A systematic review evaluating health-related quality of life, work impairment, and healthcare costs and utilization in bipolar disorder

Menorraghia's impact on quality of life: A case control study from a teaching Hospital in Lahore

Background and Objective:

Menorrhagia is one of the common complaints presenting in gynaecology outdoor and clinics. Menorrhagia is defined as excessive uterine bleeding occurring at regular intervals or prolonged uterine bleeding lasting for more than seven days. This is a very distressing condition effecting almost all ages, and has multiple causes. The objective of this study was to determine effect of menorrhagia on quality of life of a woman.

Methods:

It was a case control study, conducted at Arif Memorial Teaching Hospital Lahore from January 2017 to December 2017. It included 230 women. Out of these, 150 women who had menorrhagia were included in Group A (cases). Group B included 80 women accompanying them and have normal menstrual cycles (controls).

Results:

The mean age of the participants was 35.56±8.85 years. Duration of menorrhagia was more than 4 years in 11% of the patients, 22% had menorrhagia for 1-2 years and 1.2% for three months. Among all age groups, quality of life was better in female without menorrhagia as compared to female with menorrhagia (p-value <0.001).

Conclusion:

Health care providers should have knowledge to treat patients with menorrhagia, also future qualitative studies should be done to determine perception of patients regarding treatment and management of menorrhagia.

B-positive: a randomized controlled trial of a multicomponent positive psychology intervention for euthymic patients with bipolar disorder - study protocol and intervention development

BACKGROUND

Bipolar disorder (BD) is characterized by recurrent (hypo)manic and depressive episodes, alternating with euthymic states in which patients are relatively symptom free. Besides clinical recovery, it is important to also strive for improvement of mental well-being and personal recovery. One prominent field focussing on the improvement of well-being is positive psychology. However, studies assessing the effects of positive psychology or personal recovery interventions for people with BD are scarce and have used weak methodological designs. The study described in this protocol article aims to assess the effectiveness of a multicomponent positive psychology intervention ("Living well with bipolar disorder") adjusted for people with BD in the euthymic phase to improve well-being and personal recovery.

METHOD

The study concerns a pragmatic randomized multicenter trial. The principle objective of the study is to assess whether the positive psychology intervention offered to BD patients in remission in addition to usual care (CAU) is more effective than CAU. The study will include 112 participants randomized to either the experimental condition receiving the intervention in addition to CAU or the control condition receiving CAU. The study population are patients with BD I or II in the euthymic phase. The inclusion criteria are 1) diagnosis of BD I or BD II, 2) between the ages of 18-65, 3) four or more supportive sessions in the last year, and 4) only residual depressive or manic symptoms. Patients are excluded if they are in a depressive or manic episode, have current addiction problems or have optimal levels of well-being. Measurements take place at baseline, post-intervention and follow-up 6 and 12 months from baseline. Outcomes of measures include positive well-being, personal recovery, psychopathology, self-compassion, positive relationships, dampening of positive affect and relapse.

DISCUSSION

The outlined study will be the first RCT examining the effects of a multicomponent positive psychology intervention for patients with bipolar disorder. Several limitations, including generalizability of the results and possible attrition issues, are discussed in advance.

TRIAL REGISTRATION

This study has been registered in the Netherlands Trial Register ( NTR6729 ) on 12 October 2017.

Quality of life in stabilized outpatients with bipolar I disorder: Associations with resilience, internalized stigma, and residual symptoms

OBJECTIVES

Improving Quality of Life (QoL) is an important objective in the treatment of bipolar disorder. The aim of the current study was to examine to which extent resilience, internalized stigma, and psychopathology are correlated to QoL.

METHODS

We recruited 60 outpatients diagnosed with bipolar I disorder according to DSM-IV criteria and 77 healthy control subjects from the general community. In patients, symptoms were quantified by the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Young Mania Rating Scale (YMRS) and internalized stigma by the Internalized Stigma of Mental Illness (ISMI) scale. In order to assess QoL and resilience, the Berliner Lebensqualitätsprofil (BELP) and the Resilience Scale (RS-25) were used in both patients and control subjects.

RESULTS

Despite presenting with a very mild symptom level and relatively low internalized stigma, patients with bipolar I disorder indicated significantly lower QoL and resilience as compared to healthy control subjects. In patients, QoL correlated significantly with resilience, internalized stigma, and residual symptoms of depression. No significant correlations were observed between QoL and residual manic symptoms.

LIMITATIONS

The cross-sectional design and the relatively small sample size limit the generalizability of our results. Furthermore, levels of resilience and internalized stigma may change over the course of the illness and have different impacts on the long-term outcome of patients with bipolar disorder.

CONCLUSION

Our results show that QoL of patients suffering from bipolar I disorder, even when only mildly ill, is strongly associated with the degree of resilience and internalized stigma, and that particularly residual depressive symptoms have a negative impact on QoL. In addition to drug treatment, psychotherapeutic approaches should be applied to strengthen resilience, to reduce internalized stigma, and, ultimately, to improve quality of life.

Lowered quality of life in mood disorders is associated with increased neuro-oxidative stress and basal thyroid-stimulating hormone levels and use of anticonvulsant mood stabilizers

RATIONALE, AIMS

Major affective disorders including bipolar disorder (BD) and major depressive disorder (MDD) are associated with impaired health-related quality of life (HRQoL). Oxidative stress and subtle thyroid abnormalities may play a pathophysiological role in both disorders. Thus, the current study was performed to examine whether neuro-oxidative biomarkers and thyroid-stimulating hormone (TSH) levels could predict HRQoL in BD and MDD.

METHODS

This cross-sectional study enrolled 68 BD and 37 MDD patients and 66 healthy controls. The World Health Organization (WHO) QoL-BREF scale was used to assess 4 QoL subdomains. Peripheral blood malondialdehyde (MDA), advanced oxidation protein products, paraoxonaxe/CMPAase activity, a composite index of nitro-oxidative stress, and basal TSH were measured.

RESULTS

In the total WHOQoL score, 17.3% of the variance was explained by increased advanced oxidation protein products and TSH levels and lowered CMPAase activity and male gender. Physical HRQoL (14.4%) was associated with increased MDA and TSH levels and lowered CMPAase activity. Social relations HRQoL (17.4%) was predicted by higher nitro-oxidative index and TSH values, while mental and environment HRQoL were independently predicted by CMPAase activity. Finally, 73.0% of the variance in total HRQoL was explained by severity of depressive symptoms, use of anticonvulsants, lower income, early lifetime emotional neglect, MDA levels, the presence of mood disorders, and suicidal ideation.

CONCLUSIONS

These data show that lowered HRQoL in major affective disorders could at least in part result from the effects of lipid peroxidation, protein oxidation, lowered antioxidant enzyme activities, and higher levels of TSH.

In major affective disorders, early life trauma predict increased nitro-oxidative stress, lipid peroxidation and protein oxidation and recurrence of major affective disorders, suicidal behaviors and a lowered quality of life

Early life trauma (ELT) may increase the risk towards bipolar disorder (BD) and major depression (MDD), disorders associated with activated neuro-oxidative and neuro-nitrosative stress (O&NS) pathways. It has remained elusive whether ELTs are associated with O&NS and which ELTs are associated with distinct affective disorder phenotypes. This case-control study examined patients with BD (n = 68) and MDD (n = 37) and healthy controls (n = 66). The Child Trauma Questionnaire (CTQ) was used to assess specific ELT. We measured malondialdehyde (MDA), lipid hydroperoxides (LOOH), superoxide dismutase (SOD), catalase, advanced oxidation protein products (AOPP); NO metabolites (NOx), paraoxonase 1 activity, zinc, albumin, high density lipoprotein cholesterol and -SH groups and computed z-unit weighted composite scores. Physical neglect significantly predicts higher z-unit weighted composite scores of LOOH+SOD, LOOH+SOD+NOx, LOOH+SOD+NOx + MDA and LOOH+SOD+NOx + AOPP. Sexual abuse was associated with a significantly lower composite score of zinc+albumin+SH. Emotional abuse was associated with severity of depression and anxiety, number of depressive and manic episodes, alcohol and hypnotics use, lifetime suicidal behavior and lowered quality of life. Sexual abuse was associated with an increased risk towards BD, but not MDD. ELT, especially physical neglect, may drive increased (nitro-)oxidative stress coupled with lipid and protein oxidation, which - together with emotional abuse - may play a role in severity of illness, lowered quality of life and MDD. ELTs are also associated with the onset of BD, but this link did not appear to be related to activated O&NS pathways. These novel findings deserve confirmation in prospective studies.

