Copyright Blackwell Munksgaard 2007

Bipolar Disorders 2007: 9: 589595 BIPOLAR DISORDERS

Original Article

Coping styles in prodromes of bipolar mania

Parikh SV, Velyvis V, Yatham L, Beaulieu S, Cervantes P, MacQueen G,
Siotis I, Streiner D, Zaretsky A. Coping styles in prodromes of bipolar
mania.
Bipolar Disord 2007: 9: 589595. Blackwell Munksgaard, 2007
Objectives: Psychological studies have identied that dierent coping
strategies aect outcome in bipolar disorder (BD), with the possibility of
preventing mania by eective coping with prodromes. This study seeks to
examine coping mechanisms using a recently developed scale to clarify
the relationship of coping styles to clinical and demographic
characteristics, and to identify coping dierences between bipolar I and
II subjects.
Methods: The Coping Inventory for Prodromes of Mania (CIPM) was
completed by 203 bipolar patients, along with other diagnostic and
clinical measures. The CIPM is organized into four factors of coping
including: stimulation reduction (SR), problem-oriented coping (PR),
seeking professional help (SPH), denial and blame (DB). CIPM
psychometric properties and its relationship to demographic and clinical
factors, dysfunctional attitudes, and mood symptoms were examined.
Coping proles were generated by BD subtype (I versus II).
Results: The CIPM displayed psychometric properties consistent with
the single previous study with this instrument. Neither demographic/
clinical characteristics nor mood symptoms showed any particular
relationship with the CIPM. Clear dierences in coping also emerged
between BD I and BD II subjects. BD I tended to use a wider range of
coping strategies and scored highly on the SPH factor as compared to
BD II subjects. BD II participants preferred to use DB and PR, but were
less likely to use SPH and SR.
Conclusions: The CIPM appears to be a valid measure of coping.
Coping style preferences appear to dier according to bipolar subtype.
Sagar V Parikha, Vytas Velyvisb,
Lakshmi Yathamc, Serge Beaulieud,
Pablo Cervantesd, Glenda
MacQueene, Irene Siotise, David
Streinera and Ari Zaretskya
a
Department of Psychiatry, University of Toronto,
b
Centre for Addiction and Mental Health, Toronto,
Ontario, cDepartment of Psychiatry, University of
British Columbia, Vancouver, British Columbia,
d
Department of Psychiatry, McGill University,
Montreal, Quebec, eDepartment of Psychiatry,
McMaster University, Hamilton, Ontario, Canada
Key words: bipolar disorder bipolar type II
cognitive behavioral therapy coping behavior
insight mania psychoeducation
Received 23 September 2005, revised and
accepted for publication 28 September 2006
Corresponding author: Sagar V. Parikh, MD,
FRCPC, Department of Psychiatry, Toronto Western
Hospital, 399 Bathurst Street, Toronto, ON, M5T
2S8, Canada. Fax: +1 416 603 5039;
e-mail: sagar.parikh@uhn.on.ca

