The impact of child sexual abuse on the course of bipolar disorder: a systematic review.

Objectives: To elucidate the impact of child sexual abuse on all clinical phenomena that occur after the onset of bipolar disorder, including associated clinical features that are not part of the diagnostic criteria for the disorder. Methods: Five databases were searched, supplemented with hand-search of reference lists from retrieved papers. Study quality was assessed using a validated quality assessment tool. Blind assessments of study eligibility and quality were conducted by two independent researchers to reduce bias, minimize errors, and enhance reliability of findings. Disagreements were resolved by consensus. Results: Eighteen studies, including 2,996 adults and youths with bipolar disorder and meeting minimum quality criteria that were enough to ensure objectivity and to not invalidate results, were analyzed. Across studies, child sexual abuse was strongly (and perhaps directly) associated with posttraumatic stress disorder, whereas it was less strongly (and perhaps indirectly) related to suicide attempts, alcohol and/or drug abuse or dependence, psychotic symptoms, and an early age of illness onset. In regard to the association between child sexual abuse and other clinical variables concerning the course of bipolar disorder, evidence was scant or conflicting. Conclusions: Child sexual abuse is associated (either directly or indirectly) with some clinical phenomena that represent a more severe form of bipolar disorder. While such traumatic experience may directly affect the development of posttraumatic stress disorder, the effects of early sexual abuse on later suicidal behavior, substance abuse, and psychotic symptoms may operate through the mediating influences of certain psychopathological or neurobiological variables.