Effects of adjunctive N-acetylcysteine on depressive symptoms: Modulation by baseline high-sensitivity C-reactive protein

Outcomes in a RCTs of 12 weeks of theclinical efficacy of N-acetylcysteine (NAC) as an adjunctive treatment on depression and anxiety symptoms and its effects on high-sensitivity C-reactive protein (hs-CRP) levels. A wide array of measures were made. The 17-item version of the Hamilton Depression Rating Scale (HDRS17); the Hamilton Anxiety Rating Scale (HAM-A); Sheehan Disability Scale; Quality of Life; Clinical Global Impression (CGI); anthropometrics measures; and vital signs and biochemical laboratory. There were no significant differences among the groups regarding demographic, clinical features, use of medication, metabolic syndrome and comorbidities. From baseline to week 12, individuals receiving NAC, versus placebo, had a statistically significant reduction in depressive symptoms on HDRS₁₇ (p < 0.01) and anxiety symptoms on HAM-A (p = 0.04), but only for individuals with levels of hs-CRP > 3 mg/L at baseline. Individuals receiving NAC with baseline levels of hs-CRP > 3 mg/L, had more significant reduction in uric acid levels compared to individuals with baseline levels of hs-CRP ≤ 3 mg/L on week 12. Participants receiving placebogained significantly more weight during the 12 weeks for baseline levels of hs-CRP ≤ 3 mg/L and hs-CRP > 3 mg/L, and individuals receiving NAC in both groups did not have significant weight change during the 12 weeks. No individuals were withdrawn from the study because of adverse event. NAC group exhibited significantly greater reduction on hs-CRP levels than placebo group from baseline to week 12.

TRIAL REGISTRATION

clinicaltrials.gov Identifier; NCT02252341.

Efficacy of shared decision-making on treatment adherence of patients with bipolar disorder: a cluster randomized trial (ShareD-BD)

BACKGROUND

Shared decision-making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. SDM has raised great interest in mental healthcare over the last decade, as it is considered a fundamental part of patient-centered care. However, there is no research evaluating the efficacy of SDM compared to usual care (CAU), as it relates to quality of care and more specifically treatment adherence, in bipolar disorder (BD).

METHODS/DESIGN

This is a 12-month multi-centre, cluster-randomized controlled trial comparing the efficacy of SDM to CAU. Adult BD patients (n = 300) will be eligible after stabilization for at least 4 weeks following an acute mood episode. The intervention will consist of applying the standardized SDM process as developed by the Ottawa Hospital Research Institute in order to choose the maintenance treatment of BD. A multidisciplinary team developed a decision aid "choose my long-term treatment with my doctor" for BD patients to clarify possible therapeutic options. Primary outcome will assess the patient's level of adherence (based on hetero-evaluation) of ongoing treatment at 12 months. Secondary outcomes will assess the difference between the 2 groups of patients in terms of adherence to maintenance drug therapy based on other measures (self-assessment scale and plasma levels of mood stabilizers). Additionally, other dimensions will be assessed: decisional conflict, satisfaction with care and involvement in decision making, beliefs about treatment, therapeutic relationship, knowledge about information for medical decision and clinical outcomes (depression, mania, functioning and quality of life). The primary endpoint will be analysed without adjustment by comparison of adherence scores between the two groups using Student t-tests or Mann-Whitney tests according to the variable distribution. A set of secondary analyses will be adjusted for covariates of clinical interest using generalized linear mixed regression models.

DISCUSSION

This will be the first study evaluating the effect of an SDM intervention on patient adherence in BD. This is also an innovative protocol because it proposes the development of an evidence-based tool that should help patients and clinicians to initiate discussions regarding the use of BD treatment.

TRIAL REGISTRATION

The study has been registered with ClinicalTrials.gov as NCT03245593 .

Are affective temperaments determinants of quality of life in euthymic patients with bipolar disorder?

BACKGROUND

Bipolar disorder (BD) is a disabling illness that is associated with low quality of life (QoL). This low QoL goes further than mood episodes, which suggests that stable traits, such as affective temperaments, can cause functional impairment.

OBJECTIVE

Our study analyses the impact of affective temperaments on the Physical Component Summary (PCS) and Mental Component Summary (MCS) of QoL in euthymic BD patients.

METHODS

A multicentre study was conducted in 180 euthymic BD patients and 95 healthy controls. Firstly, statistical analyses were performed to compare QoL and affective temperaments between the two groups. Secondly, Adaptive Lasso Analysis was carried out to identify the potential confounding variables and select the affective temperaments as potential predictors on the PCS and MCS of QoL in BD patients, as well as the control group.

RESULTS

QoL scores in terms of PCS and MCS in BD patients were significantly lower than in healthy individuals. Whereas anxious temperament, anxiety disorder comorbidity, and age were the best predictors of PCS impairment in BD patients, anxious temperament, subclinical depressive symptoms, and age were the best predictors of MCS impairment.

LIMITATIONS

Further longitudinal studies with unaffected high-risk relatives are needed to examine the potential interaction between affective temperament and psychopathology.

CONCLUSIONS

Anxious temperament has an impact on QoL in BD in terms of both the physical component and the mental component. Systematic screening of temperament in BD would give clinicians better knowledge of QoL predictors. Further research should allow more individualized treatment of BD patients based on temperamental factors.

Eye gaze perception in bipolar disorder: Self-referential bias but intact perceptual sensitivity

OBJECTIVES

Deficits in social cognition predict poor functional outcome in severe mental illnesses such as schizophrenia and autism. However, research findings on social cognition in bipolar disorder (BD) are sparse and inconsistent. This study aimed to characterize a critical social cognitive process-eye gaze perception-and examine its functional correlates in BD to inform psychopathological mechanisms.

METHODS

Thirty participants with BD, 37 healthy controls (HC), and 46 psychiatric controls with schizophrenia (SZ) completed an eye-contact perception task. They viewed faces with varying gaze directions, head orientations, and emotion, and made eye-contact judgments. Psychophysics methods were used to estimate perception thresholds and the slope of the perception curve, which were then compared between the groups and correlated with clinical and functional measures using Bayesian inference.

RESULTS

Compared with HC, patients with BD over-perceived eye contact when gaze direction was ambiguous, and this self-referential bias was similar to that in SZ. Patients with BD had lower thresholds (i.e., needed weaker eye-contact signal to start perceiving gaze as self-directed) but a similar slope compared with HC. Regression analyses showed that steeper slope predicted better socio-emotional functioning in HC and SZ, but not in BD.

CONCLUSIONS

The psychopathology of social dysfunction was fundamentally different between BD and SZ in this modest sample. Eye gaze perception in BD was characterized by a self-referential bias but preserved perceptual sensitivity, the latter of which distinguished BD from SZ. The relationship between gaze perception and broader socio-emotional functioning in SZ and HC was absent in BD.

The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update

Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.

Promoting medication adherence among patients with bipolar disorder: a multicenter randomized controlled trial of a multifaceted intervention

BACKGROUND

The present research aimed to investigate the efficacy of a multifaceted intervention that included motivational interviewing (MI) and psychoeducation in improving medication adherence (MA) among patients with bipolar disorder (BD).

METHOD

A multicenter, cluster randomized, observer-blind, controlled, parallel-group trial was conducted in ten academic centers in Iran. Patients with BD were randomly assigned to the experimental group (EXP; n = 136) or the usual care group (UC; n = 134). The EXP group received five sessions of MI and psychoeducation together with their family members. The primary outcome measure was changes in scores on the Medication Adherence Rating Scale from baseline to 6 months post-intervention. Other outcome measures included serum levels of mood stabilizers, clinical symptoms, quality of life, as well as measures of intention, beliefs about medicine, perceived behavioral control, automaticity, action and coping planning, and adverse reactions.

RESULTS

Medication adherence improved over time in both groups, but patients in the EXP group improved more (baseline score: 6.03; score at the sixth month: 9.55) than patients in the UC group (baseline score: 6.17; score at the sixth month: 6.67). In addition, patients in the EXP group showed greater improvement than patients in the UC group in almost all secondary outcomes 6 months following the intervention.

CONCLUSIONS

Multifaceted interventions that include motivational-interviewing and psychoeducation can significantly improve MA and clinical and functional outcomes in patients with BD.

TRIAL REGISTRATION NUMBER

The trial was registered with theClinicalTrials.gov database (NCT02241863) https://clinicaltrials.gov/ct2/show/NCT02241863.

Enhancing quality of life among adolescents with bipolar disorder: A randomized trial of two psychosocial interventions

BACKGROUND

Adolescents with bipolar disorder (BD) report lower quality of life (QoL) than adolescents with other psychiatric disorders. This study compared the efficacy of family-focused therapy for adolescents (FFT-A) plus pharmacotherapy to brief psychoeducation (enhanced care, or EC) plus pharmacotherapy on self-rated QoL in adolescents with BD over 2 years.

METHODS

Participants were 141 adolescents (mean age: 15.6±1.4yr) with BD I or II who had a mood episode in the previous 3 months. Adolescents and parents were randomly assigned to (1) FFT-A, given in 21 sessions in 9 months of psychoeducation, communication enhancement training, and problem-solving skills training, or (2) EC, given in 3 family psychoeducation sessions. Study psychiatrists provided patient participants with protocol-based pharmacotherapy for the duration of the study. QoL was assessed with The KINDL^RQuestionnaire (Ravens-Sieberer and Bullinger, 1998) during active treatment (baseline to 9 months) and during a post-treatment follow-up (9-24 months).