Bipolar disorder (BD) is a highly recurrent illness
with current pharmacotherapy providing only
moderate treatment success. Intensive eorts have
been made in recent years to systematically study
psychosocial interventions, including psycho-edu-
cation, cognitive-behavioral therapy, family ther-
apy, and interpersonal psychotherapies. All of
these interventions teach patients formal symptom
self-monitoring, identication of early warning
signs of relapse, and foster enhanced coping
techniques once serious symptoms have emerged
(1). Ideally, the goal of self-monitoring is to detect
The authors of this paper do not have any nancial or other rela-
tionships that might result in a conict of interest.
early warning signs and initiate adaptive coping
responses in the prodromal stages of mania with
the aim of minimizing or preventing acute manic
episodes, as well as the negative social and
psychological sequelae of these episodes.
The systematic investigation of coping strategies
in the context of prodromes of mania began with a
study by Lam and Wong (2) in which 40 bipolar I
patients were interviewed on illness prodromes and
coping. Their study found that 93% of bipolar
patients could identify prodromes of mania and led
to the development of a self-report questionnaire,
the Coping Inventory for Prodromes of Mania
(CIPM) (3). Following classical scale develop-
ment procedures, a scale of 23 items was created.
Using principal components analysis, the scale
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Parikh et al.
demonstrated four factors: stimulation reduction
(SR), problem-directed coping (PR), seeking pro- diagnosis of BD I or II, in partial or complete
fessional help (SPH), and denial or blame (DB). remission [17-item Hamilton Depression Rating
Both SR and SPH were positively related to
improved social functioning whereas DB was neg-
atively related to social functioning. Evaluation of
coping mechanisms also proved to be predictive: an
18-month follow-up study from this same popula-
tion showed that investigator ratings of coping
responses at time 1 signicantly predicted manic
symptom severity at time 2, 18 months later (4).
With a valid tool to characterize coping strat-
egies, the next step is to identify which strategies
augur successful disease management, and how
these coping strategies may be inuenced by
disease or patient characteristics. Research into
general coping processes suggests that the use and
timing of coping mechanisms depends both on
individual characteristics, such as personal values
and self-appraisal of resources to deal with stress,
as well as external factors, such as how to appraise
and assess the specic attributes of the threatening
situation (5). The general purpose of the current
study is to investigate coping with early warning
signs of mania in BD, and particularly if BD I and
II patients dier in their coping strategies, given
that bipolar I patients endure disabling manic
episodes. More specically, this study is designed
to: (i) examine normative data on the CIPM in a
large Canadian sample of BD patients; (ii) deter-
mine whether the CIPM is related to current mood
symptoms and dysfunctional attitudes; (iii) investi-
gate whether demographic and clinical character-
istics impact coping preferences in BD; and (iv)
examine coping proles as a function of bipolar
subtype.
Methods
Sample
Subjects (n 203) were obtained from four large
urban sites across Canada that were involved in an
ongoing randomized controlled trial evaluating
two psychosocial treatments for BD. Both of the
psychosocial interventions given included strat-
egies for monitoring and coping with early warning
signs of mania, thus, the CIPM was used as one of
the outcome measures of that study. The results
described herein reect only the pre-treatment
(baseline) data as many participants are still in
the follow-up phase. Further information will be
obtained at the conclusion of the follow-up phase
regarding the ability of the CIPM to detect post-
treatment change and its relationship with other
variables of interest.
590
Inclusion criteria for this study were: principal
Scale (HDRS) < 14, Clinician Administered Rat-
ing Scale for Mania (CARS-M) < 12], 1865 years
of age, on a consistent dose of a mood stabilizing
medication for at least four weeks prior to
enrollment, at least two mood episodes or clinically
signicant subsyndromal periods in the past three
years. Exclusion criteria were the following: elec-
troconvulsive therapy within one month of enroll-
ment, severe personality disorder, active general
medical condition that could interfere with treat-
ment, current suicidality or homicidality. Subjects
were excluded from the overall cognitive behavior-
al therapy versus psychoeducation study if they
endorsed any severe substance abuse or depen-
dence in the previous three months. All subjects
were required to provide their written informed
consent prior to participation, and institutional
research ethics board approval was granted.
Procedures
Recruitment was largely through self-referral from
information being posted in local hospitals and
other advertising methods. Interested subjects
called for information, and attended an initial
appointment at which point they gave written
consent to participate. The initial part of the
interview obtained basic demographic and general
clinical information and history, followed by a
comprehensive diagnostic interview using a stand-
ardized semi-structured instrument [Structured
Clinical Interview for DSM-IV (SCID)] (6) to
conrm diagnostic criteria. Care was taken to
ensure inclusion criteria were met and that no
exclusionary criteria were met. Subsequently, cli-
ents lled out several questionnaires and were
assessed for their current manic and depressive
symptom severity using standardized clinician-
administered rating scales.
Background information
Data were collected on demographic information
such as age, sex, occupational status, marital
status, as well as clinical information such as
estimated number of previous depressive and
manic episodes, duration of illness, and age of
onset.
Diagnostic information
Diagnostic information and clinical history
was obtained using the SCID (6). This was

