1. Predictors of Recurrence in Bipolar Disorder: Primary Outcomes From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) Dr. Hena Jawaid

2. Introduction American Journal of Psychiatry 2006 Feb;163(2) Impact factor – 12.759 Author – Roy H. Perlis. Type of the study – Prospective cohort Area of Study – America

3. Types of study Observational studies Experimental studies / Intervention studies

4. Observational studies - Descriptive study – Occurrence of disease i. Case Series - Analytical study - analyzing relationships i. Ecological ii. Cross-sectional iii. Case-control iv. Cohort

5. Experimental studies - Randomized controlled trials - Cluster randomized controlled trials - Field trials - Community trials

6. Study Design Population | People Without the disease / \ Exposed Not exposed / \ / \ Disease No disease

7. Questions

8. 1. Did the authors use an appropriate method to answer their question?

9. Answer - For pro

10. 2. Was the cohort recruited in an acceptable way? Clue - Was the cohort representative of a defined population? Was there something special about the cohort? Was everybody included who should have been included?

11. 3. Was the exposure accurately measures to minimise bias? Clue - Consider if subjective or objective measurements were used. Have the measures been validated? Were all subjects classified into exposure groups using the same procedure?

12. 4. Was the outcome accurately measured to minimise bias? Clue - Consider if subjective or objective measurements were used. Have the measures been validated? Has a reliable system been established for detecting all cases? Were the measurement methods similar for the different groups. Were the subjects/outcome assessors blinded to exposure (does this matter)?

13. 5. Have the authors identified all important confounding factors? Have they taken account of confounding factors in design and/or analysis? Clue - Look for restriction in design and techniques e.g. modeling, stratified-, regression or sensitivity analysis to correct, control or adjust confounding factors

14. 6. Was the follow up of subjects complete and long enough? Clue - Have good/bad effects have had long enough to reveal themselves; in an open or dynamic cohort, was there anything special about the outcome of the people leaving or the exposure of people entering the cohort?

15. 7. What are the results of this study? Clues – Have they reported the rate or the proportion between the exposed / unexposed, the ratio / the rate difference? How strong is the association between exposure and outcome (RR)? What is the ARR?

16. 8. How precise are the results / is the estimate of risk? Clue – What is the size of the confidence intervals?

17. 9. Can the results be applied to the local population? Clues – Are the subjects of the study different from your population; is the local setting different? Can you quantify the local benefits and harms?

18. 10. Do the results of this study fit with other available evidence?

19. Summary We can conclude after going through this study that complete remission of symptoms is necessary for prevention of next episode to recur. Current substance use and anxiety symptoms are other predictors for recurrence. Bipolar disorder remains highly recurrent illness in spite of modern Evidence based treatment.

20. Thank you