RESULTS

The two treatment groups did not differ in overall QoL scores over 24 months. However, adolescents in FFT-A had greater improvements in quality of family relationships and physical well-being than participants in EC. For quality of friendships, the trajectory during active treatment favored EC, whereas the trajectory during post-treatment favored FFT-A.

LIMITATIONS

We were unable to standardize medication use or adherence over time. Quality of life was based on self-report rather than on observable functioning.

CONCLUSIONS

A short course of family psychoeducation and skills training may enhance relational functioning and health in adolescents with BD. The effects of different psychosocial interventions on peer relationships deserves further study.

Quality of life in children and adolescents with bipolar I depression treated with olanzapine/fluoxetine combination

BACKGROUND

We examined the efficacy of olanzapine/fluoxetine combination (OFC) in improving health-related quality of life (QoL) in the treatment of bipolar depression in children and adolescents.

METHODS

Patients aged 10-17 years with bipolar I disorder, depressed episode, baseline children's depression rating scale-revised (CDRS-R) total score ≥40, Young Mania Rating Scale (YMRS) total score ≤15, and YMRS-item 1 ≤ 2 were randomized to OFC (6/25-12/50 mg/day olanzapine/fluoxetine; n = 170) or placebo (n = 85) for up to 8 weeks of double-blind treatment. Patients and parents completed the revised KINDL questionnaire for measuring health-related QoL in children and adolescents (KINDL-R) at baseline and endpoint. The mean change in CDRS-R total and item scores were used to compare improvement in symptomatology in patients taking OFC and placebo. Tests were 2-sided using a Type I error cutoff of 0.05, and no adjustments for multiple comparisons were made.

RESULTS

Baseline QoL as measured by the KINDL-R was substantially impaired relative to published norms for a healthy school-based sample. OFC-treated patients demonstrated an improvement over placebo at endpoint with respect to mean change from baseline in the patient-rated KINDL-R Self-esteem subscale score (p = 0.028), and in the parent KINDL-R ratings of emotional well-being (p = 0.020), Self-esteem (p = 0.030), and Family (p = 0.006). At endpoint, OFC-treated patients still had a lower QoL compared to the normative population. OFC showed significant improvement (p ≤ 0.05) versus placebo on the CDRS-R total score and on 7 of the 17 CDRS-R items.

CONCLUSIONS

Patients aged 10-17 years with an acute episode of bipolar depression and their parents reported greater improvements (parents noticed improvements in more areas than did their offspring) on some aspects of QoL when treated with OFC compared with placebo. However, after 8 weeks of treatment, KINDL-R endpoint scores remained lower than those of the, presumably healthy, control population. Clinical trial registration information A Study for Assessing Treatment of Patients Ages 10-17 with Bipolar Depression; http://www.clinicaltrials.gov; NCT00844857.

What does quality of life refer to in bipolar disorders research? A systematic review of the construct's definition, usage and measurement

BACKGROUND

Quality of life (QoL) is increasingly investigated in bipolar disorders (BD) research, yet little attention has been paid to its optimal definition and measurement. This is a significant limitation, as the broader QoL literature recognises a number of divergent meanings and measurement tensions. The aim here was to advance understanding of QoL in BD by clarifying use of the construct in the existing literature and considering measurement implications.

METHODS

Thematic analysis techniques were used to interrogate articles identified via systematic search for (a) explicit discussion of QoL definitional/measurement issues, and (b) usage of the term QoL.

RESULTS

A total of 275 articles were included in the analysis. A range of definitional and methodological issues confounding the study of QoL in BD were identified. While explicit definition of QoL proved rare, thematic analysis of usage of the construct revealed the concepts of functioning, health, subjective experience and wellbeing were thought to be relevant to QoL in BD.

LIMITATIONS

The review does not engage in top-down theory development. Our analysis was grounded in the empirical literature to support future theoretical work relevant to existing usage of QoL in BD.

CONCLUSIONS

There was no evidence of a consensus definition of QoL in BD. A plurality of QoL definitions is not necessarily a flaw in the literature, but points to empirical and conceptual issues demanding attention. Awareness of the diversity of constructs associated with QoL will enable clinicians to better select treatments on the basis of specific QoL outcomes. A research agenda and provisional considerations for empirical research are outlined based on the present analyses.

Is history of suicidal behavior related to social support and quality of life in outpatients with bipolar I disorder?

Bipolar disorder (BD) affects the social functioning and quality of life (QoL) of its patients. This study aimed to investigate whether there is an association between social support (SS), and suicidal behavior in BD I patients compared to healthy controls; secondarily, we evaluated the influence of QoL on those variables. A total of 119 euthymic outpatients with BD I, 46 of whom had attempted suicide (SAs) and 73 who had not (non-SAs), were compared to 63 healthy controls, through the Medical Outcomes Study Social Support Scale and World Health Organization's Quality of Life Instrument. No differences were noted in SS and QoL between SAs and non-SAs. Compared to healthy controls, non-SAs showed lower values in the positive social interaction domain of SS, and the patients, as a whole, showed lower values in affectionate and positive social interaction domains of SS. Compared to healthy controls, SAs had lower values in the environmental domain of QoL, and the patients, as a whole, had lower values in the environmental, social, and psychological domains of QoL. There was positive correlation between SS and QoL. Although BD is a disabling disease, patients receive inadequate SS. Interventions that may alter the SS in these patients should be investigated.

The Relationship Between Neurocognitive Functioning and Occupational Functioning in Bipolar Disorder: A Literature Review

Neurocognitive impairment in Bipolar Disorder (BD) has been widely reported, even during remission. Neurocognitive impairment has been identified as a contributing factor towards unfavourable psychosocial functioning within this population. The objective of this review was to investigate the association between neurocognitive impairment and occupational functioning in BD. A literature review of English-language journal articles from January 1990 to November 2013 was undertaken utilising the PsychINFO, Scopus and Web of Knowledge databases. Studies that made specific reference to occupational outcomes were included, and those that reported on global psychosocial measures were excluded. Majority of the papers reviewed (20 out of 23) identified an association between neurocognitive impairment (particularly in executive functioning, verbal learning and memory, processing speed and attention) and occupational functioning. Several methodological issues were identified. There was a discrepancy in the measures used to assess neurocognitive function across studies and also the definition and measurement of occupational functioning. The clinical features of the samples varied across studies, and confounding variables were intermittently controlled. The review focused on English-language papers only and hence there is a bias toward the Western labour market. These limitations therefore influence the generalizability of the interpreted findings and the reliability of comparisons across studies. Neurocognitive impairment in BD appears to play a role in occupational outcomes. The findings of this review highlight the challenges for future research in this area, particularly in the measurement of neurocognitive and occupational functioning. Incorporating neurocognitive interventions in the treatment of BD, which has traditionally focussed solely on symptomatic recovery, may advance the vocational rehabilitation of these patients.

Positive beliefs about mental illness: Associations with sex, age, diagnosis, and clinical outcomes

BACKGROUND

Beliefs about mental illness affect how individuals cope with their symptoms. Positive beliefs about mental illness (PBMI) refer to perceptions of positive attributes individuals may identify in their illness, such as beneficial consequences, enhanced creativity or cognition, or growth through adversity.

METHODS

The present study developed and tested a brief measure of PBMI in 332 adults presenting for partial hospitalization with a variety of acute psychiatric conditions.

RESULTS

Results indicated that older individuals and women had lower levels of PBMI than others, while individuals with bipolar disorder had higher levels of PBMI than others. PBMI significantly increased over the course of brief standard treatment. Baseline levels of PBMI, as well as changes in PBMI over the course of treatment, were associated with clinical outcomes including, but not limited to, depression and well-being. A diagnosis of bipolar disorder moderated the relationship between PBMI and only one clinical outcome, emotional lability. Increases in PBMI during treatment were associated with reduced emotional lability only in participants without bipolar disorder.

LIMITATIONS

Our findings are limited by the naturalistic study design. In addition, the lack of ethnoracial diversity in our sample limits the generalization of results.

CONCLUSIONS

Our results suggest that PBMI are a distinct set of beliefs that meaningfully relate to demographic characteristics, diagnostic characteristics, and clinical outcomes. Future research should examine the mechanisms through which PBMI and outcomes are related, as well as determine whether interventions designed to address PBMI (and perhaps tailored for different diagnostic groups) have clinical utility.

Stress and reward processing in bipolar disorder: a functional magnetic resonance imaging study

OBJECTIVES

A link between negative life stress and the onset of mood episodes in bipolar disorder (BD) has been established, but processes underlying such a link remain unclear. Growing evidence suggests that stress can negatively affect reward processing and related neurobiological substrates, indicating that a dysregulated reward system may provide a partial explanation. The aim of this study was to test the impact of stress on reward-related neural functioning in BD.