administered to all subjects by trained clinical
interviewers.
Coping with prodromes of mania
Coping Inventory for Prodromes of Mania
(CIPM). This 23-item scale was designed to
assess four types of coping responses to pro-
dromes of mania which include stimulation reduc-
tion, problem directed coping, seeking professional
help, and denial or blame. Respondents are asked
to rate the frequency with which they use each
coping strategy on a scale from 1 (never) to 4 (all
the time). The original article by Wong and Lam
(3) reports that all of the subscales demonstrate
good stability and internal consistency (alphas
range from 0.700.85, except for seeking profes-
sional help 0.50).
Current mood symptoms
Hamilton Depression Rating Scale (HDRS-
17). Current depressive symptoms were assessed
with the 17-item HDRS (7). It is the gold-standard in
clinician-administered rating scales for depression.
It contains 17 items that are rated by an interviewer
for the past week. It has been shown to be a valid and
reliable measure of depressive symptom severity in
numerous studies and is sensitive to change over
time. The point spread of items range between 04 or
02 (0 none; 4/2 severe).
Clinician Administered Rating Scale for Mania
(CARS-M). Manic symptom severity was
assessed using the CARS-M (8). It is a 15-item
semi-structured interview and rating scale that
assesses symptoms of mania over the last seven
days and is comprised of two facets: mania (10
items) and psychosis (5 items). The current study
used only the mania factor in all statistical
analyses. Most of the items on the scale reect
DSM-IV criteria for mania. All items are rated
on a 6-point scale based on increasing severity
(05). This scale has been normed on a large
sample and has demonstrated high correlations
with Young Mania Rating Scale scores (r
0.94).
Dysfunctional Attitudes Scale (DAS). The DAS is
a 40-item self-report instrument, designed to iden-
tify cognitive distortions related to depression (9).
All items are scored on a 7-point scale where higher
scores reect more maladaptive beliefs. The DAS
reports very good internal consistency (alpha
ranges from 0.840.92) and excellent testretest
reliability (8-week 0.800.84).
Coping styles in prodromes of mania
Statistical analyses
Multivariate analyses of variance was used to
screen for multivariate eects of general demo-
graphic or clinical characteristics on the four
CIPM subscales, followed by univariate analyses
to identify where these dierences may lie. In
addition, to identify prole preferences for coping
strategies within bipolar subtype (I versus II), a
within subjects multivariate analysis of variance
was used.
Results
Background information
The current study sample was comprised of 203
bipolar I and II patients. There were 147 BD I
patients (73%) and 56 BD II patients; 118 of which
were female (58%), while 85 were male. The mean
(SD) age for this sample was 40.8 (10.96) years
(range 1861 years). In terms of education,
16.4% had either partially completed or completed
high school, 17.9% had attended post-secondary
specialized training or college, 17.9% had attended
university, 34.3% had completed a university
degree, 12% either nished or had received post-
graduate education. In the sample, 52.7% were not
currently working at the time of recruitment,
however, only 18% considered themselves as fully
unemployed; 34.5% were being at least partially
subsidized through welfare or disability payments,
while a further 14.2% were being supported by
their spouses or family members.
Symptom measures
The means (SD) for all of the measures used in this
study are provided in Table 1.
Both current depressive symptom (HDRS-17)
severity scores [mean (SD) 6.82 (4.94)] as well as
current manic symptom (CARS-M) severity scores
[mean (SD) 1.79 (2.92)] are indicative of symp-
toms that are consistent with remission status
according to published interpretive guidelines. The
mean (SD) DAS score for this sample was 134.10
(35.86). Scores in this range are slightly higher than
those previously found in a remitted unipolar
depressed sample; however, they are consistent
with remission status for bipolar patients (10).
Coping style measure (CIPM)
The means (SD) for all CIPM subscale scores
are also presented in Table 1 and are similar to
those of Wong and Lam (3). Except for the
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Parikh et al.

