnessin |he
sampleexamin€dhere.lt remainsopenwhcrherelen clearerdifferenceswoDIdhave
beenfound had shoneror longerobservationperiodsafter Novemb€r9, 1989,been
analyzed.Ye1,il shouldbe takeninlo accountlhat the sampleis highlyselective, tbal
th€ diagnoslicsubgroups are small, and that prophylactic lithium or carbamazepine
could have affec1€diiability lo relapse.On average,palientswilh bipolar affective
psychosis did not sbowadifferentcourseofillnesslhan in the yearbefore.However,
the eventsin Berlin 1989-90seem1()have had opposileeffectson palientswirh
schizoaffeclivepsychosisvs. thosewith unipolar depressive disorder.Ahhough the
two groups did not differ in their subjeclive views of the cvents as assessed
retrosp€ctivelyon a bri€f queslionnaire, one may speculate as to wh€ther the
depr€ssive parients were affected by an at that time -.elated and partly euphoric

mood in Wes!Berlin and by a generallyrather stimulatingatmosphereln contrasl

to unipolar depressive palients,pati€ntswith schizoaffectivepsychosismay have
experiencedieelirgs of insecurity and irritation as a result of the chang€dand
Dncertainsituationassociated with many negativeprospectsfor living conditionsin
west Berlin aswell aswith positiveones.
The openincoflhe Berlin Wall wasan eventrhat wasentirelyoutsidelhe parients'
cont.ol and independentof their illnesses.Obviously. the possibl€associalionof
politicalchangeand courseol affectivepsychoses suggcsledin this studyaroseunder
specialhistorical circumstances and cannot be generalizedro olher situationsof
polilical change.

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