METHODS

Thirteen euthymic or mildly depressed individuals with BD and 15 controls performed a Monetary Incentive Delay (MID) task while undergoing functional magnetic resonance imaging during no-stress and stress (negative psychosocial stressor involving poor performance feedback and threat of monetary deductions) conditions.

RESULTS

In hypothesis-driven region-of-interest analyses, a significant group-by-condition interaction emerged in the amygdala during reward anticipation. Relative to controls, while anticipating a potential reward, subjects with BD were characterized by amygdalar hyperactivation in the no-stress condition but hypoactivation during stress. Moreover, relative to controls, subjects with BD had significantly larger amygdala volumes. After controlling for structural differences, the effects of stress on amygdalar function remained, whereas groups no longer differed during the no-stress condition. During reward consumption, a group-by-condition interaction emerged in the putamen due to increased putamen activation in response to rewards in participants with BD during stress, but an opposite pattern in controls.

CONCLUSIONS

Overall, findings highlight possible impairments in using reward-predicting cues to adaptively engage in goal-directed actions in BD, combined with stress-induced hypersensitivity to reward consumption. Potential clinical implications are discussed.

[Factors predicting functioning in type 1 bipolar patients during remission period]

INTRODUCTION

Recent studies indicate that bipolar disorder is associated with a profound impairment in almost all areas of functioning. This study aims to evaluate functional recovery in type 1 bipolar patients during remission period.

METHOD

We conducted a cross-sectional study of euthymic type 1 bipolar patients followed up on an ambulatory basis. In the analysis to be reported here we used Hamilton Depression Scale, Young Mania Rating Scale (YMRS), Rosenberg Self-Esteem Scale, and Functioning Assessment Short Test (FAST).

RESULTS

More than half of the study population (53.3%) had overall functional impairment. The overall functioning was associated with age, education level, professional activity, the number of manic and depressive episodes, the number of hospitalizations, a higher HDRS score as well as with the two self-esteem subscores: "self-confidence" and "self-deprecation".

CONCLUSION

Our results suggest that a paradigm shift in the treatment of bipolar disorders should happen and that the goals of therapy should be modified from symptomatic remission to functional remission.

The development of lurasidone for bipolar depression

Bipolar disorder is a chronic, recurrent illness that ranks among the top 10 causes of disability in the developed world. As the illness progresses, major depressive episodes increasingly predominate. However, few treatment options are available that have demonstrated efficacy in the treatment of bipolar depression, either as monotherapy or adjunctive therapy in combination with mood stabilizers. Lurasidone is an atypical antipsychotic drug that was initially developed for the treatment of schizophrenia. Since no previous atypical antipsychotic development program had proceeded directly from work on schizophrenia to bipolar depression, the decision to focus on this indication represented an innovation in central nervous system drug development and was designed to address a clinically significant unmet need. The current review summarizes key results of a clinical development program undertaken to characterize the efficacy and safety of lurasidone in patients diagnosed with bipolar depression. Lurasidone is currently the only treatment for bipolar depression approved in the United States as both a monotherapy and an adjunctive therapy with lithium or valproate. The approval of lurasidone expands available treatment options for patients with bipolar depression and provides a therapy with an overall favorable risk-benefit profile.

Was ist Betroffenen wichtig? Bestimmung patientennaher Therapiezieldimensionen in der Behandlung von bipolaren Störungen

Zusammenfassung. Patientenorientierung schließt die Berücksichtigung von Therapiezielpräferenzen ein. Shared decision making kann dazu beitragen, die Therapiezufriedenheit und -mitarbeit zu verbessern. Fragestellungen: 1) Bestimmung, der von Patienten priorisierten Therapieziele in der Behandlung bipolarer Störungen, 2) Extraktion der wichtigsten Therapiezieldimensionen, 3) Darstellung von Unterschieden in der Wichtigkeit abhängig von Geschlecht, Alter und Behandlungsstatus. Im Rahmen einer BMBF-geförderten Studie wurde die Wichtigkeit (1 = unwichtig bis 5 = sehr wichtig) von 73 Therapiezielen in der Behandlung bipolarer Störungen aus Betroffenensicht (N = 333) untersucht. Störungsbewältigung (R2 = 29 %), Lebensqualität (R2 = 9 %), Beteiligung am therapeutischen Geschehen (R2 = 7 %) und Nebenwirkungen von Medikamenten (R2 = 5 %) stellten die bedeutsamsten Zieldimensionen dar. Morbiditätsparameter (Symptome, Episoden) hatten dagegen einen geringeren Stellwert (R2 = 3,6 %). Die Wichtigkeitseinschätzungen variierten in Abhängigkeit von Geschlecht, Alter und Behandlungsstatus. In der Behandlung von bipolaren Störungen legen Patienten vor allem Wert auf die Bearbeitung störungsbezogener Probleme sowie die Verbesserung von Lebensqualität. Durch eine verstärkte Orientierung an Bedürfnissen von bipolar Betroffenen auf Seiten ihrer Behandler lassen sich Prozesse des shared decision making optimieren.

Early interventions for youths at high risk for bipolar disorder: a developmental approach

In recent decades, ongoing research programmes on primary prevention and early identification of bipolar disorder (BD) have been developed. The aim of this article is to review the principal forms of evidence that support preventive interventions for BD in children and adolescents and the main challenges associated with these programmes. We performed a literature review of the main computerised databases (MEDLINE, PUBMED) and a manual search of the literature relevant to prospective and retrospective studies of prodromal symptoms, premorbid stages, risk factors, and early intervention programmes for BD. Genetic and environmental risk factors of BD were identified. Most of the algorithms used to measure the risk of developing BD and the early interventions programmes focused on the familial risk. The prodromal signs varied greatly and were age dependent. During adolescence, depressive episodes associated with genetic or environmental risk factors predicted the onset of hypomanic/manic episodes over subsequent years. In prepubertal children, the lack of specificity of clinical markers and difficulties in mood assessment were seen as impeding preventive interventions at these ages. Despite encouraging results, biomarkers have not thus far been sufficiently validated in youth samples to serve as screening tools for prevention. Additional longitudinal studies in youths at high risk of developing BD should include repeated measures of putative biomarkers. Staging models have been developed as an integrative approach to specify the individual level of risk based on clinical (e.g. prodromal symptoms and familial history of BD) and non-clinical (e.g. biomarkers and neuroimaging) data. However, there is still a lack of empirically validated studies that measure the benefits of using these models to design preventive intervention programmes.

Quality of life in Iranian patients with bipolar disorder: a psychometric study of the Persian Brief Quality of Life in Bipolar Disorder (QoL.BD)

PURPOSE

To assess the reliability, validity, and factor structure of the Persian Brief Quality of Life in Bipolar Disorder (QoL.BD) in Iranian patients with bipolar disorder (BD).

METHODS

After translation and cross-cultural adaptation of the Brief QoL.BD, we administered the questionnaire to 184 patients diagnosed with BD. To determine factor structure, we performed both exploratory and confirmatory factor analyses. To investigate the reliability, we assessed internal consistency, reproducibility and agreement. Construct validity was assessed by calculating correlations between the Brief QoL.BD and the Short Form-36 (SF-36), Positive And Negative Affect Schedule (PANAS), Hamilton Depression Rating Scale, Young Mania Rating Scale (YMRS) and Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q-SF). We also investigated gender differences in interpretations of QoL.BD items.

RESULTS

The results obtained from reliability analysis confirmed internal consistency (Cronbach's alpha was 0.87 and 0.89 for two assessments) and reproducibility and agreement (the intraclass correlation coefficient ranged between 0.74 and 0.94). Validity analyses showed that the items loaded on a single-factor structure. The inter-item correlations varied from 0.31 to 0.68. Significantly lower scores on the Brief QoL.BD were observed in people diagnosed with BD I compared to BD II. Significant correlations were observed between the Brief QoL.BD and SF-36 summary measures, HAMD, YMRS, Q-LES-Q-SF and PANAS subscales. Items in the Brief QoL.BD were interpreted similarly by men and women.

CONCLUSIONS

The Brief Persian QoL.BD is a psychometrically sound measure with acceptable validity and reliability and provides a rapid assessment tool for measuring QoL in patients with BD.

Predictors of long-term work disability among patients with type I and II bipolar disorder: a prospective 18-month follow-up study

OBJECTIVES

Bipolar disorder (BD) is one of the leading causes of disability worldwide. However, vocational ability and predictors of long-term work disability have rarely been studied among patients with BD. We investigated clinical predictors of work disability among patients with BD in psychiatric care.

METHODS

The Jorvi Bipolar Study (JoBS) is a naturalistic prospective cohort study (N = 191) representing adult (18-59 years) psychiatric inpatients and outpatients with DSM-IV bipolar I disorder (BD-I) and bipolar II disorder (BD-II) in three Finnish cities. Within the JoBS, we investigated the prevalence of disability pensions at baseline, and predictors for being granted a disability pension during an 18-month follow-up of the 151 patients in the labor force at baseline. Cox models were used to determine predictors for onset of disability pension.

