How does work work for people with bipolar affective disorder?

Disability and its correlates among persons with bipolar disorder: Exploratory findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Aim

This study aimed to evaluate the disability and its correlates in persons with Bipolar Disorder during the remission phase.

Materials and Methods

As part of the multicentric study, 773 patients with bipolar disorder, currently in clinical remission, were evaluated for disability on the Indian Disability Assessment Evaluation Scale.

Results

About one-fifth of the participants had some level of disability in the domain of self-care, one-third had some level of disability in the interpersonal domain, one-fourth had some level of disability in communication and understanding, and a maximum proportion (43.7%) had some disability in the domain of work. Overall, about one-fifth (18.4%) were considered to have a benchmark disability (i.e., disability >40%). In terms of correlates, those with a disability had a short duration of current remission, a higher number of manic and mixed episodes, a higher mean number of total episodes, spent more time in the episodes, had lower severity of the depressive episodes, higher residual depressive and manic symptoms, had overall higher manic affective morbidity, had a higher level of cognitive deficits, and had poorer insight.

Conclusion

A significant proportion of patients with bipolar disorder have disability in work domain, and the presence of residual symptoms of either polarity are associated with higher level of disability.

An epidemiological study of externally determined and self-identified mental and physical disability across the spectrum of bipolar disorders

BACKGROUND

Studies exploring disability in bipolar disorder (BD) have primarily assessed clinical samples of full-threshold BD-I and BD-II alongside so-called objective criteria such as unemployment or receipt of government disability payments. This study extends research on disability by examining externally determined and self-identified disability in a community sample and by including subthreshold BD (BDS).

METHODS

Data were extracted from the USA Collaborative Psychiatric Epidemiology Surveys about individuals who met recognized criteria for BD-I, BD-II and BDS who had completed self-ratings of physical and mental disability, comorbidities, and health risk factors (e.g., obesity). Rates of disability were estimated, and logistic regression analyses were used to determine demographic and clinical variables associated with externally determined and self-identified of disability.

RESULTS

Of 408 individuals who met eligibility criteria (BD-I = 100; BD-II=104; BDS=204), 35% met criteria for externally determined disability, about 40% self-reported mental disability and about 23% self-reported physical disability. The odds were three-fold (Odds Ratio (OR): 3.05; 95% Confidence Intervals (CI): 1.69, 5.53) that someone with self-identified physical disability would meet criteria for externally determined disability, but associations with mental disability were non-significant (OR: 1.06; 95% CI: 0.63, 1.80). Regression analyses demonstrated that mental disability was associated with being a current or past smoker and physical disability was associated with BD-I.

LIMITATIONS

the adequacy of the assessments of disability and definition of BDS can be questioned.

CONCLUSIONS

Future clinical and community studies need to consider both externally determined and self-identified disability across the entire Bd spectrum.

Neurocognition and psychosocial functioning in adolescents with bipolar disorder

BACKGROUND

Adults with bipolar disorder demonstrate significantly poorer psychosocial functioning and neurocognition compared to controls. In adult bipolar disorder neurocognition predicts a substantial portion of variance in functioning. Adolescents with bipolar disorder have reducedpsychosocial functioning, but less is known about neurocognitive impairments, and no studies have examined the relationship between neurocognition and functioning in an adolescent sample.

METHODS

38 adolescents with bipolar disorder and 49 healthy controls under 20 years of age completed assessments of psychosocial functioning, neurocognitive ability, and psychiatric symptoms.

RESULTS

Adolescents with bipolar disorder had significantly poorer psychosocial functioning in domains of daily activities, social functioning, and satisfaction with functioning, ps<.006, compared to healthy controls. They also had poorer general neurocognitive functioning than controls, p=.004, with the greatest impairment on a test of sustained attention. Neurocognition was not a significant predictor of psychosocial functioning in this sample, but depressive symptoms significantly predicted functioning in all domains, p<.033.

LIMITATIONS

Limited sample size did not allow for complex statistical analyses. Differences in demographic characteristics of the clinical and control groups may limit generalization of these results.

CONCLUSIONS

This adolescent sample with bipolar disorder experiences significantly poorer neurocognitive and psychosocial functioning compared to controls; however, psychosocial functioning appears to be more strongly related to mood symptoms than to neurocognition. Future work is needed to delineate the time course of neurocognitive functioning and its relation to psychosocial functioning across the course of illness. Adolescence may provide an ideal time for cognitive enhancement and intensive psychosocial intervention.

