Life Charts

What is Life Charting?

A life chart is a systematic collection of retrospective (past) and prospective (current) data on the course of illness and treatment recorded by a patient and/or clinician on the retrospective (by month) and prospective (by day) Life Chart Methodology (LCM) forms.

On each life chart, the horizontal line across the middle of the chart represents the baseline (euthymia, neither depressed nor hypomanic or manic) and the dateline. Retrospective life charting is done monthly and prospective ratings are done daily. Hypomania and mania are charted above the dateline, and depression is charted below the dateline, creating a graphical picture of mood fluctuations above and below normal over time. Any hospitalization (for mood) is considered a severe episode and is completely darkened for easy recognition.

Dotted lines represent estimated episodes (unsure of date). Ultra-rapid (four or more episodes per week) or ultradian (rapid mood shifts within a day) cycling is indicated by vertical lines. Treatments, including medications and psychotherapy, are charted above the top of the mania section. Comorbid symptoms, such as alcohol and/or substance abuse, anxiety, panic attacks, and others are recorded below the depression section. Significant life events are charted below the comorbidity section with an impact rating from -4 (very negative) to +4 (very positive), with 0 representing no impact.

What is the History of Life Charting?

At the beginning of the twentieth century, the German psychiatrist Dr. Emil Kraepelin first distinguished manic-depressive (or bipolar) illness from schizophrenia. His approach to recording and delineating the course of affective illness was the basis for the National Institute of Mental Health Life Chart Methodology (NIMH-LCM™).

Dr. Kraepelin’s early life chart graphs charted episodes at monthly intervals with color codes (e.g. red for mania, lighter red for hypomania, dark and light blue for severe and mild depression, respectively). Dr. Kraepelin’s early studies found that patients often undergo a progressive increase in cycle frequency, or a decrease in the well interval between episodes; that initial episodes were often triggered by external events, but later episodes emerged spontaneously; and that affective illness tended to continue in families (genetic vulnerability).

The NIMH-LCM was developed in the 1980’s based on Dr. Kraepelin’s principles of charting the course of affective illness (Roy-Byrne et al., 1985, Acta Psychiatrica Scandinavica [Suppl.] 71: 1–34; Post et al., 1988, Am J Psychiatry 145: 844–848). This method was then further developed, codified, and computerized (Leverich and Post, 1996, Current Review of Mood and Anxiety Disorders 1: 48–61; 1998, CNS Spectrums 3: 21–37). The availability of so many new medications and other treatments for bipolar disorder has made it more important than ever to track the course of illness and the response to treatment. The knowledge of a patient’s past course of illness, such as prior number of episodes, illness pattern, and treatment response, can have a significant impact on the choice of current and future treatment strategies.

Does Life Charting Work?

Hundreds of patients have used the NIMH-LCM successfully to keep track of their illness. Many different patterns of illness were unknown to both patients and their physicians before a life chart was constructed. The life chart also provides a portable psychiatric history for patients, useful when changing treatment providers or settings.

Is life charting accurate, however? In other words, is life charting consistent and dependable when repeated (reliability), and does it measure what it is supposed to measure (validity)?

Two different studies have confirmed both the validity and reliability of the NIMH-LCM. In 1997, Denicoff et al. (J Psychiatric Res; 31: 593–603) found that the Prospective Life Chart (LCM-p) reliability was extremely consistent between two different raters in 27 bipolar patients, over a two-week period of daily ratings by each rater. To assess validity, Denicoff et al. correlated LCM-p depression and mania ratings with other more established rating scales, such as the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI), the Young Mania Rating Scale (YMRS), and the Global Assessment Scale (GAS). They found statistically significant correlations between the LCM-p depression ratings and the two depression scales (HRSD and BDI), between the LCM-p mania ratings and the YMRS, and between the LCM-p average severity rating and the GAS.

In a second study (Psychological Med 2000; 30: 1391–1397), Denicoff et al. compared LCM-p ratings in 270 bipolar patients to the Inventory of Depressive Symptomatology-clinician rated (IDS-C) scale, the YMRS, and the Global Assessment of Functioning (GAF) scale. Again, the validity of the NIMH-LCM was confirmed, this time in a study with a much larger number of patients. Statistically significant correlations were found between severity of depression ratings on the LCM-p and the IDS-C, between LCM-p mania ratings and the YMRS, and between LCM-p average severity of illness ratings and the GAF.

A study of the NIMH-LCM in the Netherlands found that most of the patients found it worthwhile, and were able to complete their life charts with minimal outside assistance (Honig et al., 2001; Patient Education and Counseling 43: 43–48).