RESULTS

At baseline, 21% (40/191) of the patients already had a disability pension. During the follow-up, a further 38 patients (25% of the 151 followed) were granted a new disability pension. The predictors included older age, male gender, depressive index episode, higher number of psychiatric hospitalizations, generalized anxiety disorder, avoidant personality disorder, and depressive burden during follow-up. However, the predictors differed depending on bipolar subtype, age, and gender.

CONCLUSIONS

BD-I and BD-II are associated with a major risk of long-term work disability, the proportion of patients with a disability pension rising to 41% in the medium-term follow-up of the Finnish cohort investigated in the present study. Severe clinical course, depression, comorbidities, age, and gender are likely to be the main predictors but predictors may vary depending on the subgroup.

Long-Term Clinical Outcomes from a Randomized Controlled Trial of Two Implementation Strategies to Promote Collaborative Care Attendance in Community Practices

This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.

Differences in body mass index according to fat mass- and obesity-associated (FTO) genotype in Mexican patients with bipolar disorder

OBJECTIVES

The prevalence of obesity has dramatically increased in many countries and it is particularly high in patients with bipolar disorder (BD). A region in the first intron of the fat mass- and obesity-associated (FTO) gene, encompassing markers rs9939973, rs8050136, and rs9939609, has been consistently associated with obesity and body mass index (BMI) in different populations. We sought to determine whether FTO is associated with BMI and/or obesity in patients with BD.

METHODS

The sample included 129 Mexican Mestizo patients with bipolar I or bipolar II disorder. After obtaining informed consent, participants were evaluated with the Structured Clinical Interview for DSM-IV Axis I Disorders and weight, height, and body measurements were recorded. DNA was extracted from a 5-mL blood sample and real-time polymerase chain reaction was performed. The results were analyzed with Haploview v4.2 and SPSS v21.

RESULTS

Differences in mean BMI were explained by rs8050136 and rs9939609 genotypes, especially by comparing non-carriers and carriers of two copies of the risk allele (Tukey's p ≤ 0.019), with a mean difference in BMI as high as 7.81 kg/m(2) . Differences in BMI were also explained by the interaction of the genotype (rs8050136 and/or rs9939609), the use of second-generation antipsychotics, and the use of mood stabilizers (p ≤ 0.41). Obesity was also associated with these two markers when patients with and without obesity were compared.

CONCLUSIONS

In patients with BD, differences in BMI may be affected by the presence of FTO risk alleles, especially in homozygous individuals for these variants. Besides evaluating the possible metabolic effects of certain antipsychotics or mood stabilizers, it is important to evaluate the role of other factors such as FTO risk alleles.

Cost-of-illness studies for bipolar disorder: systematic review of international studies

BACKGROUND AND OBJECTIVES

Bipolar disorder (BD) may result in a greater burden than all forms of cancer, Alzheimer's disease and epilepsy. Cost-of-illness (COI) studies provide useful information on the economic burden that BD imposes on a society. Furthermore, COI studies are pivotal sources of evidence used in economic evaluations. This study aims to give a general overview of COI studies for BD and to discuss methodological issues that might potentially influence results. This study also aims to provide recommendations to improve practice in this area, based on the review.

METHODS

A search was performed to identify COI studies of BD. The following electronic databases were searched: MEDLINE, EMBASE, PsycInfo, Cochrane Database of Systematic Reviews, HMIC and openSIGLE. The primary outcome of this review was the annual cost per BD patient. A narrative assessment of key methodological issues was also included. Based on these findings, recommendations for good practice were drafted.

RESULTS

Fifty-four studies were included in this review. Because of the widespread methodological heterogeneity among included studies, no attempt has been made to pool results of different studies. Potential areas for methodological improvement were identified. These were: description of the disease and population, the approach to deal with comorbidities, reporting the rationale and impact for choosing different cost perspectives, and ways in which uncertainty is addressed.

CONCLUSIONS

This review showed that numerous COI studies have been conducted for BD since 1995. However, these studies employed varying methods, which limit the comparability of findings. The recommendations provided by this review can be used by those conducting COI studies and those critiquing them, to increase the credibility and reporting of study results.

Disability in bipolar I disorder: the 36-item World Health Organization Disability Assessment Schedule 2.0

BACKGROUND

The WHODAS 2.0 is an ICF-based multidimensional instrument developed for measuring disability. The present study analyzes the utility of the 36-item interviewer-administered version in a sample of patients with bipolar disorder. There is no study to date that analyses how the scale works in a sample that only comprises such patients.

METHODS

A total of 291 patients with bipolar disorder (42.6% males) according to DSM-IV-TR criteria from a cross-sectional study conducted in outpatient psychiatric clinics were enrolled. In addition to the WHODAS 2.0, patients completed a comprehensive assessment battery including measures on psychopathology, functionality and quality of life. Analyses were centered on providing evidence on the validity and utility of the Spanish version of the WHODAS 2.0 in bipolar patients.

RESULTS

Participation domain had the highest percentage of missing data (2.7%). Confirmatory factorial analysis was used to test three models formulated in the literature: six primary correlated factors, six primary factors with a single second-order factor, and six primary factors with two second-order factors. The three models were plausible, although the one formed by six correlated factors produced the best fit. Cronbach's alpha values ranged between .73 for the Self-care domain and .92 for Life activities, and the internal consistency of the total score was .96. Relationships between the WHODAS 2.0 and measures of psychopathology, functionality and quality of life were in the expected direction, and the scale was found to be able to differentiate among patients with different intensity of clinical symptoms and work situation.

LIMITATIONS

The percentage of euthymic patients was considerable. However, the assessment of euthymic patients is less influenced by mood. Some psychometric properties have not been studied, such as score stability and sensitivity to change.

CONCLUSIONS

The Spanish version of the 36-item WHODAS 2.0 has suitable psychometric properties in terms of reliability and validity when applied to patients with bipolar disorder. Disability in bipolar patients is especially prominent in Cognition, Getting along, Life activities, and Participation domains, so functional remediation interventions should emphasize these areas in order to improve the daily living activities of these patients.

Behavioral activation therapy for return to work in medication-responsive chronic depression with persistent psychosocial dysfunction

OBJECTIVE

Chronic depression is associated with significant impairment in work functioning, relationships, and health. Such impairment often persists following medication-induced remission of depressive symptoms. We adapted and tested Behavioral Activation therapy with a goal of return to work (BA-W) in subjects with chronic depression who had responded to medication treatment but remained unemployed.

METHOD

Sixteen adults aged 18-65 with DSM-IV diagnosed Dysthymic Disorder or chronic Major Depression were recruited from clinical trials taking place at the New York State Psychiatric Institute between 4/2009 and 12/2012 and enrolled in 12 weeks of individual manual-driven BA-W. Functioning was measured at intake, post-treatment and at 24 week follow-up.

RESULTS

Eighty-seven percent (n=14) of subjects completed the full 12 weeks of BA-W. Hours of work related activity (p<.005, d=0.83), hours of paid work (p<.0003, d=0.54), and work productivity (p<.0004, d=-0.48) increased significantly over the study period. Earned income increased post-treatment (p=.068) with significant changes by 24 week follow-up (p=.011). Secondary outcomes including behavioral avoidance (p<.004, d=-0.56), and global functioning (p<.0003, d=1.42) were also significantly improved post-treatment. Effect sizes, including for outcomes with non-significant changes, were generally in the range of 0.5-0.8.

CONCLUSIONS

This pilot study provides preliminary evidence of the efficacy of a work-targeted psychotherapy to remediate vocational impairment in subjects with chronic depression. Data suggests that further testing of BA-W using a randomized controlled trial is warranted and may represent a significant advance in treatment for the residual disability present after successful pharmacotherapy.

Impact of initiation of asenapine on patterns of utilization and cost of healthcare resources associated with the treatment of bipolar I disorder

OBJECTIVE

To assess the impact of initiation of asenapine on "real-world" levels of utilization and cost of healthcare services for the treatment of bipolar I disorder (BPD) in the US.

METHODS

Using two large US healthcare claims databases that collectively included commercially insured patients aged < 65 years and Medicare enrollees, this study identified all adults (≥ 18 years) with evidence of BPD who began therapy with asenapine between 2009-2012. The date of the earliest claim for asenapine during this period was deemed the 'index date', and patients without continuous enrollment for the 6-month periods before and after this date were excluded ('pre-index' and 'post-index', respectively). Healthcare claims with a BPD diagnosis, plus psychiatric medications and the costs thereof (2012 dollars) were deemed 'BPD-related'. Differences in BPD-related utilization and cost of healthcare services were compared between the pre- and post-index periods.

RESULTS

A total of 1403 patients met all selection criteria; the mean age was 42.8 years and 70.6% were women. Relative to pre-index, significant decreases were noted in post-index use of BPD-related healthcare services, most notably admissions (from 24.0% to 12.3% during the post-index period) and emergency department visits (from 4.6% to 2.6%) (both p < 0.05). While pharmacy costs increased, mean total post-index BPD-related healthcare costs were $979 lower than pre-index ($5002 vs $5981; p < 0.05), primarily due to the decrease in BPD-related admissions.