Meta-analysis of predictors of favorable employment outcomes among individuals with bipolar disorder

OBJECTIVES

Although several studies have reported on predictors of employment in individuals with bipolar disorder (BD), the magnitude of the impact of these variables is unclear as no previous studies have estimated the collective effect sizes (ESs). The present meta-analysis estimated ESs and explored which of these variables are associated with positive employment outcomes.

METHODS

We searched for articles published between 2000 and 2011 that reported associations between sociodemographic, clinical, psychosocial, and/or cognitive variables with employment outcomes in BD. Of the 781 articles identified, 22 met the inclusion criteria and were included in the final analysis (n = 6,301). Weighted correlation coefficients (r-index) were computed as ESs for each of the predictor variables, which were grouped into six categories: cognitive performance, symptomatology, sociodemographic factors, course of illness, clinical variables, and other personal factors. The overall ES (Rw) was estimated by assuming random-effect models. Sensitivity analyses were also performed to determine the robustness of the findings.

RESULTS

Significant predictors of favorable employment outcomes included: cognitive performance (e.g., verbal memory, Rw = 0.33; executive function, Rw = 0.26), sociodemographic factors (e.g., years of education, Rw = 0.23), course of illness (e.g., number of lifetime psychiatric hospitalizations, Rw = -0.35), symptomatology (e.g., depression, Rw = -0.25), and other personal factors (e.g., personality disorder, Rw = -0.49).

CONCLUSIONS

Overall, the cognitive performance and course of illness had larger average ESs than symptomatology or sociodemographic factors on favorable employment outcomes. These findings may help to guide the design of more effective work interventions for people with BD.

Using comparative effectiveness design to improve the generalizability of bipolar treatment trials data: contrasting LiTMUS baseline data with pre-existing placebo controlled trials

BACKGROUND

Efficacy-based double-blind placebo controlled trials were conducted to establish efficacy and safety for FDA approval. Such designs allowed and encouraged the use of exclusion criteria to improve assay sensitivity and internal validity. The LiTMUS trial increased the representation of real-world individuals with bipolar disorder despite the acknowledgment that this compromises assay sensitivity.

METHOD

To maximize generalizability, LiTMUS used broad inclusion and narrow exclusion criteria: participants experiencing mood symptoms of sufficient intensity (at least with a CGI-BP ≥ 3) that would warrant a change in treatment, and that lithium treatment would be a reasonable therapeutic option if they were randomized to it. At baseline demographic, illness, clinical, and treatment characteristics were collected. The LiTMUS study design and baseline sociodemographic data were compared to previous efficacy studies.

RESULTS

As compared to the previous bipolar disorder efficacy studies, LiTMUS participants were of similar age, gender, weight and illness severity; however LiTMUS participants were more racially and ethnically representative of the general population, had a greater number of mood episodes in the past 12 months, more Axis I/II comorbidity, a greater number of prior suicide attempts, and higher functional capacity.

CONCLUSIONS

LiTMUS was a comparative effectiveness trial that had broad inclusion and minimal exclusion criteria that produced a more representative sample comprised of real-world participants. This design enables the results of the LiTMUS study to be a more representative of real world pharmacotherapuetic outcomes.

LIMITATIONS

Limitations include possible selection bias, paucity of sociodemographic data in efficacy trials, and lack of a placebo.

Probability and predictors of treatment-seeking for prescription opioid use disorders: a national study

BACKGROUND

Prescription opioid use disorders are the second most common drug use disorder behind only cannabis use disorders. Despite this, very little is known about the help-seeking behavior among individuals with these disorders.

METHODS

The sample included respondents of the Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with a lifetime diagnosis of prescription drug use disorders (N=623). Unadjusted and adjusted hazard ratios are presented for time to first treatment-seeking by sociodemographic characteristics and comorbid psychiatric disorders.

RESULTS

The lifetime cumulative probability of treatment seeking was 42% and the median delay from prescription drug use disorder onset to first treatment was 3.83 years. Having an earlier onset of prescription opioid use disorder and a history of bipolar disorder, major depression disorder, specific phobia and cluster B personality disorders predicted shorter delays to treatment.

CONCLUSIONS

Although some comorbid psychiatric disorders increase the rate of treatment-seeking and decrease delays to first-treatment contact rates of treatment-seeking for prescription drug use disorder are low, even when compared with rates of treatment for other substance use disorders. Given the high prevalence and adverse consequences of prescription drug use disorder, there is a need to improve detection and treatment of prescription opioid use disorder.