Table 1. Total sample mean, SD, and internal consistencies for main tionship between stimulation reduction and denial
measures or blame subscales. Moreover, all of the adaptive
Scales (n 203) Mean SD Alpha coping subscales were positively intercorrelated,
while the one negative factor (denial and blame)
HDRS-17 6.82 4.94 0.739 was negatively correlated with all of the other
CARS-M 1.79 2.92 0.786
DAS 134.03 35.88 0.934
subscales of the CIPM as might be expected.
CIPM-SR 1.96 (1.97) 0.58 (0.70) 0.585 (0.77)
CIPM-PR 2.15 (2.22) 0.59 (0.72) 0.804 (0.85)
CIPM-SPH 2.17 (2.27) 0.86 (0.83) 0.626 (0.53)
CIPM multivariate analyses
CIPM-DB 2.16 (2.21) 0.52 (0.54) 0.712 (0.72) A multivariate analysis of variance (MANOVA)
Parentheses indicate comparative data from Wong and Lam (3).
was performed for demographic and clinical var-
HDRS-17 17-item Hamilton Depression Rating Scale; CARS- iables on the CIPM subscales. The multivariate
M Clinician Administered Rating Scale for Mania; DAS analysis was performed on the four CIPM sub-
Dysfunctional Attitudes Scale; CIPM-SR Coping Inventory for scales using four demographic variables which
Prodromes of Mania-Stimulation Reduction; CIPM-PR Coping included sex, marital status, occupation category,
Inventory for Prodromes of Mania-Problem-directed Coping;
CIPM-SPH Coping Inventory for Prodromes of Mania-Seeking
and age. The MANOVA analysis found no signif-
Professional Help; CIPM-DB Coping Inventory for Prodromes icant main eects for any of the demographic
of Mania-Denial or Blame. variables tested.
The second multivariate analysis examined main
stimulation-reduction subscale, the remainder of eects for clinical characteristics of BD including
the CIPM subscale internal consistencies ranged bipolar subtype (I versus II), duration of illness,
between 0.630.80. The average Cronbachs alpha age of onset, and number of previous depressive,
reliability in our sample was slightly lower than manic, and hypomanic episodes on the four CIPM
that of the original study by Wong and Lam (0.68 factors. A signicant multivariate main eect was
and 0.72 respectively). Furthermore, our study found for bipolar subtype [F(4,123) 3.49, p
found two factors with inadequate reliability lev- 0.01]. Univariate ANOVA results showed that the
els (CIPM-SR and CIPM-SPH <0.70), whereas eect for bipolar subtype was evidenced only on
Wong and Lam only had one factor below this the CIPM seeking professional help factor
threshold (CIPM-SPH). [F(1,133) 13.15, p < 0.001]. No other signi-
Intercorrelations among the CIPM subscales as cant univariate eects of BD subtype were found
well as with symptom scales and DAS measures are for any other CIPM factor.
presented in Table 2.
None of the CIPM subscales was found to be
BD I and II CIPM profiles
related to either current depressive or mania
symptoms. All but the stimulation reduction factor The means (SD) for the CIPM subscales for both
of the CIPM were related to dysfunctional atti- BD I and II subjects are presented in Table 3. Due
tudes. Furthermore, the subscales all were related to the signicant multivariate eect of BD subtype,
to the DAS in theoretically predictable ways (i.e., a more detailed analysis should identify signicant
only the denial and blame subscale was positively dierences among the four CIPM coping strategies
associated with the DAS). separately for bipolar I and II subjects.
Intercorrelations among the CIPM subscales all Thus, two within subjects MANOVAs were
were signicant except for a non-signicant rela- performed for BD I and II groups separately

Table 2. Total sample zero-order intercorrelations

CIPM scales HDRS-17 CARS-M DAS CIPM-PR CIPM-SPH CIPM-DB

CIPM-SR )0.096 )0.002 )0.125 0.630** (0.51**) 0.422** (0.44**) )0.130 ()0.05)
CIPM-PR )0.111 0.093 )0.164* 0.360** (0.48**) )0.189* ()0.02)
CIPM-SPH )0.130 )0.028 )0.216** )0.154* (0.06)
CIPM-DB 0.049 0.088 0.355**

Parentheses indicate comparative data from Wong and Lam (3).