CONCLUSIONS

Relative to the 6-month period beforehand, levels of utilization of BPD-related healthcare services and costs decreased during the 6-month period immediately following initiation of asenapine therapy.

Treatment of bipolar disorders during pregnancy: maternal and fetal safety and challenges

Treating pregnant women with bipolar disorder is among the most challenging clinical endeavors. Patients and clinicians are faced with difficult choices at every turn, and no approach is without risk. Stopping effective pharmacotherapy during pregnancy exposes the patient and her baby to potential harms related to bipolar relapses and residual mood symptom-related dysfunction. Continuing effective pharmacotherapy during pregnancy may prevent these occurrences for many; however, some of the most effective pharmacotherapies (such as valproate) have been associated with the occurrence of congenital malformations or other adverse neonatal effects in offspring. Very little is known about the reproductive safety profile and clinical effectiveness of atypical antipsychotic drugs when used to treat bipolar disorder during pregnancy. In this paper, we provide a clinically focused review of the available information on potential maternal and fetal risks of untreated or undertreated maternal bipolar disorder during pregnancy, the effectiveness of interventions for bipolar disorder management during pregnancy, and potential obstetric, fetal, and neonatal risks associated with core foundational pharmacotherapies for bipolar disorder.

Functional impairment in adolescents and young adults with emerging mood disorders

BACKGROUND

Between 30 and 60% of adults with unipolar or bipolar disorders exhibit impairments across multiple domains. However, little is known about impaired functioning in youth with mood disorders.

AIMS

To examine the prevalence of objective, subjective and observer-rated disability in a large, representative sample of young people with a primary mood disorder.

METHOD

Individuals aged 16-25 years presenting to youth mental health services for the first time with a primary mood disorder participated in a systematic diagnostic and clinical assessment. Impairment was assessed using objective (unemployment or disability payments), observer- (Social and Occupational Functioning Assessment Scale; SOFAS) and self-rated measures (role functioning according to the Brief Disability Questionnaire).

RESULTS

Of 1241 participants (83% unipolar; 56% female), at least 30% were functionally impaired on the objective, self-rated and/or observer-rated measures, with 16% impaired according to all three criteria. Even when current distress levels were taken into account, daily use of cannabis and/or nicotine were significantly associated with impairment, with odds ratios (OR) ranging from about 1.5 to 3.0. Comorbid anxiety disorders were related to lower SOFAS scores (OR = 2-5).

CONCLUSIONS

Levels of disability were significant, even in those presenting for mental healthcare for the first time. Functional impairment did not differ between unipolar and bipolar cases, but some evidence suggested that females with bipolar disorder were particularly disabled. The prevalence of comorbid disorders (50%) and polysubstance use (28%) and their association with disability indicate that more meaningful indicators of mood episode outcomes should focus on functional rather than symptom-specific measures. The association between functioning and nicotine use requires further exploration.

Associations with quality of life and the effect of psychopathology in a community study

PURPOSE

Quality of life (QoL) is considerably impaired in mental illness and especially in depression. In this study, we aimed to determine the demographic, personality-related and psychopathological associations with QoL. In addition, we studied how the associations with QoL differ depending on the burden of psychopathology.

METHODS

We used a longitudinal observational cohort study, enriched for high levels of psychopathology, to examine data for QoL when the subjects were 34-35. We conducted a hierarchical linear regression analysis to determine how sex, personality, sociodemographics, somatic symptoms and psychopathology affect QoL.

RESULTS

Once all the variables were included in the model, total psychopathology is strongly negatively associated with QoL, while mastery and income were shown to have positive associations with QoL. Sex, personality and somatic symptoms had no significant associations with QoL once the other variables had been introduced into the regression. Due to the outstanding association with psychopathology, we tested whether the relationship had any interaction with the other predictors, but none reached statistical significance.

CONCLUSIONS

The most important association with QoL is psychopathology, regardless of sex, personality, coping resources, sociodemographics or the extent somatic symptoms. The relationship holds across the other variables included and the results are, thus, widely applicable.

Self-efficacy and quality of life among people with bipolar disorder

People with bipolar disorders report a lower quality of life than the general population does, and few mutable factors associated with health-related quality of life (HRQoL) among people with bipolar disorders have been identified. Using a cross-sectional design, these analyses examined whether self-efficacy was associated with mental and physical HRQoL in a sample of 141 patients with bipolar disorder who completed baseline assessments for two randomized controlled trials. Multiple linear regression analyses indicated that higher levels of self-efficacy were associated with higher mental and physical HRQoL, after controlling for demographic factors and clinical factors (including mood symptoms, comorbid medical conditions, and substance use). Future research should examine whether targeted treatments that aim to improve self-efficacy (such as self-management interventions) lead to improvements in HRQoL among people with bipolar disorder and other serious mental illnesses.

Public health significance of bipolar disorder: implications for early intervention and prevention

OBJECTIVES

Early intervention and preventive strategies have become major targets of research and service development in psychiatry over the last few years. Compared to schizophrenia, bipolar disorder (BD) has received limited attention in this regard. In this paper, we review the available literature in order to explore the public health significance of BD and the extent to which this may justify the development of early intervention strategies for this disorder.

METHODS

The main computerized psychiatric literature databases were accessed. This included Medline and PsychInfo, using the following keywords: bipolar, early intervention, staging model, burden, caregiver, public health, and manic depression.

RESULTS

BD is often recurrent and has an impact that goes well beyond symptomatic pathology. The burden it incurs is linked not only to its cardinal clinical features, but also to cognitive dysfunction, poor functional outcome, poor physical health, high rate of comorbidities, and suicide. At a societal level, BD induces enormous direct and indirect costs and has a major impact on caregivers. The available literature reveals a usually long delay between illness onset and the start of treatment, and the absence of specific guidelines for the treatment of the early phase of BD.

CONCLUSIONS

Considering the major impact of BD on patients and society, there is an urgent need for the development of early intervention strategies aimed at earlier detection and more specific treatment of the early phase of the disorder.

Cost of illness for bipolar disorder: a systematic review of the economic burden

OBJECTIVES

Recent reviews lack important information on the high cost-of-illness worldwide for bipolar disorder (BD). Therefore, the present study systematically analyzed those costs, their driving components, and the methodological quality with which the few existing cost-of-illness investigations have been performed.

METHODS

In June 2012, we conducted a systematic literature review of electronic databases to identify relevant cost-of-illness studies published since 2000. Their methodological quality was assessed. Costs were standardized by first extrapolating them to 2009 using country-specific gross domestic product inflators and then converting them into US dollars via purchasing power parities (PPP).

RESULTS

The main characteristics of 22 studies were evaluated. Ignoring outliers, costs per capita ranged from 8,000 to 14,000 US$-PPP for overall direct healthcare, from 4,000 to 5,000 US$-PPP for direct mental healthcare, and from 2,500 to 5,000 US$-PPP for direct BD-related care. Indirect costs ranged from 2,000 to 11,000 US$-PPP. Inpatient care was the main cost driver in three studies; drug costs, in two studies. Methodological quality was deemed satisfactory.

CONCLUSIONS

The cost variance was great between studies. This was likely due to differences in methodology rather than healthcare systems, thereby making such comparisons difficult. The results showed that BD has a substantial economic burden on society. To gain more evidence, international standardized checklists are needed when undertaking cost-of-illness studies.

Effects of childhood trauma and clinical features on determining quality of life in patients with bipolar I disorder

BACKGROUND

We explored how childhood trauma (CHT) affects the clinical expression of disorder and quality of life in patients with bipolar I (BP-I) disorder.

METHODS

Euthymic patients (n=116) who subsequently received a diagnosis of BP-I disorder were consecutively included and were interviewed using the following sociodemographic and clinical data forms; Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), Childhood Abuse and Neglect Questionnaire (CANQ) and the 36-item Medical Outcome Study Short Form Health Survey (SF-36). The quality of life of BP-I patients with and without a history of CHT were examined.

RESULTS

The percentage of trauma was 61.2%. Patients who had CHT had higher frequencies of depressive episodes (t=-2.38, p=0.019), total episodes (t=-2.25, p=0.026), attempted suicide more often (χ(2)=18.12, p=0.003) and had lower scores on the pain subscale of the SF-36 (z=-2.817, p=0.005). In patients with mixed or rapid-cycling episodes, SF-36 subscale scores except general health and pain were found to be lower.

LIMITATIONS

Our sample may fail to reflect the general BD population; the patients were included consecutively and consisted of a majority of female patients.

CONCLUSIONS

CHT plays an important role in the clinical expression of BP-I disorder and having mixed/rapid-cycling episodes negatively affects both physical and mental components, as measured by the SF-36. While both males and females reported experiencing sexual abuse, female BP-I patients complained about pain more often. It is suggested that treatment of BP-I patients with a history of CHT should differ from that provided for patients with no CHT history.