Preliminary Outcomes from an Individualised Supported Education Programme Delivered by a Community Mental Health Service

This paper describes the implementation and preliminary results of a supported education programme designed to complement a youth-oriented supported employment programme.

Method:

The programme was delivered by occupational therapists employed by a community mental health service in the Hunter New England region, New South Wales, Australia. Twenty mental health service users were assisted with their course of study over an 18-month period.

Results:

Education outcomes were promising, with 70% of service users either continuing or completing their chosen course of formal study. The education support provided was modelled on the Individual Placement and Support approach to supported employment.

Conclusion:

Occupational therapists working in public mental health can use this promising approach to supplement supported employment programmes, which should also be closely coordinated with the mental health service.

What are the predictors of work impairment in Iranian patients with depressive disorders?

The purpose of this study is to estimate the predictors of working ability in depressed patients. Two hundred and twenty-six patients with depression consecutively admitted on outpatient basis from March 2003 to May 2006 were classified into working and non working groups. Severity of depression was measured by the Beck Depression Inventory and their occupational adjustment 2 months prior to the last episode was determined by Occupational Adjustment Scale, a subscale of Social Adjustment Scale. The groups were almost similar in terms of age, sex, education, and marital status. There were significant differences between them in terms of family history of depression, episodes of depression, history of suicide attempts, duration of illness and severity of depression (P < 0.01). The working depressed group differed significantly from the impaired depressed group in terms of work experience, job turnover, and overall occupational adjustment (P < 0.01). History of suicide attempt, family history of depression, time lost, severity of depression, pre-morbid occupational adjustment, age, and illness duration emerged as the most important predictors, explaining 64% of the patients' working ability. Our observations are on line with robust literature across the globe. Nature of illness condition as well as societal attitude can explain the impairment condition in depressed patients. Presence of a comprehensive integrated approach to their treatment and rehabilitation is imperative.

Lithium treatment -- moderate dose use study (LiTMUS) for bipolar disorder: rationale and design

BACKGROUND

Recent data indicate that lithium use for bipolar disorder has declined over the last decade and that lithium largely has been replaced with alternate, commercially promoted medications that may or may not result in better outcomes.

PURPOSE

This article describes the rationale and study design of LiTMUS, a multi-site, prospective, randomized clinical trial of outpatients with bipolar disorder. LiTMUS seeks to address whether initiating therapy at lower doses of lithium as part of optimized treatment (OPT, guideline-informed, evidence-based, and personalized pharmacotherapy) improves outcomes and decreases the need for other medication changes across 6 months of therapy.

METHODS

LiTMUS will randomize 284 adults with bipolar disorder (Type I or II) across 6 study sites. The co-primary outcomes are overall illness severity on clinical global improvement scale for bipolar disorder and a novel measure, necessary clinical adjustments. This metric provides a composite that reflects both clinical response and tolerability. Other relevant outcomes include full symptomatic recovery, quality of life, suicidal behaviors, and moderators of suicidality.

RESULTS

As of August 28th, 2009, we have consented 338 patients and randomized 281 for this study.

LIMITATIONS

The potential limitations of the study include an arbitrary definition of 'low, but effective' doses of lithium, lack of a placebo-controlled group, open treatment, and use of a new outcome measure (i.e., necessary clinical adjustments).

CONCLUSION

We expect that this study will inform our understanding of the effectiveness of low to moderate doses of lithium therapy for individuals with bipolar disorder.

Extra dimensions in all aspects of life-the meaning of life with bipolar disorder

Living with Bipolar Disorder (BD) greatly affects the whole life; still the meaning of it is poorly explored from the perspective of the individuals actually living with it. The aim of this study is thus to explore the existential meaning of life with BD. Ten persons, six women and four men, (aged 30–61), diagnosed with BD were interviewed. A reflective lifeworld perspective based on phenomenological philosophy was used. The findings show that living with BD entails experiencing extra dimensions in all aspects of life, expressed in terms of a magnitude and complexity beyond that which is perceived as pertaining to normal life. The essential meaning of the phenomenon is further described by its constituents: “a specific intensity”, “a struggle to understand”, “an illness that is intertwined with one's whole being”. Living with BD means more for the individual than having episodes of depression and mania and must therefore be understood from a holistic perspective. Adequate care for persons with BD, therefore, includes places for safe and profound reflecting about existential issues, such as identity, trust and self-confidence. The present study recommends the caring services to change their ways to explain and talk about the BD illness.