HDRS-17 17-item Hamilton Depression Rating Scale; CARS-M Clinician Administered Rating Scale for Mania; DAS Dysfunc-
tional Attitudes Scale; CIPM Coping Inventory for Prodromes of Mania; CIPM-SR Coping Inventory for Prodromes of Mania-Stim-
ulation Reduction; CIPM-PR Coping Inventory for Prodromes of Mania-Problem-directed Coping; CIPM-SPH Coping Inventory for
Prodromes of Mania-Seeking Professional Help; CIPM-DB Coping Inventory for Prodromes of Mania-Denial or Blame.
*p < 0.01; **p < 0.001.

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 Coping styles in prodromes of mania

Table 3. Coping Inventory for Prodromes of Mania subscale means and SD by bipolar subtype I versus II

CIPMSR, mean (SD) CIPMPR, mean (SD) CIPMSPH, mean (SD) CIPMDB, mean (SD)

Bipolar I 1.9898 (0.5994) 2.1882 (0.5929) 2.3152 (0.8411) 2.1424 (0.5251)

Bipolar II 1.8691 (0.5153) 2.0602 (0.5839) 1.7576 (0.7723) 2.2159 (0.4962)

CIPM-SR Coping Inventory for Prodromes of Mania-Stimulation Reduction; CIPM-PR Coping Inventory for Prodromes of Mania-
Problem-directed Coping; CIPM-SPH Coping Inventory for Prodromes of Mania-Seeking Professional Help; CIPM-DB Coping
Inventory for Prodromes of Mania-Denial or Blame.