Correlates of real world executive dysfunction in bipolar I disorder

BACKGROUND

Bipolar disorder is characterized by impairments in cognitive functioning, both during acute mood episodes and periods of euthymia, which interfere with functioning. Cognitive functioning is typically assessed using laboratory-based tests, which may not capture how cognitive dysfunction is experienced in real-life settings. Little is known about the specific illness characteristics of bipolar disorder that contribute to cognitive dysfunction in everyday life.

METHODS

Participants met DSM-IV criteria for bipolar I disorder (n = 68) in a depressed or euthymic state. Everyday executive functioning was evaluated using the Behavior Rating Inventory of Executive Functioning (BRIEF) and the Frontal Systems Behavior Rating Scale (FrSBe). Participants completed clinician rated measures of mood state (Hamilton Depression Rating Scale, Young Mania Rating Scale), prior illness course and co-morbidities (Mini International Neuropsychiatric Interview), as well as self-report measures of psychotropic medication use and medical co-morbidity.

RESULTS

Individuals in this study reported significant impairment in every domain of executive functioning. These deficits were associated with a multitude of illness factors, some directly impacted by mood symptoms and others shaped by illness chronicity, psychiatric comorbidity, medical co-morbidity, and medication use.

DISCUSSION

Executive functioning problems observed in everyday functioning in bipolar disorder are not entirely mood-state dependent. Cognitive rehabilitation for executive dysfunction should be considered an important adjunctive treatment for many individuals with bipolar disorder.

Asenapine treatment and health-related quality of life in patients experiencing bipolar I disorder with mixed episodes: post-hoc analyses of pivotal trials

OBJECTIVE

To evaluate the baseline impact of episode type (manic vs. mixed), defined using DSM-IV-TR criteria, in bipolar I disorder (BD-I) on health-related quality of life (HRQoL), and to investigate the differential effect of asenapine vs. placebo and olanzapine on HRQoL in BD-I patients with mixed episodes.

METHODS

In two identically designed 3 week, randomized, double-blind, flexible-dose, placebo- and olanzapine-controlled trials of asenapine, HRQoL was assessed using the 36-item Short-Form Health Survey (SF-36v2) administered at baseline and endpoint. In addition to evaluating the impact of clinical presentation (manic vs. mixed episodes) on baseline HRQoL, the impact of treatment intervention on HRQoL was assessed via analysis of covariance models at study endpoint, with center and treatment-by-diagnosis interaction as fixed effect and baseline score as covariates.

RESULTS

A total of 960 BD-I patients (asenapine: 372; olanzapine: 391; placebo: 197) were included in the two studies. The observed burden of disease on HRQoL was substantial compared to general US population norms, particularly in patients experiencing mixed episodes. The greatest impairments were observed in the mental domains of HRQoL (Mental Component Summary scores: mixed = 31.9; manic = 42.8). For patients with mixed episodes, when compared to olanzapine, asenapine treatment was associated with improvements noted in every domain, which did not reach statistical significance except for Vitality (asenapine = 55.0, olanzapine = 51.3; p = 0.014) and Role-Emotional (asenapine = 44.8, olanzapine = 40.3; p = 0.020). Compared to placebo patients with mixed episodes, asenapine treatment provided significant improvements (p < 0.05) in Bodily Pain (asenapine = 50.9, placebo = 45.9), Social Functioning (asenapine = 44.1, placebo = 39.6) and Mental Health (asenapine = 46.6, placebo = 42.7) by Week 3; by comparison, olanzapine treatment did not lead to significant improvements in any domain of HRQoL compared to placebo.

CONCLUSIONS

Post-hoc analyses of two trials showed that BD-I patients with mixed episodes reported considerable impairments in HRQoL compared to patients with manic episodes. At 3 weeks, in patients with mixed episodes, asenapine was shown to lead to significant improvements in HRQoL compared to olanzapine and placebo. Results from these post-hoc analyses should be confirmed in prospective studies.

TRIAL REGISTRATION

NCT00159744, NCT00159796.

Psychosocial Functioning in Depressive Patients: A Comparative Study between Major Depressive Disorder and Bipolar Affective Disorder

Introduction. Major depressive disorder (MDD) and bipolar affective disorder (BAD) are among the leading causes of disability. These are often associated with widespread impairments in all domains of functioning including relational, occupational, and social. The main aim of the study was to examine and compare nature and extent of psychosocial impairment of patients with MDD and BAD during depressive phase. Methodology. 96 patients (48 in MDD group and 48 in BAD group) were included in the study. Patients were recruited in depressive phase (moderate to severe depression). Patients having age outside 18-45 years, psychotic symptoms, mental retardation, and current comorbid medical or axis-1 psychiatric disorder were excluded. Psychosocial functioning was assessed using Range of Impaired Functioning Tool (LIFE-RIFT). Results. Domains of work, interpersonal relationship, life satisfaction, and recreation were all affected in both groups, but the groups showed significant difference in global psychosocial functioning score only (P = 0.031) with BAD group showing more severe impairment. Conclusion. Bipolar depression causes higher global psychosocial impairment than unipolar depression.

Co-occurring psychiatric disorders and alcoholism

Alcohol use disorder (AUD), a term that comprises both alcohol abuse and alcohol dependence, is a highly prevalent psychiatric disorder. Over 50% of treated AUD patients also suffer from other psychiatric disorder(s). Detailed study has revealed disorders across multiple psychiatric domains with rates of co-occurrence far greater than chance, suggesting a synergistic relationship. The basis of this synergy is explored along with its multiple forms, including behavioral and neurobiologic. Specific topics include the predisposition to both AUD and co-occurring psychopathology, the vulnerability to environmental risk factors that exacerbate these predispositions, and the nature of reinforcement in acute intoxication. Co-occurrence can also modify and exacerbate the neuroadaptations underpinning chronic dependence and relapse, the manifestations of acute and protracted withdrawal, emergence of medical and psychiatric complications, and ultimately the potential for relapse. The outcomes of co-occurrence as well as the unique impact it has on proper treatment are also discussed. Throughout, the significance of recognizing co-occurrence is emphasized since, both neurobiologically and clinically, the synergies between co-occurring disorders yield a result far more complex than a mere sum of the component disorders.

The estimation of utility weights in cost-utility analysis for mental disorders: a systematic review

OBJECTIVE

To systematically review approaches and instruments used to derive utility weights in cost-utility analyses (CUAs) within the field of mental disorders and to identify factors that may have influenced the choice of the approach.

METHODS

We searched the databases DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), HTA (Health Technology Assessment), and PubMed for CUAs. Studies were included if they were full economic evaluations and reported quality-adjusted life-years as the health outcome. Study characteristics and instruments used to estimate utility weights were described and a logistic regression analysis was conducted to identify factors associated with the choice of either the direct (e.g. standard gamble) or the preference-based measure (PBM) approach (e.g. EQ-5D).

RESULTS

We identified 227 CUAs with a maximum in 2009, 2010, and 2012. Most CUAs were conducted in depression, dementia, or psychosis, and came from the US or the UK, with the EQ-5D being the most frequently used instrument. The application of the direct approach was significantly associated with depression, psychosis, and model-based studies. The PBM approach was more likely to be used in recent studies, dementia, Europe, and empirical studies. Utility weights used in model-based studies were derived from only a small number of studies.

LIMITATIONS

We only searched four databases and did not evaluate the quality of the included studies.

CONCLUSIONS

Direct instruments and PBMs are used to elicit utility weights in CUAs with different frequencies regarding study type, mental disorder, and country.

Employment outcomes in people with bipolar disorder: a systematic review

OBJECTIVE

Employment outcome in bipolar disorder is an under investigated, but important area. The aim of this study was to identify the long-term employment outcomes of people with bipolar disorder.

METHOD

A systematic review using the Medline, PsychInfo and Web of Science databases.

RESULTS

Of 1962 abstracts retrieved, 151 full text papers were read. Data were extracted from 25 papers representing a sample of 4892 people with bipolar disorder and a mean length of follow-up of 4.9 years. Seventeen studies had follow-up periods of up to 4 years and eight follow-up of 5-15 years. Most studies with samples of people with established bipolar disorder suggest approximately 40-60% of people are in employment. Studies using work functioning measures mirrored this result. Bipolar disorder appears to lead to workplace underperformance and 40-50% of people may suffer a slide in their occupational status over time. Employment levels in early bipolar disorder were higher than in more established illness.

CONCLUSION

Bipolar disorder damages employment outcome in the longer term, but up to 60% of people may be in employment. Whilst further studies are necessary, the current evidence provides support for extending the early intervention paradigm to bipolar disorder.

MDQ positive people's searching for effective and ineffective treatments for bipolar disorders: a screening study in France

INTRODUCTION

The objective was to estimate the rate of subjects who tested positive at a screening for bipolar disorders among the people insured by a French Health Company, and subsequently to measure treatment patterns.