Bipolar depression: trial-based insights to guide patient care

For the majority of patients with bipolar disorder, major depressive episodes represent the most debilitating and difficult-to-treat illness dimension. Patients spend significantly more time depressed than manic or hypomanic, and attempt suicide more frequently during this illness phase, yet the availability of treatments remains limited. The discovery of more effective therapeutics for managing depressive episodes is arguably the greatest unmet need in bipolar disorder. This article provides an evidence-based summary of pharmacological treatments for the acute and longitudinal management of bipolar depression. Clinical trial results are reviewed for a diverse array of compounds, inclusive of traditional mood stabilizers (eg, lithium and divalproex), atypical antipsychotics, unimodal antidepressants, and modafinil. Where applicable, differences in efficacy across compounds are examined through discussion of number needed to treat and effect size determinations. A pragmatic clinical approach is presented for management of the depressed phase of bipolar disorder.

Working, receiving disability benefits, and access to mental health care in individuals with bipolar disorder

OBJECTIVE

The objective of this study was to determine the extent to which people in a bipolar disorder (BPD) registry were working, factors associated with working and obtaining disability benefits, and the impact disability benefits have on work.

METHODS

We compared the socio-demographic, disease, treatment, and health insurance characteristics among three work disability groups - working, not working, and not working and receiving disability benefits - using a chi-square statistical test on categorical data, one-way analysis of variance (ANOVA) to compare means, and a Kruskal-Wallis non-parametric test of significance with skewed data.

RESULTS

Among 1,855 individuals, 49.4% reported they were working. Those working were younger, more frequently self-identified as Caucasian, were more highly educated, had a higher income, were more often married, had a shorter duration of illness, and reported the shortest illness duration, the lowest percentage of suicide attempts, and manic and mixed or rapid symptoms in the past 6 months compared to the two non-working groups. Working individuals least often reported receiving electroconvulsive therapy and being hospitalized and had the longest median duration since last hospitalization and the lowest percentage with treatment in the past 6 months. They were currently likelier to be treated by a primary care physician or other health professional than a psychiatrist compared to non-working groups. Finally, compared to the non-working groups, the working group had the highest percentage with no health insurance and private health insurance, the highest percentage using managed care, and the lowest percent under a fee-for-service plan. All work disability groups had similar perceptions of their mental health care plan in terms of the number of doctors or clinics from which to choose, the location of their health care providers, and the quality of mental health care. Those in the working group were least satisfied with the range of mental health services provided in their health plan.

CONCLUSIONS

Disability benefits are rarely awarded when a person is working. Moreover, receipt of disability benefits increases the likelihood that a person with BPD will be receiving health care benefits and, in many cases, those benefits provide greater access to treatment compared to health care insurance received through an employer. We conclude that the incentives to work run counter to access to treatment among people with BPD.

The impact of bipolar disorder upon work functioning: a qualitative analysis

OBJECTIVES

One important but sometimes poorly-captured area of functioning concerns an individual's ability to work. Several quantitative studies have now indicated that bipolar disorder (BD) can have a severe, and often enduring, negative impact upon occupational functioning. While this data indicates that employment rates are relatively low in this patient population, it throws little light on the specific ways in which this complex psychiatric condition can affect work, or upon how these effects are subjectively interpreted by individuals with BD. In order to further elucidate the relationship between BD and work, we report here on a series of exploratory qualitative interviews undertaken to develop a disease-specific measure of quality of life in BD.

METHODS

We conducted 52 interviews with people with BD (n = 35), their caregivers (n = 5) and healthcare professionals (n = 12) identified by both convenience and purposive sampling. The affected sample came from a variety of employment situations, ranging between people with no employment history through to those in highly skilled, stable professional positions. Interviews were tape recorded, transcribed verbatim and analysed thematically.

RESULTS

Respondents described the different ways in which the symptoms of depression and hypo/mania presented in the workplace. Five main themes emerged from the data: lack of continuity in work history, loss, illness management strategies in the workplace, stigma and disclosure in the workplace, and interpersonal problems at work.

CONCLUSIONS

Patient outcome in BD has traditionally been determined by the assessment of clinical characteristics such as rates of relapse, hospitalization, or degree of symptom reduction. More recently, however, there has been increasing interest in expanding the assessment of outcome to include the measurement of indices such as functioning, a key facet of which relates to an individual's ability to work. The qualitative data obtained here highlights the often complex, varied and intermittent effects of an episodic condition such as BD upon work functioning, and points to the importance of developing more sophisticated and precise measures of occupational functioning for this population.