which would allow examination of the relative
preferences or proles of coping strategies
employed for prodromes of mania. Signicant
within subjects multivariate eects were found for
BD I subjects [F(3,144) 12.30, p < 0.001] as
well as for BD II subjects [F(3,52) 8.37,
p < 0.001], indicating that at least one CIPM
subscale was signicantly dierent from at least
one other CIPM subscale for both BD I and II
patients. Examination of the post hoc pairwise
comparisons for BD I subjects reveals that the
most preferred coping strategy is to seek profes-
sional help followed by problem directed coping.
These pairwise comparisons for BD I are presented
in Table 4.
BD I patients are also likely to use a wider variety
of coping strategies as inferred by the fact that all of
the means of the CIPM subscales are at or above 2.
Examination of the post hoc pairwise comparisons
for BD II subjects shows that the most preferred
coping strategy for prodromes of mania is denial
and blame, while the least preferred coping strat-
egies are to seek professional help or to use
stimulation reduction techniques. These pairwise
comparisons for BD II are presented in Table 5.
Only two of the subscale means were above 2,
indicating a smaller repertoire of coping strategies
Table 4. Post hoc comparisons for Coping Inventory for Prodromes of
Mania (CIPM) subscales within bipolar I group
SR DB PR SPH
Means 1.99 2.14* 2.19* 2.32*
SR 1.99 0.15 0.20 0.33
DB 2.14 0.05 0.18
PR 2.19 0.13
SPH 2.32
Note: CIPM subscale means presented in ascending numerical
order; numbers within cells refer to mean differences from lowest
mean score (i.e., higher mean score indicates that it is used
more often). Those subscales marked with an asterisk (*)
indicate that they are significantly different from any subscales
which do not have an asterisk. (i.e., DB, PR & SPH do not differ
from each other but are all significantly different from SR).
SR Stimulation Reduction; DB Denial or Blame; PR
Problem-directed Coping; SPH Seeking Professional Help.
Table 5. Post hoc comparisons for Coping Inventory for Prodromes of
Mania (CIPM) subscales within bipolar II group
SPH SR PR DB
Means 1.76 1.87 2.06* 2.22*
SPH 1.76 0.11 0.30 0.46
SR 1.87 0.19 0.35
PR 2.06 0.16
DB 2.22
Note: CIPM subscale means presented in ascending numerical
order; numbers within cells refer to mean differences from lowest
mean score (i.e., higher mean score indicates that it is used
more often). Those subscales marked with an asterisk (*) indi-
cate that they are significantly different from any subscales
which do not have an asterisk. (i.e., PR and DB are both sig-
nificantly different from SPH & SR; PR & DB do not differ
significantly from each other).
SPH Seeking Professional Help; SR Stimulation Reduction;
PR Problem-directed Coping; DB Denial or Blame.
in response to manic prodromes for BD II subjects
as compared to BD I.
Discussion
In an era where many psychosocial interventions
for bipolar disorder are being tested, it is critical to
have some understanding of the mechanisms of
action. Enhanced coping styles are a common
feature of all major interventions, but have not
been evaluated in a rigorous way. Wong and Lams
development of the CIPM provides a tool to
systematically characterize coping methods and
allows clarication of the factors which inuence
coping. Our current study substantially advances
the understanding of psychosocial interventions by
providing the rst replication of the validity of the
CIPM and by clarifying that neither demographic
nor general illness characteristics are correlated to
coping styles. Furthermore, our study demon-
strates that bipolar I and bipolar II subjects dier
in coping mechanisms to the prodromes of mania/
hypomania. Bipolar I subjects rely more on seeking
professional help and stimulus reduction, while
bipolar II subjects rely more on denial and blame.
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Parikh et al.
In terms of psychometric properties, the means
and SD of the scale in our study are similar to
those reported in Wong and Lams original article,
while Cronbachs alpha reliability statistics were
slightly lower but still acceptable. Consequently,
the results obtained using the CIPM-SR and
CIPM-SPH factors should be interpreted with
some degree of caution. Nonetheless, the ndings
of this replication are strongly encouraging with
respect to the validity of the CIPM, given that the
validation employed a large sample drawn from
four distinct Canadian centres as opposed to the
original single centre European sample.
Prodromal coping strategies were not related to
current mood symptoms. This nding is not
necessarily surprising given that the majority of
the subjects in the study were in remission from
their symptoms as a necessary condition of their
participation. The lack of signicant associations
between the CIPM and symptom ratings of
depression (HDRS) and mania (CARS-M) might
therefore be an artifact of mood symptom oor
eects. Another possibility is that patients retro-
spective perceptions of coping with past manic
prodromes might not actually be inuenced by
their mood symptoms. While the present study
cannot contribute further to the interpretation of
this nding, the distinction between these two
possible interpretations would be important in
determining whether the CIPM should be seen as a
stable trait measure of coping as opposed to being
state-dependent. Lam and Wong (2) originally
hoped that the CIPM could be sensitive to change
over time and with treatment; however, the ques-
tion of whether this measure shows this type of
sensitivity must still be evaluated prospectively
over time as opposed to using cross-sectional
designs.
Correlational analyses between the CIPM sub-
scales and the DAS served as a validity check for
the CIPM. We expected that adaptive coping
strategies (i.e., stimulation reduction, problem
directed coping, and seeking professional help)
would be negatively related to the DAS whereas
the denial and blame factor would be positively
associated with the DAS. The rationale for these
predictions was that dysfunctional attitudes about
the self, the world, and ones future are likely
important determinants for how to cope in the face
of stress. Examination of the correlations were all
generally in line with these predictions except for
the stimulation reduction factor of the CIPM which
showed a non-signicant trend in the predicted
direction, likely explained by the poor internal
reliability of this factor. Overall, such consistent
predictable correlations between the CIPM factors
594
and the DAS bode well for the construct validity of
this measure.
The primary purpose of this study was to
determine whether demographic and/or clinical
variables inuenced the use of coping strategies for
prodromes of mania as measured by the CIPM in a
sample of 203 BD patients in full or partial
remission. To our knowledge, this is the rst study
to have examined coping strategies in BD as a
function of demographic and clinical characteris-
tics of BD. We found that of all of the demo-
graphic and clinical variables examined, only
bipolar subtype signicantly predicted dierences
in the use of coping strategies.
Of all the clinical variables examined including
age of onset, duration of illness, number of
previous mood episodes, and bipolar subtype,
multivariate analysis found only bipolar subtype
to predict dierential coping response to pro-
dromes of mania. Given that bipolar II patients
experience only hypomania, while bipolar I
patients may experience hypomania but must have
experienced mania which is dened as being more
disabling, we would expect some dierences in
coping responses. Subjects with BD I were signif-
icantly more likely to seek professional help at the
rst signs of mania, whereas for BD II subjects,
seeking professional help was the last choice. These
results would seem to be in keeping with coping
theories as described by Folkman and Lazarus (5).
Those authors dened coping as consisting of both
cognitive and behavioral eorts to manage specic
external or internal demands that are appraised as
taxing or exceeding the persons current resources.
Choosing a specic coping strategy is greatly
inuenced by how the stress is appraised in terms
of the nature of the danger, its duration, ambigu-
ity, and imminence, as well as by how ones own
coping resources are evaluated by the individual.
In keeping with this general theory of coping, BD I
patients may seek professional help more often
than BD II subjects because manic episodes
generally are more severe, imminent and unambig-
uous as compared to hypomanic episodes. Seeking
the assistance of a specialized professional may be
thought of as an eective coping strategy for any
severe condition such as mania. Conversely, hypo-
manic episodes may be experienced as pleasurable
or as a relief from depressions. Thus BD II subjects
may appraise the stress of hypomania as neither
threatening nor consequential, and therefore dis-
avow more drastic coping strategies. Relatively
lower scores on stimulation reduction and seeking
professional help may be understandable then with
a BD II sub-population. The higher scores on the
denial or blame factor for BD II subjects suggest