METHODS

Cross-sectional postal survey on the "Mutuelle Générale de l'Education Nationale" (MGEN) policyholders. A self-rated questionnaire was sent by mail to 20,099 individuals randomly selected among MGEN policyholders. Tools: questionnaire on socio-demographic variables and health-care use; Mood Disorder Questionnaire (MDQ); Composite International Diagnostic Interview Short Form Self-Administered (CIDI-SA).

RESULTS

Responders were 10,288 (53%). The prevalence of MDQ positivity (MDQ(+)) was 3.6%. The respondents older than 65 showed the lowest frequencies. High frequencies were recorded by the people who had left work because of long term sickness and by people with invalidity. Subjects having a diagnosis of ICD-10 major depression were found to be at risk. Positive subjects had no more contacts with general practitioners than negative subjects; on the contrary they had more contacts with psychiatrists, alternative medicine professionals, psychologists, psychoanalysts, spiritual guides or welfare workers. MDQ+ subjects had a higher risk to use all kinds of psychodrugs, including antidepressants (27.7%, OR=2.7, CI95% 1.9-3.9).

DISCUSSION

The prevalence of MDQ(+) was similar to the surveys in the USA and Italy. The use of ADs in people with MDQ(+) and MDD diagnosis needs to be taken into account when managing the public health-care system. A large rate of positive subjects reported to have used ineffective treatments for bipolar disorders.

LIMITS

Relative low response rate and observational design.

Persistence of cognitive impairment and its negative impact on psychosocial functioning in lithium-treated, euthymic bipolar patients: a 6-year follow-up study

BACKGROUND

Previous cross-sectional studies report that cognitive impairment is associated with poor psychosocial functioning in euthymic bipolar patients. There is a lack of long-term studies to determine the course of cognitive impairment and its impact on functional outcome. Method A total of 54 subjects were assessed at baseline and 6 years later; 28 had DSM-IV TR bipolar I or II disorder (recruited, at baseline, from a Lithium Clinic Program) and 26 were healthy matched controls. They were all assessed with a cognitive battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory and visual memory) twice over a 6-year follow-up period. All patients were euthymic (Hamilton Rating Scale for Depression score lower than 8 and Young mania rating scale score lower than 6) for at least 3 months before both evaluations. At the end of follow-up, psychosocial functioning was also evaluated by means of the Functioning Assessment Short Test.

RESULTS

Repeated-measures multivariate analysis of covariance showed that there were main effects of group in the executive domain, in the inhibition domain, in the processing speed domain, and in the verbal memory domain (p<0.04). Among the clinical factors, only longer illness duration was significantly related to slow processing (p=0.01), whereas strong relationships were observed between impoverished cognition along time and poorer psychosocial functioning (p<0.05).

CONCLUSIONS

Executive functioning, inhibition, processing speed and verbal memory were impaired in euthymic bipolar out-patients. Although cognitive deficits remained stable on average throughout the follow-up, they had enduring negative effects on psychosocial adaptation of patients.

Does risk for bipolar disorder heighten the disconnect between objective and subjective appraisals of cognition?

BACKGROUND

Deficits in cognitive functioning have been associated with bipolar disorder during episodes of depression and mania, as well as during periods of symptomatic remission. Separate evidence suggests that patients may lack awareness of these deficits and may even be overly confident with self-appraisals. The extent to which these separately or together represent prodromes of the disorder versus a consequence of the disorder remains unclear. The present study sought to test whether risk for bipolar disorder in a younger, college-aged cohort of individuals would be associated with lower performance in cognitive ability yet higher self-appraisal of cognitive functioning.

METHOD

Participants (N=128) completed an objective measure of working memory, a self-report measure of everyday cognitive deficits, and a measure associated with risk for bipolar disorder.

RESULTS

Contrary to expectation, risk for bipolar disorder did not significantly predict poorer working memory. However, a person's risk for bipolar disorder was associated with higher self-appraisal of cognitive functioning relative to those with lower risk despite there being no indication of a difference in ability on the working memory task.

LIMITATIONS

Participant recruitment relied on an analog sample; moreover, assessment of cognitive functioning was limited to working memory.

CONCLUSIONS

Results add to a growing body of evidence indicating that overconfidence may be part of the cognitive profile of individuals at risk for bipolar disorder.

Prevalence, chronicity, burden and borders of bipolar disorder

Bipolar disorder (BD) has traditionally been thought of as an episodic condition, characterized by periods of hypomania/mania and depression. However, evidence is accumulating to suggest that this condition is associated with significant chronicity. For a large proportion of patients with BD, residual, sub-syndromal symptoms persist between major syndromal episodes, and studies have shown that many patients with bipolar disorder are symptomatic for approximately 50% of the time over follow-up periods of greater than 10 years. Moreover, while the prevalence of BD has been estimated to be around 1-2%, there is growing evidence that this may be a substantial underestimation. There are a number of reasons for this potential underestimation, including difficulties in diagnosis. Adding to the burden of BD is the issue of comorbidity, with an increased prevalence of many chronic conditions in those with a primary diagnosis of BD. Conversely, for many patients with chronic conditions, both medical and psychiatric, BD frequently exists as a comorbid secondary diagnosis. This issue of comorbidity complicates estimates of use of pharmaceutical agents for BD, such as mood stabilizers, which are known to be used off-label in conditions such as borderline personality or substance use disorder. We speculate that such off-label prescribing may not be truly off-label but may be instead fully justified by an overlooked secondary diagnosis of BD. Finally, we discuss the association of bipolar disorder with a significant economic burden, to the individual and to society, both due to the direct costs of medical expenditure and indirect costs such as loss of productivity and increased mortality.

Occupational outcome in bipolar disorder is not predicted by premorbid functioning and intelligence

OBJECTIVES

Bipolar disorder (BD), over the long term, can manifest a variety of outcomes depending on a number of different conditions. There is a need for further knowledge regarding preventive factors as well as predictors of the disabling course of the disorder. Studies regarding the impact on functional outcome of premorbid and current general intellectual function [intelligence quotient (IQ)] and premorbid functioning in BD patients are sparse. The present study addressed the role of premorbid functioning [assessed with the Premorbid Adjustment Scale (PAS)], intelligence, course of illness, and sociodemographics on occupational outcome in BD.

METHODS

Bipolar disorder patients were recruited consecutively from psychiatric units (outpatient and inpatient) in four major hospitals in Oslo, Norway [(N = 226: 64.4% bipolar I disorder (BD-I); 30.1% bipolar II disorder (BD-II); 5.5% bipolar disorder not otherwise specified (BD-NOS); 38.6% males]. The associations between current IQ, premorbid IQ [assessed using the National Adult Reading Test (NART)], PAS, clinical and sociodemographic characteristics, and receipt of disability benefit were analysed using descriptive statistics and logistic regression analyses.

RESULTS

The number of hospitalizations for depressive episodes and illness duration was associated with a higher risk of receipt of disability benefit. PAS, premorbid and current IQ, as well as decline in IQ, did not explain the higher risk of receipt of disability benefits.

CONCLUSIONS

Severe clinical course of BD was associated with receipt of disability benefit. Occupational outcome was unrelated to PAS, premorbid and current IQ, as well as decline in IQ. This suggests that the persistence of severe clinical symptoms, rather than global cognitive functioning, determines occupational outcome in BD and emphasizes the protective potential of early and continuous clinical treatment.

Occupational disability in bipolar disorder: analysis of predictors of being on severe disablement benefit (PREBIS study data)

OBJECTIVE

Patients diagnosed with bipolar disorder (BD) are reported to have significant work impairment during interepisode intervals. This study was carried out to assess potential predictors of occupational disability in a longitudinal follow-up of euthymic patients.

METHOD

We included 327 euthymic patients diagnosed with BD type I or type II, 226 of whom were employed and 101 were receiving a severe disablement benefit (SDB). Sociodemographic data were studied and episode recurrence was assessed along a 1-year follow-up. Logistic regression analysis was applied to determine predictors of receiving SDB. Cox regression was built to study recurrences.

RESULTS

Predictors of receiving SDB were: axis II comorbidity [Odds Ratio (OR) = 2.94, CI: 1.26-6.86, P = 0.013], number of manic episodes (OR = 1.21, CI: 1.10-1.34, P < 0.001), being without stable partner (OR = 2.44, CI: 1.34-4.44, P = 0.004) and older age (OR = 1.08, CI: 1.05-1.12, P < 0.001). Bipolar patients receiving SDB presented more episodic recurrences regardless of polarity than employed bipolar patients (P = 0.002). The time until recurrence in 25% of the bipolar patients receiving SDB was 6.08 months (CI: 4.44-11.77) being 13.08 months (CI: 9.60 to -) in the employed group.

CONCLUSION

Occupational disability in bipolar patients is associated with axis II comorbidity, more previous manic episodes, not having a stable relationship, older age, and more recurrences at 1-year follow-up.