that it is the most popular coping strategy for
hypomanic prodromes; however, it is also clear
that the use of denial or blame may indicate a lack
of insight. Studies have suggested that poor insight
is related to poor management of the disorder (11)
and may also contribute to the worsening of the
condition over time. Gaining insight into ones
illness and coping with prodromes is a central
concern for most psychosocial interventions for
BD. These novel ndings of dierences in preferred
coping strategies between bipolar I and II argue for
further exploration in terms of etiology and clinical
implications.
Our study has several important limitations. We
have used the CIPM for both bipolar I and II
subjects and found dierences, while it was not
explicitly created with bipolar II subjects in mind.
Study selection criteria dictated medication treat-
ment adherence at study entry, recent mood stabil-
ity, and an absence of recent severe substance abuse,
which limits generalizability. The cross-sectional
design also limited our ability to infer causality of
signicant relationships and prevented more
detailed investigation of scale sensitivity to change
over time. Fortunately, since we will have follow-up
data on the CIPM and clinical outcomes on these
subjects, the sensitivity of CIPM as a measure of
change may be ascertained in future studies.
In summary, our study of 203 relatively stable
and treatment adherent BD subjects from Canada
replicated the normative data of Wong and Lam
(3) from the UK. The construct validity of the
CIPM was supported in this study as evidenced by
its multiple signicant associations with a measure
of dysfunctional assumptions (DAS). Sex, age,
occupational status and marital status were not
found to signicantly predict coping style. The
number of previous depressive and manic episodes,
duration of illness, and age of onset did not predict
dierences in coping strategies. BD II subjects
showed signicantly less of a tendency to seek
professional help as compared to BD I subjects.
BD II subjects demonstrated a preference for
denial or blaming others for relapses. Furthermore,
BD II subjects were less likely to use a wide range
of coping strategies, as compared to BD I subjects.
The implications of these ndings on the newly-
emerging psychosocial interventions are threefold:
Coping styles in prodromes of mania
rst, that the CIPM may be used as a useful and
valid measure of the coping styles of patients;
second, that dierent interventions may alter
coping styles dierentially, providing evidence of
possible mechanisms of action; and nally, that
bipolar II subjects may need modications of
psychosocial interventions to reect a dierent
pattern of coping styles compared to bipolar I
patients.
Acknowledgements
This study has been funded in part by the Canadian Institutes
of Health Research and the Stanley Medical Research
Institute.
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